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date: 23 August 2017

Narratives in Health and Risk Messaging

Summary and Keywords

In health and risk communication, evidence is a message feature that can add credibility, realism, and legitimacy to health and risk messages. Evidence is usually defined into two types: statistical or narrative. Statistical evidence employs quantifications of events, places, phenomena, or other facts, while narrative evidence involves stories, anecdotes, cases, or testimonials. While many health and risk messages employ statistical or factual information, narrative evidence holds appeal for health and risk communication for its utility in helping individuals learn their risks and illnesses through stories and personal experiences. In particular, narratives employed as evidence in a health or risk message especially hold value for their ability to communicate experiences and share knowledge, attitudes, beliefs, and ideas about complex health issues, propose behavior change, and assist individuals coping with disease. As a result, the personal experiences shared, whether they are from first-hand knowledge, or recounting another’s experience, can focus attention, enhance comprehension for risks, and recall of health and risk information. Furthermore, readers engage with the story and develop their own emotional responses which may align with the purpose of the health and risk message. Narratives, or stories, can occur in many ways or through various points of view, but the stories that “ring true” to readers often have a sense of temporality, coherence, and fidelity. As a result, formative research and pre-testing of health and risk messages with narratives becomes important to understand individual perceptions related to the health issue and the characters (or points of view). Constructs of perceived similarity, interest, identification, transportation, and engagement are helpful to assess in order to maximize the usefulness and persuasiveness of narratives as evidence within a health and risk message. Additionally, understanding the emotional responses to narratives can also contribute to perceptions of imagery and vividness that can make the narrative appealing to readers. Examining what is a narrative as evidence in health and risk messages, how they are conceptualized and operationalized and used in health and risk messages is needed to understand their effectiveness.

Keywords: narratives, evidence, emotions, identification, transportation, persuasion, vividness, statistical evidence, health and risk message design and processing

Introduction

Health and risk communication messages often rely on message design features that can enhance the credibility and trustworthiness for individuals to process and engage in the recommended health and risk behaviors. Evidence is a common health message design feature used in health and risk messages, often in the form of statistics or narratives. Health and risk communication scholars often consider the benefits of using a narrative as evidence in their messages to communicate risk, prevention behaviors, and promote attitude and/or health behavior change. Therefore, it becomes important to consider the role of evidence in health and risk messages, and the value of narratives as evidence in these messages.

Evidence and Narratives

Evidence is defined as “factual statements originating from a source other than the speaker, objects not created by the speaker, and opinions of persons other than the speaker that are offered in support of the speaker’s claims” (McCroskey, 1969, p. 171). Often, health and risk messages use either facts or personal stories to convey risk associated with a behavior towards disease (e.g., tanning and skin cancer, see Greene & Brinn, 2003). Original definitions found factual information to represent reports and statistics, while testimonial, or personal, assertions illustrated more of a narrative form (Reinard, 1988). More recent research defines the differences between these types of evidence as a narrative versus non-narrative approach (Bilandzic & Busselle, 2013). While each type of evidence has been studied for their ability to increase the persuasiveness of a message or enhance processing of a message (Reinard, 1988; Allen & Preiss, 1997; Allen, Brunflat, Fucilla, Kramer, McKellips, Ryan, & Speigelhoff, 2000; Reynolds & Reynolds, 2002; Shen, Sheer, & Li, 2015; Volkman & Parrott, 2012; Zebregs, van den Putte, Neijens, & de Graaf, 2015), narrative evidence holds much promise for health and risk communication scholars in its ability to communicate to individuals about health and risks. For example, that a “narrative has the potential to facilitate attention, comprehension, and recall of cancer-related information” (Kreuter et al., 2007, p. 225) is critical for health and risk communication scholars.

Narrative evidence is sometimes defined in comparison to statistical evidence. For example, scholars identify statistical evidence as “empirically quantified descriptions of events, persona, places, or other phenomena” (Church & Wilbanks, 1986, p. 108), and narratives represent a story, anecdote, case history, or testimonial (Baesler & Burgoon, 1994) often in absence of numbers or quantification. Leaving narratives to such definitions, however, limits the understanding and implications of narratives as evidence for health and risk communication research. Such definitions neglect the meaning of narratives in terms of their structure, their type (e.g., story, illness narrative), the salience they convey to readers, and/or how the experience of listening to a narrative can influence one’s own understanding of risk and disease.

To illustrate such richness of narratives and their meaning, one needs to understand the full scope and potential of a narrative. Bleakley (2005) writes that “narrative (L. narrare) means to ‘to know’ and storytelling involves knowledge production and sharing of experience, not simply transparent recounting of events . . . [and] story brings temporal order to what would otherwise be experienced as a series of chaotic events” (p. 535). Kreuter et al. (2007) in their paper examining narratives and cancer communication, define narrative as “a representation of connected events and characters that has an identifiable structure, is bounded in space and time, and contains implicit or explicit messages about the topic being addressed” (p. 222). Furthermore, Green and Brock (2000) posit that a narrative account “requires a story that raises unanswered questions, presents unresolved conflicts, or depicts not yet completed activity; characters may encounter and then resolve a crisis or crises” (p. 701). One part of understanding a narrative even further is to examine the structure of a narrative.

Narrative Structure

Examining the literature on narratives, it appears that there are four basic elements needed in a narrative. Fisher’s (1985) narrative theory posits two key elements: consistency and fidelity. This is interpreted as “the narrative must be cohesive—free of inconsistencies, realistic, and meaningful . . . the narrative also should have fidelity; in other words, it must seem reliable and truthful” (Bylund, 2005, pp. 24–25). Ochs and Capps (1996) describe two other elements needed in a narrative, which are temporality and point of view. Temporality gives a sense of time to the events. It is not to limit narratives into only chronological order, but refer to the plot of the narrative, and the action that as temporally sequenced (Thorne, Korobov, & Morgan, 2007). Thus, the “beginning, middle and end” of a narrative offers a way to tie together actions and implications in a casual chain (Green, 2006). Ochs and Capps’ (1996) reference to point of view in narratives pertains to the perspective of the teller that influences how the narrative is framed, and narratives are intricately linked to the teller’s perspective. In health and risk messages, these elements add to the believability and realism of the narrative.

With these four basic elements in mind, Kreuter et al. (2007) identified an overall five attributes of quality narratives, with key structural components within each attribute. These attributes include: (a) sequence (e.g., coherence, plot development, theoretical adherence); (b) character (e.g., character development, characters’ articulateness, eloquence, emotional intensity/range); (c) structure (e.g., suspense/dramatic tension, canonical violation); (d) bounded in space and time (e.g., fidelity/realism, imagery, cultural appropriateness); and (e) message production (e.g., production values such as lighting, close-ups, and sound) (Kreuter et al., 2007). While much research on narratives does not focus on explicating narrative quality, Kreuter and his colleagues posit that these considerations are needed when understanding narrative persuasiveness and impact (2007). Overall, temporality, point of view, coherence, and fidelity are identified to be the most important in the structure of narratives (Ochs & Capps, 1996; Bylund, 2005). Structure, however, is not the only component needed when examining what is a narrative. It is equally important to consider the types of narratives that exist that can be used in health and risk messages.

Types of Narratives

The commonality of structure within narratives does not imply that all narratives are the same or identical. In the health and risk communication domain, narratives appear as public service announcements, telenovelas (or soap opera dramas), or personal stories, illness narratives, and conversations (Thomas-MacLean, 2004; Green, 2006; Thorne et al., 2007; Greene & Brinn, 2003; Gray & Harrington, 2011). Ochs and Capps (1996) write that “personal narratives comprise a range of genres from story to novel, diaries and letters to memoirs, gossip to legal testimony, boast to eulogy, troubles talk to medical history, joke to satire, bird song to opera, etching to palimpsest, and mime to dance” (p. 19). Bleakley (2005) cautions researchers to not typecast all narratives into many preset categories as it can limit how “specific narratives work for specific social occasions” (p. 536). In health and risk communication, specific situations of health, nuances of an illness, and personal risks also make narratives used as evidence unique to certain circumstances. Schank and Berman’s (2002) identification of five types of stories thus seems appropriate for its utility in categorizing some narratives, but enabling researchers to not miss the unique contribution of narratives and the situation specific occasions that elicit narratives.

The five types of stories identified by Schank and Berman (2002) include: (a) official; (b) invented; (c) first-hand experiential; (d) second-hand; and (e) culturally common. Official stories are those relayed by organizations where general story is imagined, but without real life complexities, and can be called “stories that people in authority instruct us to tell” (Schank & Berman, 2002, p. 289). Invented stories are fictional and are created from elements of one’s own stories, stories one has heard (Schank & Berman, 2002). Soap operas can be considered a type of invented story. First-hand stories are those stories experienced personally, and can be altered with each retelling, whereas second-hand stories are those recalled from memory and told to others (Schank & Berman, 2002). An illness narrative would be a type of first-hand story, where individuals recount their experience with an illness (Thomas-MacLean, 2004). Culturally common stories are generalized and are known because they are salient in the culture (e.g., Yiddish phrases) (Schank & Berman, 2002). Volkman and Parrott (2012), in their study of osteoporosis narratives, found college-age women did differentiate first-hand and second-hand narratives about osteoporosis experiences from official, organizationally written narratives. But, the narrative type of first-hand or second-hand narrative did not differ on perceptions of behavioral intentions towards osteoporosis prevention (Volkman & Parrott, 2012). It suggests that personal stories or narratives can be useful to communication health and risks of diseases, and the need for more personal expressions from personal or second-hand experiences (Volkman & Parrott, 2012). From this overview of the types of narratives, it clear that narratives are more than stories or anecdotes, and highlights the richness of narratives to use as evidence in health and risk communication.

Illness Narrative

One type of narrative is used often in health and risk communication: the illness narrative. The illness narrative is a narrative where an individual’s first-hand experience is expressed (Sunwolf et al., 2008. Illness narratives are those experiences of the ill that, according to Frank, fulfill the “need to become storytellers in order to recover the voices that illness and its treatment often take away” (as cited in Thomas-MacLean, 2004, p. 1647). These type of narratives offer the perspective of the person experiencing the illness, and could be considered a first-hand experience following Schank and Berman’s (2002) typology. First-hand experiences hold promise for health and risk communication messages as they allow the reader to understand and experiences the storyteller’s point-of-view, and their own sense of temporality associated with an illness.

There are three types of illness narratives: the restitution, chaos, and quest narratives. The restitution narrative focuses on “the movement away from and back toward health, exploring experiences of tests, treatments, and results” (Thomas-MacLean, 2004, p. 1648). The chaos illness narrative emphasizes life never getting better and the despair that encapsulates some individuals with illness, while the quest narratives highlight an illness as challenge to be battled and won (Thomas-MacLean, 2004). As Bleakley (2005) cautioned, it is important to not typecast narratives too much, as it hinders the situation-specific circumstances influencing such narratives. In the context of illness narratives, categorization may trivialize the uniqueness of an individual’s illness experience. Yet, this typology does offer an understanding into the individual differences that influence how an illness story is told, and how the individuals understand and engage with the story. For example, if a person feels victimized by their illness, or challenged by their illness, it may cause a different type of narrative to be told (Ott Anderson & Geist Martin, 2003; Volkman & Parrott, 2012), and thus would influence how individuals may perceive the health risk (e.g., cancer can be defeated; or cancer is a death sentence). Others, however, only consider illness narratives as an autobiographical account shared to help individuals make sense of their own illness. By expressing their illness, it helps others understand and identify that there is a larger story of the illness (Sunwolf et al., 2008). Thus, when selecting narratives to use as evidence, it is important for health and risk communication scholars to understand the implications with selecting a type of narrative to use. The persuasive associations with narrative evidence are thus linked with structure and types of narratives that are used in health and risk messages.

Persuasiveness of Narratives

The importance of understanding narratives as evidence stems from the long history of “narratives make life meaningful” (Thomas-MacLean, 2004, p. 1648). Throughout life, individuals tell narratives, listen to narratives, and/or “turn our own experiences into stories and file them in our memories” (Schank & Berman, 2002, p. 291). These

stories center on events that disrupt experience and are deemed worthy of sharing with others . . . Stories can be scattered throughout conversation or can emerge in clusters, on the heels of prior stories. Stories can be about one’s own experiences, a shared experience, or something that happened to someone else, and be unilaterally or collaterally told.

(Thorne et al., 2007, p. 1010)

Therefore, the persuasive potential of narratives is great for health and risk communication. Dependent upon the capabilities of narratives, however, is interest, a frame of reference, the timing of telling a story, and meeting the goals and curiosity of the audience (Schank & Berman, 2002). Thus, health and risk communication scholars must be cognizant of the various characteristics of narratives that influence their persuasiveness to audiences. The following are overarching characteristics identified in narratives that researchers have studied when examining narrative evidence. Many of these characteristics stem from a social scientific and empirical perspective where narratives are tested as ways to persuade individuals toward attitude, belief, or behavior change.

Statistical Versus Narrative Evidence and Persuasion

Researching the use of narrative evidence immediately unlocks a debate on the persuasiveness between statistical evidence and narrative evidence, or narrative versus non-narrative forms. In one of the first meta-analysis of statistical and narrative evidence in persuasion, Allen and Preiss (1997) found statistical evidence is more persuasive than narrative evidence (r = .101) among 15 studies. A follow-up investigation of persuasive evidence found that messages combining narrative and statistical evidence are more persuasive than either one alone, and replicated findings of the meta-analysis (Allen et al., 2000). Baesler and Burgoon (1994) in their study of the evidence’s influence on belief change discovered that statistical evidence is more persuasive than narrative evidence.

Yet, these studies relied more on persuasion and non-health and risk contexts. Recent research in health communication suggests that narrative evidence may be more persuasive than other forms of evidence. A recent meta-analysis of 15 studies using narrative or statistical evidence in health communication research found statistical evidence had a stronger impact on beliefs and attitudes, but narrative evidence had a stronger impact on intention (Zebregs et al., 2015). Similarly, Shen, Sheer, and Li’s (2015) meta-analysis of 25 studies using evidence in health communication discovered that “when compared to control groups, narratives had a small and significant effect (r = .063) on persuasion, as measured by changes in attitudes, intentions, and behaviors” (p. 110). Additionally, one study found narrative evidence can promote higher intentions to obtain a hepatitis B vaccine compared to statistical evidence (de Wit, Das, & Vet, 2008). But, there still needs to be more research about which type of evidence may be more persuasive. Nan, Dahlstrom, Richards, and Rangarajan (2015) suggest that hybrid messages having both statistical and narrative evidence can be more persuasive in regards to perceived risk of getting HPV compared to either form of evidence alone. Such findings echo the Allen et al. (2000) meta-analysis recommending the use of both forms of evidence in a message. Thus, research still needs to investigate the persuasive outcomes related to narrative evidence.

Narrative as “One”

One of the central arguments towards the persuasiveness of narratives is their focus on one. Narratives have been credited with providing more of an interest for audiences because of the specific case represented in a narrative (Cox & Cox, 2001). For health and risk communications scholars, this is important to consider when selecting evidence in a message; it is possible individuals will recall the risk of one versus statistics (or odds and probabilities) associated with an audience’s risk of diseases. The heuristic sample size associated with narrative evidence (a story of one), however, versus the sample size associated with statistical evidence (one of many) may be a limitation. In particular, “because a claim based on a large sample should have more of an impact than an identical claim based on a small sample” (Baesler & Burgoon, 1994, p. 584). Yet, this position is not universally supported, as case studies, or narratives may be more effective because “readers underuse information presented in a statistical or strictly informational format” (Greene & Brinn, 2003, p. 445). Furthermore, it is possible that “the numerical representation of statistics is encountered less frequently in everyday life than in stories, and since statistics are more difficult to interpret than a story, statistics are expected to be less readable and more complex than stories” (Baesler, 1997). In health and risk communication, this debate is critical when providing evidence about health risk information, treatments, and diagnoses. Thus, when communicating about the severity of a health issue, it is important to understand if statistics will provide behavior change (e.g., probabilities or odds), or if a personal testimonial or illness narrative (e.g., someone’s experience with a disease) is more persuasive towards health and risk communication outcomes.

Counter-arguing

Counter-arguing is another element of persuasion often studied in conjunction with narratives. While counter-arguing is often associated with persuasion literature, it is important to consider within health and risk communication. In particular, it is possible that “absorption in the narrative, and responses to characters in the narrative, should enhance persuasive effects and suppress counter-arguing” (Slater & Rouner, 2002, p. 173). Thus, arguments against the health and risk information being disseminated could be reduced when using narratives in health messages (Green, 2006). Recently, Niederdeppe, Shapiro, and Porticella (2011) found that narrative conditions could reduce counter-arguing regarding obesity information compared to non-narrative conditions. Volkman and Parrott’s (2012) analysis of supportive (i.e., agreement with message content) and non-supportive (i.e., disagreement with message content) statements after reading osteoporosis narratives found more supportive statements (n = 702) than non-supportive statements (n = 165). Bilandzic and Busselle (2013) advised, though, that it is difficult to determine the exact mechanisms causing the suppression of counter-arguing within narratives. Further research is advised to understand how this occurs, whether it is the persuasive elements within the narrative, or the actual narrative itself (Bilandzic & Busselle, 2013).

Similarity, Identification, Interest, and Engagement

Several constructs have emerged as important when considering the persuasive influence of narratives. Notably, perceived similarity, identification, interest, and engagement have surfaced as equally important constructs to consider. Perceived similarity can be defined as the “receivers’ judgments about how similar the narrative source is to them” (Kreuter et al., 2007). Greater levels of perceived similarity are associated with higher levels of attention and persuasiveness of the message (Kreuter et al., 2007), and perceived similarity to a character can be positively related to intentional and/or actual behavior and attitude change (Moyer-Gusé, Chung, & Jain, 2011). Perceived similarity, however, can be moderated by other characteristics perceived about the source (Kreuter et al., 2007). For instance, if an African-American woman believes breast cancer is a disease affecting only Caucasian women, an autobiographical narrative by another African-American woman may be considered more persuasive (Kreuter et al., 2007).

In comparison, identification is “when a reader or audience member becomes one with the character in a story” (Oatley, 2002). Identification with the characters is encapsulated within high levels of engagement and can be affected by perceived similarity (Slater & Rouner, 2002; Kreuter et al., 2007). For example, as individuals are able to identify with the characters in the story it will increase the engagement with the narrative (Slater & Rouner, 2002; Kreuter et al., 2007), and higher perceived similarity can lead to more identification (Kreuter et al., 2007; Larkey & Hecht, 2010). Yet, “experiments that test identification have often operationalized the concept in terms of perceived similarity to a character” (Dillard & Main, 2013, p. 674). Identification research also proposed that individuals who perceived higher levels of similarity to a character were more likely to visualize themselves as that character (Cohen, 2001; Moyer-Gusé, 2008). This action reflected the process of empathetic feeling towards the character, adoption of the character’s goals and point of view, and allocation of the character’s subjective experience (Campbell & Babrow, 2004; Tal-Or & Cohen, 2010).

Interest has been defined as “the extent to which a recipient finds the narrative engrossing,” or elements of a story that the audience finds “gripping” (Stephenson & Palmgreen, 2001, p. 55). Yet, Slater and Rouner (2002) state that engagement with a narrative is a function of the topic relevance to the receiver, and how well the narrative matches the goals and needs of the receiver determines the degree of engagement. In this sense, audiences should feel connected with the narrative based on how it meets their individual needs (Slater & Rouner, 2002). For example, if a narrative by a cancer patient does not meet the goals and needs of a family member of a cancer patient, the family member will have low engagement with the narrative. Both perceived similarity and engagement are considered associated with the amount of interest and identification an individual has with a narrative (Slater & Rouner, 2002). Some have proposed that the experiences of identification and engagement can lead towards a vicarious experience, in which an individual can learn and model a character’s behavior (Bilandzic & Busselle, 2013).

Health and risk communication researchers constructing narratives, or utilizing previously written narratives, must be careful to identify these characteristics within the narrative in order to maximize persuasive effects of using narratives as evidence. Yet, narratives are not limited to these constructs alone; one must consider the emotional connection attributed to narratives.

Emotions and Narratives

While it is outside the scope of this essay to describe the relationship between emotion and health and risk communication, it is important to note the emotional ties associated with narratives. Oatley (2002) posits that identification is intricately linked to the emotional connection that audiences have with stories; as the audience member becomes “one” with the character, the emotions experienced by the character become the audience member’s own emotions. Additionally, individuals that are more empathic may be more likely to identify with narratives (Green, 2006). Empathy has shown to be linked with identification with story characters as well (Kim, Bigman, Leader, Lerman, & Cappella, 2012). Polichak and Gerrig (2002) posit that emotional responses to narratives are due to the participatory response of audience members. They reason that affective responses “encode, on a basic level, how individuals feel about a stimulus, and through that, their assessment of its likely effects on them” (Polichak & Gerrig, 2002, p. 76).

Emotional responses are most evident when considering narratives in health and risk communication, and the content of some messages involving topics such as susceptibility and vulnerability to illness and disease (Green, 2006). For instance, the topic of cancer is often considered threatening, and it is difficult for emotions to not be aroused intentionally or unintentionally when discussing cancer risk and treatment (Dillard & Nabi, 2006). It is possible for individuals to have more than one emotional response to a message in general (Dillard & Nabi, 2006). As narratives of cancer include “journeys with despair, quests for meaning, personal growth, [and] spiritual transformation” (Kreuter et al., 2007, p. 228), it is not surprising that various emotions are experienced with narratives. For example, osteoporosis narratives that explicitly stated either negative (e.g., fear, anger, or sadness) or positive (e.g., happiness, hope, and relief) expressions with the disease elicited more than one emotional response by participants (Volkman & Parrott, 2012). It is possible that some emotional responses (e.g., fear and hope) may predict cognitive statements’ behavioral intentions after reading an emotionally expressive positive narrative (Volkman & Parrott, 2012). With the experiences of multiple emotions, however, health and risk communication scholars should understand the pros and cons of these emotions and their associated behaviors (Dillard & Nabi, 2006). Further research is needed to explore more about emotional responses to narratives and how they may influence individuals (Volkman & Parrott, 2012).

Imagery, Transportation, and Vividness

Adding to the importance of emotion in narratives is its theoretical connection to the vividness or imagery discussed with narratives. Individuals react with emotional responses to the vivid language and imagery evoked in narratives (Baesler & Burgoon, 1994). Specifically, emotion can be attributed to the images conjured when reading a narrative and how vivid, or real, it is perceived. Imagery concerns the “images that can be recalled, recognized, and responded to” (Green & Brock, 2002), and vivid information is, “(a) emotionally interesting, (b) concrete and imagery provoking, and (c) proximal in a sensory, temporal, or spatial way” (Nisbett & Ross, 1980, p. 45). It is perceived that narratives that evoke images and have vivid information are considered more persuasive (Baesler & Burgoon, 1994). Notably, many definitions of vividness and imagery conceptually and operationally overlap, making distinctions difficult on findings (Green & Brock, 2002).

Transportation

While another chapter discusses the importance and role of transportation in health and risk communication, it would be remiss to not mention this theory when discussing narratives. In particular, “transportation theory applies to narratives or stories rather than argument-based, non-narrative persuasive communications” (Green & Clark, 2013, p. 478). The impact of imagery is most apparent in Green and Brock’s (2000) understanding of the impact of narratives with the Transportation Theory. Green and Brock (2000) identified that transportation “into a narrative world is a distinct mental process, an integrative melding of attention, imagery, and feelings” (p. 701). In other words, the individual is “transported” into the world of the narrative, and encompasses more than identification to include cognitive, affective, and imagery processes within individuals (Green, 2006). As a result of being transported into a narrative, individuals are “more likely to change their real-world beliefs in response to information, claims, or events in a story” (Green, 2006, p. S165). This perspective highlights how individual appraisals and responses may be different when considering narrative evidence and individual characteristics.

Individual Differences and Narratives

It is important to consider individual differences when accounting for the persuasiveness of narrative evidence. Recent literature has offered new insights that may specifically influence narrative evidence.

Source and Audience

The perceived similarity with the characters, the identification with the characters, and engagement with the narrative are central for narratives (Slater & Rouner, 2002). In the area of illness narratives, this is even more salient as the source of the message is the person experiencing the illness as opposed to a character in a story. Health and risk messages involving illness narratives must be careful to ensure that the audience and source of the narrative are complementary; otherwise, the need for the narrative to match the needs and goals of the audience will fail and engagement with the narrative will not happen. It is possible that outside an “intended audience, meanings and disclosures can be misunderstood” (Kreuter et al., 2007, p. 231). For instance, illness narratives told by family members of cancer patients may not meet the goals and needs of a cancer patient reading the narrative. While reading such a narrative may be beneficial for the cancer patient to understand how a family member experiences cancer of a loved one, such a narrative may be discounted because it is not from the point of view of a cancer patient. Health communication scholars incorporating an illness narrative into a health message therefore must (a) acknowledge a source for the illness narrative, and (b) be cognizant that the source of the illness narrative match the needs and goals of the reader(s).

Culture

As health and risk communication considers how different cultures can influence health and risk behaviors, narrative evidence can also vary between cultures as cultural norms and subjective norms differ (Hornikx & Hoeken, 2007; Larkey & Hecht, 2010). In particular, it is argued that culture not be an added thought after a message is developed, but rather a central component to a health and risk communication message (Larkey & Hecht, 2010). In this way, “narratives are obtained and shaped into messages that keep much of the original content and form intact, with the intent to represent the culture” (Larkey & Hecht, 2010, p. 116). A Model of Culture-Centric Narratives in Health Promotion (Larkey & Hecht, 2010) posits that adhering to cultural norms and beliefs within a narrative can only enhance the realism and identification associated with the narrative. This model emphasizes that culture is a central component of understanding one’s health risks and should be a key element in using narratives for prevention behaviors.

Communication of Health Risk Information

Illness narratives tell the story of one individual’s experience with an illness, thereby having a heuristic sample size “n of one” in narratives (Baesler & Burgoon, 1994). Illness narratives, however, implicitly can communicate an “n of many” (Baesler & Burgoon, 1994) when discussing diagnoses, treatment decisions, and survivorship. For instance, statements about symptoms that led to a diagnosis, or recounting what a doctor said about treatment options and survival, implicitly communicate to audiences some type of epidemiological information. Individuals may interpret this specific information of one person as information pertaining to everyone about the disease. Health and risk communication scholars must be aware of the potential for “epidemiological misstatement.” In particular, “stories that accurately present one person’s experience with cancer may not reflect known base-rate information such as the true population for risk for certain cancers or the probability of survival once diagnosed” (Kreuter et al., 2007, p. 231). Therefore, health and risk communication scholars should realize the implicit health risk communication being told in the narrative, and use narrative evidence with this implication in mind.

Transparency of Persuasion

“Persuasive intent is not always transparent in narratives” (Kreuter, 2007, p. 231). The goal of narratives is often not to persuade individuals towards a behavior change, even though sometimes statements recommending a behavior change such as screening are included (Bilandzic & Busselle, 2013). More often, narratives are used to express one’s personal stories as ways to heal themselves (Sunwolf et al., 2008). Therefore, persuasive tactics may be ignored as individuals engage with telling the story, and others identify with the narrative. Caution, however, is needed in making persuasive intent evident within narratives, as this could influence the level of identification and engagement such that the health and risk message is ignored.

Discussion of the Literature

The purpose of this essay is to provide an understanding about narrative evidence for health and risk communication scholars. It is clear that narratives are complex forms of evidence, with many attributes that need to be addressed when using them in health and risk messages. Selecting a narrative to use as evidence in a health and risk message takes careful thought and consideration. This essay indicates the several attributes of a narrative, and the characteristics of a narrative, that influence its persuasiveness in health and risk communication as part of using narratives as evidence. Taken together, there are several thoughts for health and risk communication scholars. Most importantly, scholars must select and/or develop a narrative that meets the structure criteria of temporality, point of view, coherence, and fidelity. It is these characteristics of structure that are what provide the uniqueness of narrative. The essay highlights how these components are necessary, at the beginning, towards individual’s perceiving a narrative to be realistic, believable, and worthy of consideration.

Yet, health and risk communication research is still divided about what narrative evidence means and how to use it. Narratives in communication and health communication research are commonly operationalized as a story, case history, or personal experience, if at all. Yet, the term “narrative” is used generally in describing differences or effects of narrative evidence. Very rarely do the methods sections identify the narrative characteristics in the evidence, or state why this type of narrative was used over another type of narrative as evidence in the health and risk message. The lack of clearly defining a narrative presents a problem towards asserting the persuasiveness of the evidence for health and risk communication, as it is unknown if all the characteristics and structure of a narrative are incorporated into developing the evidence.

Also, it is critical for scholars to conduct formative research and pre-test health and risk messages with narrative evidence in order to ensure that the constructs of perceived similarity, interest, identification, and engagement exist among readers of the narrative. Without having these characteristics, the persuasiveness of a narrative will be limited. Additionally, scholars must be cognizant of the emotional responses to narratives, and how emotions can be connected to the imagery, vividness, and identification of a narrative. The literature on narratives supports such a connection (Green & Brock, 2002).

Perhaps most salient for health and risk communication scholars, however, is the perspective illness narratives bring to the requirements for a health message using narratives. Illness narratives, as a special type of narrative involving an individual’s personal experience with illness, highlights the need to consider components such as culture, spirituality, and the connection between sources of narratives and audiences. Caution is needed when communicating health risk information and using persuasive tactics. Such insights are important when developing messages and ensuring the appropriate use of health and risk messages.

Altogether, narrative evidence holds promise for health and risk communication for its ability to offer a way for information to be conveyed that individuals may feel engaged and act upon for their lives. Narratives themselves are unique forms of communication with many implicit and explicit components that contribute to their overall perceived effectiveness, in addition to the nuance associated with evidence in persuasion. Therefore, health and risk communications scholars wishing to use narrative evidence in messages should consider these various attributes and concerns when developing health and risk messages.

Further Reading

Bilandzic, H., & Busselle. (2013). Narrative persuasion. In J. P. Dillard & L. Shen (Eds.). The SAGE handbook of persuasion: Developments in theory and practice (pp. 200–219). Los Angeles: SAGE.Find this resource:

Busselle, R., & Bilandzic, H. (2009). Measuring narrative engagement. Media Psychology, 12(4), 321–347.Find this resource:

Campbell, R. G., & Babrow, A. S. (2004). The role of empathy in responses to persuasive risk communication: Overcoming resistance to HIV prevention messages. Health Communication, 16(2), 159–182.Find this resource:

Cohen, J. (2001). Defining identification: A theoretical look at the identification of audiences with media characters. Mass Communication & Society, 4(3), 245–264.Find this resource:

Dillard, A. J., & Main, J. L. (2013). Using a health message with a testimonial to motivate colon cancer screening: Associations with perceived identification and vividness. Health Education Behavior, 40(6), 673–682.Find this resource:

Gray, J. B., & Harrington, N. G. (2011). Narrative and framing: A test of an integrated message strategy in the exercise context. Journal of Health Communication, 16, 264–281.Find this resource:

Green, M. C., & Clark, J. L. (2013). Transportation into narrative worlds: Implications for entertainment media influences on tobacco use. Addiction, 108, 477–484.Find this resource:

Greene, K., & Brinn, L. S. (2003). Messages influencing college women’s tanning bed use: Statistical versus narrative evidence format and self-assessment to increase perceived susceptibility. Journal of Health Communication, 8, 443–461.Find this resource:

Kim, H. S., Bigman C. A., Leader, A. E., Lerman, C., & Cappella, J. (2012). Narrative health communication and behavior change: The influence of exemplars in the news on intention to quit smoking. Journal of Communication, 62, 473–492.Find this resource:

Moyer-Gusé, E. (2008). Toward a theory of entertainment persuasion: Explaining the persuasive effects of entertainment-education messages. Communication Theory, 18(3), 407–425.Find this resource:

Moyer-Gusé, E., Chung, A. H., & Jain, P. (2011). Identification with characters and discussion of taboo topics after exposure to an entertainment narrative about sexual health. Journal of Communication, 61(3), 387–406.Find this resource:

Nan, X., Dahlstrom, M. F., Richards, A., & Rangarajan S. (2015). Influence of evidence type and narrative type on HPV risk perception and intention to obtain the HPV vaccine. Health Communication, 30, 301–308.Find this resource:

Niederdeppe, J., Shapiro, M. A., & Porticella, N. (2011). Attributions of responsibility for obesity: Narrative communication reduces reactive counterarguing among Liberals. Human Communication Research, 37(3), 295–323.Find this resource:

Shen, F., Sheer, V. C., & Li, R. (2015). Impact of narratives on persuasion in health communication: A meta-analysis. Journal of Advertising, 44, 105–113.Find this resource:

Tal-Or, N., & Cohen, L. J. (2010). Understanding audience involvement: Conceptualizing and manipulating identification and transportation. Poetics, 38(4), 402–418.Find this resource:

Volkman, J. E., & Parrott, R. L. (2012). Expressing emotions as evidence in osteoporosis narratives: Effects on message processing and intentions. Human Communication Research, 38, 429–458.Find this resource:

Zebregs, S., van den Putte, B., Neijens, P., & de Graaf A. (2015). The differential impact of statistical and narrative evidence on beliefs, attitude, and intention: A meta-analysis. Health Communication, 30, 282–289.Find this resource:

References

Allen, M., Brunflat, R., Fucilla, R., Kramer, M., McKellips, S., Ryan, D. J., & Speigelhoff, M. (2000). Testing the persuasiveness of evidence: Combining narrative and statistical forms. Communication Research Reports, 17, 331–336.Find this resource:

Allen, M., & Preiss, R. W. (1997). Comparing the persuasiveness of narrative and statistical evidence using meta-analysis. Communication Research Reports, 14, 125–131.Find this resource:

Baesler, E. (1997). Persuasive effects and statistical evidence. Argumentation & Advocacy, 33, 170–177.Find this resource:

Baesler, E. J., & Burgoon, J. K. (1994). The temporal effects of story and statistical evidence on belief change. Communication Research, 21, 582–602.Find this resource:

Bleakley, A. (2005). Stories as data, data as stories: Making sense of narrative inquiry in clinical education. Medical Education, 39, 534–540.Find this resource:

Bylund, C. L. (2005). Mothers’ involvement in decision making during the birthing process: A quantitative analysis of women’s online birth stories. Health Communication, 18, 23–39.Find this resource:

Church, R. T., & Wilbanks, C. (1986). Values and policies in controversy: An introduction to argumentation and debate. Scottsdale, AZ: Gorsuch Scarisbrick.Find this resource:

Cox, D., & Cox, A. D. (2001). Communicating the consequences of early detection: The role of evidence and framing. Journal of Marketing, 65, 91–103.Find this resource:

deWit, J. B. F., Das, E., & Vet, R. (2008). What works best: Objective statistics or a personal testimonial? An assessment of the persuasive effects of different types of message evidence on risk perception. Health Psychology, 27, 110–115.Find this resource:

Dillard, J. P., & Nabi, R. L. (2006). The persuasive influence of emotion in cancer prevention and detection messages. Journal of Communication, 56, S123–S139.Find this resource:

Fisher, W. R. (1985). The narrative paradigm: In the beginning. Journal of Communication, 35(4), 74–89.Find this resource:

Green, M. C. (2006). Narratives and cancer communication. Journal of Communication, 56, S163–S183.Find this resource:

Green, M. C., & Brock, T. C. (2000). The role of transportation theory in the persuasiveness of public narratives. Journal of Personality and Social Psychology, 79, 701–721.Find this resource:

Green, M. C., & Brock, T. C. (2002). In the mind’s eye: Transportation-imagery model of narrative persuasion. In M. C. Green, J. J. Strange, & T. C. Brock (Eds.), Narrative impact: Social and cognitive foundations. (pp. 315–342). Mahwah, NJ: Thousand Oaks.Find this resource:

Hornikx, J., & Hoeken, H. (2007). Cultural differences in the persuasiveness of evidence types and evidence quality. Communication Monographs, 74, 443–463.Find this resource:

Kreuter, M. W., Green, M. C., Cappella, J. N., Slater, M. D., Wise, M. E., Storey, D., . . . Woolley, S. (2007). Narrative communication in cancer prevention and control: A framework to guide research and application. Annals of Behavioral Medicine, 33, 221–235.Find this resource:

Larkey, L. K., & Hecht, M. (2010). A mode of effects of narratives as culture-centric health promotion. Journal of Health Communication, 15, 114–135.Find this resource:

McCroskey, J. C. (1969). A summary of experimental research on the effect of evidence in persuasive communication. Quarterly Journal of Speech, 55, 169–176.Find this resource:

Nisbett, R. E., & Ross, L. (1980). Human inference: Strategies and shortcomings of social judgments. Englewood Cliffs, NJ: Prentice-Hall.Find this resource:

Oatley, K. (2002). Emotions and the story worlds of fiction. In M. C. Green, J. J. Strange, & T. C. Brock (Eds.), Narrative impact: Social and cognitive foundations. (pp. 39–70). Mahwah, NJ: Thousand Oaks.Find this resource:

Ochs, E., & Capps, L. (1996). Narrating the self. Annual Review of Anthropology, 25, 19–43.Find this resource:

Ott Anderson, J., & Geist Martin, P. (2003). Narratives and healing: Exploring one family’s stories of cancer survivorship. Health Communication, 15, 133–143.Find this resource:

Polichak, J. W., & Gerrig, R. J. (2002). Get up and win! Participatory responses to narrative. In M. C. Green, J. J. Strange, & T. C. Brock (Eds.), Narrative impact: Social and cognitive foundations. Mahwah, NJ: Lawrence Erlbaum.Find this resource:

Reinard, J. C. (1988). The empirical study of the persuasive effects of evidence: The status after 50 years of research. Human Communication Research, 15, 3–59.Find this resource:

Reynolds, R. A., & Reynolds, J. L. (2002). Evidence. In J. P. Dillard & M. Pfau (Eds.), The persuasion handbook: Developments in theory and practice. (pp. 427–444). Thousand Oaks, CA: SAGE.Find this resource:

Schank, R. C., & Berman, T. R. (2002). The pervasive role of stories in knowledge and action. In M. C. Green, J. J. Strange, & T. C. Brock (Eds.), Narrative impact: Social and cognitive foundations (pp. 287–313). Mahwah, NJ: Lawrence Earlbaum.Find this resource:

Slater, M. D., & Rouner, D. (2002). Entertainment-education and elaboration likelihood: Understanding the processing of narrative persuasion. Communication Theory, 12, 173–191.Find this resource:

Stephenson, M. T., & Palmgreen, P. (2001). Sensation seeking, perceived message sensation value, personal involvement, and processing of anti-marijuana PSAs. Communication Monographs, 68, 49–71.Find this resource:

Sunwolf, Frey, L., & Lesko, J. (2008). Story as medicine: Empirical research findings on the healing effects of health narratives. In K. B. Wright & S. D. Moore (Eds.), Applied health communication (pp. 35–61). Cresskill, NJ: Hampton Press.Find this resource:

Thomas-MacLean, R. (2004). Understanding breast cancer stories via Frank’s narrative types. Social Science & Medicine, 58, 1647–1657.Find this resource:

Thorne, A., Korobov, N., & Morgan, E. M. (2007). Channeling identity: A study of storytelling in conversations between introverted and extraverted friends. Journal of Research Personality, 41, 1008–1031.Find this resource: