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date: 23 August 2017

Persuasive Health Message Design

Summary and Keywords

The study of persuasive health messages—their design, dissemination, and impact—is ubiquitous in the communication discipline. Words, sounds, and images—alone or in combination—can move people to change their minds and their bodies. Micro-level topics surround questions of message content (argumentation scheme, evidence, qualifying language, and figurative language), structure (message sidedness, standpoint articulation, inoculation, and sequential strategies), and format (channel and audiovisual effects). Macro-level topics in this area include message sensation value, narrative, framing, emotional appeals, and tailoring. Central theoretical frameworks used to guide message design research, include health behavior change theories, information processing theories, and theories/frameworks for message design. In addition, some of the methodoligical issues inherent in message design research are questions of analysis, validity, and measurement. Four streams of past scholarship that inform persuasive health message design research: Greek rhetoric, mass communication research begun during World War II, the development of health communication as a research focus within the communication discipline, and the development of computer and telecommunications technology. Directions and challenges for future research include the need for a clear, coherent, and comprehensive taxonomy to classify message characteristics and attention to several methodological issues.

Keywords: message design, persuasion, attitude change, health, health behavior change, message tailoring

Introduction

The study of persuasive health messages—their design, dissemination, and impact—is exceptionally challenging but also exciting given the complexities inherent in this area of research. Words, sounds, and images—alone or in combination—can move people to change their minds and their bodies. It is a matter of knowing what to say, to whom, where, when, and how—no small order. This article provides a brief review of several approaches to persuasive message design, both at what might be called micro and macro levels. It also addresses some of the central theoretical and methodological issues inherent in this area of research. What this article does not do is consider how audience characteristics influence message reception and persuasion, nor does it consider the broad literature in public health communication campaigns. Although individual differences among audience members do play a central role in informing message design, and although these differences will be broached in the sections on message tailoring and directions and challenges for future research, a comprehensive treatment of the plethora of personality characteristics and psychological states studied over the past several decades in relation to message effects is beyond the scope of this article. The same holds true for communication campaign research.

How best to describe and organize message characteristics is an open question in the communication discipline. From a structural language perspective, one can consider phonological, syntactic, lexical, and textual levels of categorization (Hosman, 2002), emphasizing a micro- to macro-level organization. One also can adopt a more categorical descriptive approach, emphasizing the content, structure, and format or features of messages (Harrington, Helme, & Noar, 2015). Regardless of approach, the goal is to identify what language variations are important (i.e., explain variance in targeted outcome variables) and which aspects of the persuasion process they affect (e.g., attention, affective response, cognitive processing). This section begins with micro-level considerations of message content, structure, and format and then shifts to more macro-level approaches to message design. To be clear, the review below considers only a small sample of the myriad message variations that researchers have investigated, but it attempts to highlight a mix of some of the most prevalent and fundamental questions for persuasive health message designers.

Approaches to Message Design: Micro Level

Content

This section addresses argumentation schemes, evidence, qualifying language, and figurative language.

Argumentation Scheme

In terms of persuasive message content, the types of arguments presented can differ, whether or not they are explicitly presented as such. Types of arguments include argumentation from consequences, from cause to effect, from example, from rules, from authority, from effect to cause, and from analogy (Schellens & de Jong, 2004). O’Keefe (2011a) has observed that in persuasive communication research, the overwhelming majority of messages rely on argumentation from consequences, emphasizing the positive or negative consequences of engaging in or not engaging in a particular behavior.

Evidence

Another content dimension is evidence, data presented in some form in support of a conclusion. A long-standing question in persuasive health message design research is what type of evidence is most persuasive, with great effort focused on exploring narrative versus statistical (e.g., Han & Fink, 2012) or expository/didactic (e.g., Murphy, Frank, Chatterjee, & Baezconde-Garbanati, 2013) information. Thus far, there is no definitive conclusion for the effect of one type of evidence over another (Reynolds & Reynolds, 2002); instead, moderating factors, such as audience or evidence characteristics, appear to play a role. For example, personal relevance enhances message processing (Claypool, Mackie, Garcia-Marques, McIntosh, & Udall, 2004), and new evidence is better than old evidence (Morley, 1987; also see Reinard, 1988, p. 40). In addition, type of evidence may lead to different audience cognitive and affective reactions (Kopfman, Smith, Ah Yun, & Hodges, 1998). Regardless of the type of evidence used, audiences must be aware that the message contains evidence, they must cognitively process the evidence, and they must consider the evidence as legitimate for it to have intended effects (Reynolds & Reynolds, 2002).

Qualifying Language

Qualifying language is that which modifies the claim of a message, indicating that there are exceptions to or uncertainty about the claim. In effect, qualifying language limits a claim’s generalizability and is supposed to reduce the likelihood of a message receiver’s being misled. Instantiations of qualifying language vary, but two particular examples warrant consideration in the context of persuasive health message design.

The first is qualifying language used in direct-to-consumer (DTC) advertisements for pharmaceuticals. At present, the United States and New Zealand are the only countries that allow DTC pharmaceutical advertisements. Although the U.S. Food and Drug Administration presents guidelines for using qualifying language in health claims made about certain foods, it does not do so for claims about pharmaceutical drugs (Davis, 2007); instead, it defines three types of DTC ads (product claim, reminder, and help-seeking) and states that in product claim ads, advertisers must present drug risks and benefits in a “balanced fashion.” Evidence suggests, however, that advertisers use qualifying language strategically to increase product appeal (Davis, 2007). In particular, DTC ads have been found to include statements that qualify the severity and duration of side effects, conditional language that precedes the mention of side effects, and statements that indicate side effects were not severe enough to warrant medication discontinuation in many or most patients.

The second example of qualifying language is a particular form of what has been called powerless language, the hedge. Hedges include words such as “may,” “probably,” “in general,” and “sort of.” Research suggests that use of hedges negatively affects message persuasiveness, in particular reducing the impact of strong arguments (Blankenship & Holtgraves, 2005). Research also has revealed subtleties in the effect of hedge use, though, suggesting that hedge placement (data statements versus interpretation statements) and type of hedge (colloquial versus professional/academic) can have differential effects on persuasive outcomes (Durik, Britt, Reynolds, & Storey, 2008).

Figurative Language

Figurative language is yet another variation on message content (McGuire, 2000). Messages may be laced with alliteration, rhyme, hyperbole, or metaphor, to name but a few of the many rhetorical figures available. In the persuasive message design literature, metaphor is by far the most studied type of figurative language. Results of a meta-analysis (Sopory & Dillard, 2002) found that metaphors do, indeed, enhance persuasion. Greatest persuasive effects were found when using only one metaphor per message, using extended metaphors, placing metaphors at the beginning of a message, and using novel metaphors. In the health context, interest in metaphor appears to be increasing, with researchers considering the influence of metaphor in the context of cancer clinical trials (Krieger, 2014), genetic determinism (Parrott & Smith, 2014), HIV/AIDS (Jensen & King, 2013), emergency department admissions handoffs (Hilligoss, 2014), and infertility (Palmer-Wackerly & Krieger, 2015).

Structure

This section addresses message-sidedness, standpoint articulation, inoculation, and sequential strategies.

Message-Sidedness

Message-sidedness refers to how many sides of an argument a message presents. Although there may be several sides to a particular argument, research typically has considered only one- and two-sided messages. For example, a one-sided message promoting mammography may present statistics that breast cancer is more likely to be cured if detected early; a two-sided message might add that the chance of finding cancer during any given screening is quite small, so why bother with screening. A variation on two-sided messages involves whether or not the opposing argument is refuted. A two-sided refutational message promoting mammography may point out that although the chance of revealing cancer during a particular screening may be small, the chances increase over several years, so annual mammograms are important in the long term.

A meta-analysis by O’Keefe (1999) explored the effects of one-sided and two-sided arguments on persuasive outcomes and impressions of source credibility. Results for persuasion were relatively limited. Overall, there was no difference between one- and two-sided messages. However, one-sided messages were found to be more persuasive than two-sided non-refutational messages, and two-sided refutational messages were found to be more persuasive than one-sided messages. These effects only held for non-advertising contexts, however. In addition, two-sided refutational messages were more effective than one-sided messages when the order of supporting and opposing claims was interwoven. In terms of credibility, two-sided messages were more likely to result in higher ratings of credibility than one-sided messages; this effect held for both refutational and non-refutational two-sided messages. When message topic was considered as a moderating factor, the results were more complex. Two-sided non-refutational messages led to higher credibility ratings than one-sided messages in advertising contexts, with no differences between two-sided refutational and one-sided advertisements; two-sided refutational messages led to higher credibility ratings than one-sided messages in non-advertising contexts, with no differences between two-sided non-refutational and one-sided messages.

Standpoint Articulation

Standpoint articulation is defined as the extent to which the conclusion of an argument is made explicit. O’Keefe (2002b) considers the reasons that sources may not want to make their conclusions explicit, such as limiting the potential “disagreement space,” reducing the chance for reactance, and increasing audience involvement by requiring them to draw their own conclusions. Strategies for not making a conclusion explicit are to omit the conclusion entirely (conclusion omission) or to state the conclusion in more general than specific terms (conclusion specificity). For example, a message may simply present several reasons in support of getting mammograms, omitting the recommendation to get one, or it may present reasons and then recommend mammography in general instead of recommending annual mammograms beginning at age 40 or, with a family history of breast cancer, at an earlier age. A strategy for reducing reactance when a message does offer an explicit conclusion is to include postscripts that offer restoration of freedom (Miller, Lane, Deatrick, Young, & Potts, 2007).

A meta-analysis by O’Keefe (2002b) explored these variations in standpoint explicitness on message persuasiveness. Overall, messages with clearly articulated conclusions were more persuasive than messages with omitted conclusions, and messages with specific conclusions were more persuasive than messages with general conclusions.

Inoculation

Inoculation theory stems from work by McGuire (1964), who developed an analogy between resisting viral infection and resisting persuasion. When humans are vaccinated against viruses, they receive a minute dose of the weakened (sterilized) or dead virus to stimulate their immune system against future attack. In persuasion, humans can be “vaccinated” against future persuasive messages attacking their held attitudes by presenting them with weakened versions of those attack messages. Two components are required for effective inoculation treatments: threat, which puts the audience on notice that their current attitudes may face future attack, and refutational preemption, which provides counterarguments for audiences to use in defense of an attack. In the health context, this strategy is particularly applicable to adolescents who face risky health behavior situations. For example, on the whole, younger adolescents have attitudes in line with healthy behavior, such as negative attitudes toward cigarette smoking. As they age and become more exposed to countervailing opinions from peers and the media, those attitudes begin to erode. If they can learn at a young age, though, that tobacco companies will try to persuade them that smoking cigarettes will make them mature and popular, adolescents should be better prepared to refute those specious claims.

A meta-analysis by Banas and Rains (2010) explored variations in inoculation messages. The authors were interested in comparing inoculation messages to supportive messages (i.e., messages that supported participants’ initially held attitudes but did not provide any form of inoculation against future attack) and no-message controls. They also investigated levels of perceived threat, the effect of the refutational preemption’s including the same attack arguments (refutational same) or novel arguments (refutational different), the time interval between attack and resistance, and the level of issue involvement. Results showed that inoculation messages were more effective than supportive and no-message control conditions. Refutational same and refutational different messages were equally effective. Higher levels of perceived threat did not result in greater resistance, however. Furthermore, resistance did not vary as a function of the amount of time between inoculation and attack. Finally, resistance did not vary as a function of the amount of issue involvement.

Sequential Strategies

Foot-in-the-door (FITD) and door-in-the-face (DITF) persuasive techniques are called sequential strategies because they involve a two-step request. FITD begins with a small persuasive request (which is expected to be complied with) followed by a larger one, whereas DITF begins with a large persuasive request (which is expected to be rejected) followed by a smaller one. Although there may be different theoretical mechanisms underlying FITD and DITF effects (Dillard & Hale, 1992), these strategies can be seen as two sides of the same coin, especially considering that the target behavior could be the same for each strategy. For example, with FITD, a small request to sign a petition supporting blood drives may be followed with the request to donate a pint of blood; with DITF, a large request to become a regular blood donor, giving one pint every eight weeks, may be followed with the request to donate just one pint of blood. Researchers have been investigating these strategies for decades, and although the focus is rarely on health behavior change, FITD and DITF strategies certainly can be applied to that context.

In the most recent meta-analysis of FITD research to date, Burger (1999) found qualified support for the technique in general. However, he identified several inconsistencies in the way the technique was operationalized across studies, which may be responsible for limited effect sizes. Burger concluded that to be most effective, FITD requests need to (a) allow individuals to perform the initial request, (b) overtly label the person as helpful or as a supporter of these kinds of causes, (c) require more than a minimal amount of effort to perform the initial request, and (d) make the target request essentially a continuation of the initial request (p. 323).

A meta-analysis by Feeley, Anker, and Aloe (2012) of DITF research differentiated between verbal and behavioral compliance and considered the effects of several moderators on compliance. Results showed an overall effect for verbal compliance; this effect was moderated by requester variation (greater effects when the same person made the initial and subsequent request), study sample (greater effects with student samples and mixed sampled), and control group compliance (greater effects when the control group was less compliant). Results found no overall statistically significant effect for behavioral compliance; however, effects were greater when the beneficiary of the request remained static and when the control group was less compliant.

Examples of FITD and DITF research in a health communication context are rare, mostly dated, and almost exclusively focused on blood or organ donation. However, FITD and DITF effects have been found to obtain (Carducci & Deuser, 1984; Cialdini & Ascani, 1976; Foss & Dempsey, 1979). These strategies also have been found useful in recruiting participants into health-related research studies (e.g., Bloom, McBride, Pollak, Schwartz-Bloom, & Lipkus, 2006).

Format

This section addresses message channels and audiovisual factors, with a focus on mediated messages.

Channel

Multiple channels are available to persuasive health message designers for testing and disseminating messages, including interpersonal, print, mass media, and computer-mediated or Internet-based channels. The potential complexity introduced by variations within and across all of these channels is an important message design consideration. Some variables may be more easily manipulated via certain channels than others, especially comparing mediated to interpersonal channels (although humans can be trained to deliver messages in specific ways; see, e.g., Heritage, Robinson, Elliott, Beckett, & Wilkes, 2007), but those channels may introduce additional variations not encountered otherwise. For example, a behavioral demonstration may be easier to convey in video than in print, but using actors to demonstrate the behavior invites the possibility of poor acting, which may harm the persuasive impact of the message; computer-based animation may circumvent poor acting but may introduce technological challenges that could impact a message’s ability to reach lower socioeconomic status audiences.

Channel selection can also impose limitations on messages. A clear example is with text messaging. Texts are limited to 160 characters, which requires that messages be relatively terse, so message designers must be exquisitely mindful of language choices (Sutton, League, Sellnow, & Sellnow, 2015). Given programming algorithms, texts can be sent with varying frequency and timing, such as three times a day over two weeks or two times a day over three weeks, in fixed or random intervals, or associated with a particular time of day (e.g., breakfast). Because message frequency can impact persuasive outcome (Head, Noar, Iannarino, & Harrington, 2013), researchers need to account for this variable. In addition, the potential for interactivity with text messaging or computer-based interventions provides unprecedented opportunity for a more involved audience (Miller et al., 2001), which can enhance persuasive outcomes, but too much interactivity might overwhelm audiences and lead to negative persuasive impact (Chung, 2012).

Audiovisual Factors

Most prevalent in mass media and computer-mediated message design, audiovisual factors include the use of music, images or video, color, and various sound and visual effects, all with the goal of increasing attention to or influencing cognitive processing of the message. Although these elements have a rich history of study in related disciplines and are implicated, albeit rather holistically, in the construct of message sensation value (described below), they arguably are understudied in persuasive health message design. Extant research, however, reveals the potential impact of these variables on persuasive outcomes of interest. For example, the presence of music in a short film, particularly music that is congruent with the affective tone of the film, can increase transportation into the story, which mediates effects on film-relevant beliefs (Costabile & Terman, 2013). Incorporating threatening visual images into online newsmagazine articles can increase article selection and reading time (Knobloch, Hastall, Zillmann, & Callison, 2003). Furthermore, strategic use of color, specifically the color red, can increase the impact of loss-framed messages on willingness to be vaccinated (Chien, 2011; Gerend & Sias, 2009).

Approaches to Message Design: Macro Level

Message Sensation Value

The concept of message sensation value (MSV) stems from the activation model of information exposure (AMIE; Donohew, Palmgreen, & Duncan, 1980), which posits that people will be more likely to attend to stimuli that help them reach their optimal level of arousal. MSV is defined as a message’s ability to elicit sensory, affective, and arousal responses in audience members (Palmgreen, Stephenson, Everett, Baseheart, & Francies, 2002). Persuasive messages that meet the arousal needs of target audience members are more likely to result in greater attention (Donohew, Palmgreen, & Lorch, 1994). High sensation value messages, designed to appeal to high sensation seekers, are novel, creative, unusual, intense, arousing, and ambiguous; low sensation value (LSV) messages, designed for low sensation seekers, are more familiar, predictable, calm, and clear. Morgan and colleagues’ (2003) MSV coding system considers visual (e.g., number of cuts), audio (e.g., sound saturation), and content features (e.g., surprise ending) of messages. Decades of laboratory and field research have demonstrated the efficacy of using message sensation value targeting to reach audiences most likely to engage in risky health behaviors (e.g., substance use; Harrington, Palmgreen, & Donohew, 2014).

Narrative Messages

A narrative is “a cohesive and coherent story with an identifiable beginning, middle, and end that provides information about scene, characters, and conflict; raises unanswered questions or unresolved conflict; and provides resolution” (Hinyard & Kreuter, 2007, p. 777). Telling stories is a fundamental means of sharing information (Fisher, 1984), and narratives convey information through characters, conflict, and plot. Narratives can be brief or extended, based in fact or in fiction, and delivered through print, audio, video, or computer-mediated channels; regardless of other characteristics, perceived realism is important for narrative impact (Cho, Shen, & Wilson, 2014). Studies of narrative persuasion typically adopt one of two approaches: comparing brief narrative messages to some other kind of message, such as statistical or didactic (e.g., Kreuter et al., 2010), and using the entertainment–education approach, which involves integrating health messages into extended storylines (Singhal & Rogers, 1999). The persuasive impact of narrative is related to multiple theoretical mechanisms: transportation into the story and identification with characters (Green, 2006), normative perceptions (Noar & Zimmerman, 2005), emotional responses (Oatley, 2002), and reduced counterarguing (Dal Cin, Zanna, & Fong, 2004).

Message Framing

Message framing research adopts the “argument from consequences” scheme for persuasive message design. Gain-framed messages emphasize the positive consequences of adopting a healthy behavior or avoiding a risky behavior; loss-framed messages emphasize the negative consequences of not adopting a healthy behavior or engaging in a risky behavior. Message framing has stimulated more research than any other message characteristic, with more than 200 studies focused on framing (O’Keefe, 2011b). Prospect theory (Kahneman & Tversky, 1979), which explains decisions made under conditions of uncertainty, provides the theoretical foundation for message framing research. Specifically, people are more likely to make risk-averse decisions when outcomes are presented in terms of gains but become risk-seeking when outcomes are presented in terms of losses (Tversky & Kahneman, 1981). Although prospect theory emphasizes outcome (un)certainty, persuasive health messages usually emphasize outcome (un)pleasantness. A consensus appearing in the literature is that gain-framed messages are more effective in promoting disease prevention (risk averse) behaviors and loss-framed messages are more effective in promoting disease detection (risk seeking) behaviors (Rothman & Salovey, 1997). Recent meta-analyses, however, call this consensus into question (Gallagher & Updegraff, 2012; O’Keefe, 2015). Individual differences may be important in understanding message framing effects (Covey, 2014).

Emotional Appeals

Including emotional appeals is one strategy for enhancing persuasive effects of messages. By far, the majority of research in emotion and persuasion has focused on fear appeals; this literature has a history dating back more than 50 years. There are, however, other emotions that may be targeted for persuasive effect, including guilt, disgust, and humor. Two important observations about the nature of emotions in messages deserve mention. First, although a message may be designed to elicit a particular emotion, it may not be successful or it may elicit more than the targeted emotion. For example, Dillard, Plotnick, Godbold, Freimuth, and Edgar (1996) evaluated the impact of 31 fear appeals on six different emotions. They found that only 19 of the 31 messages actually resulted in increased fear. In addition, they found that all but one of the messages resulted in increases or decreases in two or more emotions, including surprise, puzzlement, happiness, guilt, and anger. Second, although research designs typically assess emotional impact after messages are viewed, audiences can experience emotion throughout the course of a message. This concept of emotional flow (Nabi, 2015) has implications for designing messages to evoke different patterns of emotion, which may result in greater persuasive effects.

Fear Appeals

The lion’s share of research in emotion and persuasive health behavior change belongs to fear appeals. This area of research has a rich theoretical foundation, with conceptualizations evolving from a drive model of affect suggesting that people will be motivated to reduce fear, to a parallel processing model distinguishing cognition from affect, to a protection-motivation theory focusing on multiple responses to fear messages, and culminating in the extended parallel process model (EPPM; Witte, 1992). The EPPM identifies the conditions under which fear appeals will be most effective and lead people to engage in danger control responses, including engaging in the recommended health behavior change. To be effective, a fear appeal must include content to persuade people that they are susceptible to a health problem (perceived susceptibility), that the problem would be severe (perceived severity), that there is an effective way to prevent the problem (response efficacy), and that they are capable of engaging in the recommended behavior (self-efficacy). The EPPM has generated a considerable amount of research over the past few decades (a Google Scholar search revealed 1,375 citations of the original 1992 article), with scholars investigating a wide variety of health-related behaviors, including HIV/AIDS prevention (Bastien, 2011), substance abuse prevention (Choi, Krieger, & Hecht, 2013), and hearing protection (Smith et al., 2008).

Guilt

Guilt appeal messages involve two components, one to elicit feelings of guilt and one to provide recommended actions to assuage the guilt (O’Keefe, 2002a). In persuasive health message design, guilt has been studied in several contexts, including smoking cessation (Agrawal & Duhachek, 2010) and STI testing (Boudewyns, Turner, & Paquin, 2013). On the whole, this research finds a positive impact of guilt on persuasive outcomes, with some caveats. In particular, message designers must be careful not to induce too much guilt, because that can elicit feelings of anger, ultimately compromising persuasive effects (Nabi, 2002).

Disgust

Disgust is a negative emotion caused by exposure to something perceived as revolting; it results in an experience of nausea and a desire to turn away from the source of disgust (Rozin, Haidt, & McCauley, 2008). Although disgust can be elicited through written descriptions, visual imagery is especially useful for arousing this emotion. Disgust appeals may be particularly effective for substance abuse prevention messages because the emotion is strongly related to ingesting something (Rozin & Fallon, 1987) and many of the synonyms for the term “disgusting” (e.g., nauseating, sickening, gross) can describe certain alcohol, tobacco, and other drug-related behaviors. The limited research that has explored the impact of disgust in substance abuse prevention messaging, however, has revealed mixed results. Whereas Morales, Wu, and Fitzsimons (2012) found that disgust enhanced the effects of fear appeals in anti-methamphetamine ads (as well as ads about sun protection and avoiding the chemical BPA), Leshner, Bolls, and Thomas (2009) found that combining disgust and fear content in anti-tobacco ads led to worse message processing and recognition than using disgust or fear content alone.

Humor

Humor appeals have not been extensively studied in persuasive health message design; however, extant research suggests the potential for impact using this strategy. Although humor is not an emotion, per se, it can affect the cluster of positive emotions, such as happiness, joy, surprise, and hope (Turner, 2012). Studies have found that humor appeals can act as a heuristic cue, which is particularly effective for audiences with low motivation to process a persuasive message (Conway & Dubé, 2002). Effects can be complicated, however, depending on whether or not the humor is directly related to the targeted health behavior, differentially influencing counterarguing, perceived severity, and behavioral intentions (Moyer-Gusé, Mahood, & Brookes, 2011).

Message Tailoring

Tailored communication is defined as “any combination of strategies and information intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and derived from an individual assessment” (Kreuter, Strecher, & Glassman, 1999, p. 277). Tailored message are designed for unique individuals on the basis of select demographic (e.g., age), psychosocial (e.g., self-efficacy), or behavioral characteristics (e.g., tobacco use). Messages are generated by a tailoring algorithm, which uses responses from participant assessment surveys to draw from a library housing messages specific to particular characteristics. Message tailoring is distinct from message targeting, which designs messages for particular groups of people (e.g., adult women), and generic messaging, which designs messages to fit everyone. Studies generally show that tailored messages are more effective than targeted and generic messages in promoting attitude, behavioral intention, and health behavior change (Noar, Harrington, & Aldrich, 2009). The elaboration likelihood model (Petty & Cacioppo, 1986) provides a theoretical explanation for message tailoring effects. Tailored messages are often viewed as highly relevant by target audiences, and thus they are much more likely to be centrally processed and to have impact on attitude, behavioral intention, and behavior change (Kreuter & Wray, 2003).

Theoretical Considerations in Message Design

In persuasive health message design research, there are important distinctions to be made between theories or frameworks of message design, information processing, and health behavior change (Cappella, 2006).

Health Behavior Change Theories

Health behavior change theories inform the target of change for the persuasive message, such as attitudes, normative beliefs, self-efficacy, barriers to behaviors, benefits of behaviors, and so on. Examples include the integrative model of behavior prediction (Fishbein et al., 2002), the health belief model (Janz & Becker, 1984), and the transtheoretical model (Prochaska & DiClemente, 1983). Important outcome variables are attitudes toward the health behavior, behavioral intentions, and the health behavior itself.

Information Processing Theories

Information processing theories focus on the cognitive and affective responses to messages and highlight how responses such as attention to a message, central and peripheral processing, and reactance can influence message effects. Examples include the activation model of information exposure (Donohew, Lorch, & Palmgreen, 1998), the elaboration likelihood model (Petty & Cacioppo, 1986), the unimodel (Kruglanski & Thompson, 1999), and the extended parallel process model (Witte, 1992). In addition to attitude change, important outcome variables include attention to the message and free and cued recall of message content.

Message Design Theories

Message design theories or frameworks should guide the construction of persuasive health messages, including content, structure, and format decisions. Examples include emotional appeals (Nabi, 2015), message framing (Rothman & Salovey, 1997), and narrative transportation (Hinyard & Kreuter, 2007). In addition to attitude change, important outcome variables include perceived argument strength and perceived message effectiveness.

Methodological Issues in Message Design

Analytic Issues

In terms of analytic issues, one question is to what kind of message (if any) an experimental message should be compared (O’Keefe, 2016). For example, a narrative message could be compared to an expository message, a statistical message, or no message; likewise, variations within narrative messages could be compared. The decision of comparison or control group has implications for the kinds of conclusions to be drawn about message effects.

Another analytic issue is the number of message variations to include in an experiment. Often, researchers use only one instantiation of a message, which limits the ability to draw generalizable conclusions (O’Keefe, 2015). That is, with only one message per condition, results could be specific to the particular message involved instead of reflective of the construct the message was designed to embody. A related issue is that researchers usually rely on fixed effects instead of random effects analyses in studies of persuasive health messages; this applies to analyses of original data sets and meta-analyses. A fixed factor is a variable that presents specific and limited contrasts, such as different developmental stages (e.g., adolescent, adult); a random factor is a variable that represents some larger, possibly undefined group of potential contrasts (e.g., individual human subjects). A fixed-effects approach arguably ignores the conceptual nature of what a message is. That is, although particular types of messages could be considered as specific and limited contrasts (e.g., high sensation value versus low sensation value), such contrasts more likely reflect but a small sample of potential message distinctions. A random-effects approach to analyses acknowledges this and allows generalizations to be made beyond the specific messages used in a given study (Jackson & Brashers, 1994).

Validity Issues

Issues of internal, external, and ecological validity apply to social science research broadly, of course, and studies of persuasive health messages are no different. The tight control of a laboratory setting increases internal validity but calls into question external and ecological validity when research designs virtually guarantee attention to the message. Creative solutions, such as establishing naturalistic laboratory settings (e.g., Lorch et al., 1994) or embedding test messages within other stimulus materials (e.g., McQuarrie & Mick, 2003) can somewhat allay these concerns. Outside of the laboratory, online survey tools such as Qualtrics and Survey Monkey greatly facilitate data collection. With participants engaged in the study in unknown settings with the potential for numerous, unknown distractions, however, the internal validity of such experiments can be called into question.

Measurement Issues

Two measures consistently used in message design research are perceived argument strength and perceived message effectiveness. On the whole, the literature has been peppered with multiple, study-specific variations of these measures, which makes building a cumulative body of knowledge extremely difficult. Recently, communication researchers have been striving to sort out the measurement issues, working either to develop a standard measure that can be used across contexts (perceived argument strength; Zhao, Strasser, Cappella, Lerman, & Fishbein, 2011) or to highlight the conceptual ambiguities surrounding the construct and offer guidance for future scale construction (perceived message effectiveness; Yzer, LoRusso, & Nagler, 2015).

Historiography

This section presents a brief review of the main threads of scholarship that inform persuasive health message design research, and it offers directions and identifies challenges for future research.

Threads of Scholarship

Rhetoric

Arguably, the concept of message design can be traced back to Greek scholars, in particular Aristotle in the 4th century BC and one of his classic works, the Rhetoric. The Rhetoric consists of 60 chapters organized into three books that offer practical guidelines for discovering “all the available means of persuasion” (Cooper, 1932, p. xxxvii). Roberts (1928) describes the first book of the Rhetoric as being focused on the speaker and concerned with logical and political matters, the second book as being focused on the audience and concerned with ethical and psychological matters, and the third book as being focused on the message and concerned with literary and stylistic matters. Important message design considerations are found across all three books, however, including logos, pathos, and ethos; example, maxim, enthymeme, syllogism, and topoi; definition and use of emotion in persuasion; audience analysis; and appropriate use of language ranging from metaphor and simile to word choice and diction. Although rhetoric may be considered more of an art or a craft than a science, it laid the foundation for future work on persuasion as a social science (McGuire, 2000).

Persuasion Studies

Contemporary social science persuasion research originates from the work of Carl Hovland and his colleagues at Yale University around the time of World War II. The Research Branch of the Information and Education Division of the U.S. War Department had interest in what led to effective instruction and persuasion, as well as what influenced morale in the army. Hovland was hired as its Chief Psychologist and began a long series of experimental studies into the effectiveness of army training films. From that groundwork developed the post-war Yale Program in Communication Attitude and Change (Schramm, 1997). Lines of inquiry included the following: message sidedness, message directness, conclusion specificity, fear appeals, source credibility, and characteristics of the audience that might moderate message effects (e.g., intelligence, initial attitudes). Major publications stemming from this work include Experiments on Mass Communication: Studies in Social Psychology in World War II (Vol. III; Hovland, Lumsdaine, & Sheffield, 1949) and Communication and Persuasion: Psychological Studies of Opinion Change (Hovland, Janis, & Kelley, 1953). This research emphasized the importance of systematic experimental research to reveal message effects on attitude change.

Health Communication

The communication discipline’s concern with matters of health can be traced back to the 1970s, when health communication was established as a distinct subdiscipline in communication. A small group of scholars had been convening at International Communication Association (ICA) conventions since 1972, calling themselves the “Therapeutic Communication” interest group. At the 1975 ICA convention, these scholars changed their group’s name to “Health Communication” to reflect a broader scope of interest in health. Over the next 10 years, interest in health communication grew, and 1985 saw the establishment of the “Commission on Health Communication” in the Speech Communication Association (now the National Communication Association); that commission reached division status a few years later. At present, there are at least five scholarly journals focused on publishing health communication scholarship: Health Communication, Journal of Health Communication, Journal of Communication in Healthcare, Communication & Medicine, and Journal of Health and Mass Communication; many other journals with broader scopes, such as Health Psychology, also publish health communication research.

Computer and Telecommunications Technology

The advent of computer and telecommunications technology, particularly the Internet, social media, and cell or smart phones, has paved the way for extraordinary innovation in message design research. Such technology facilitates the development and dissemination of persuasive health messages, both in terms of tailoring messages to appeal to individuals’ demographic, psychographic, and behavior characteristics and reaching them through a variety of channels, including emails, text messages, computer-based interventions, and video games. Technology-based messaging offers numerous benefits over conventional channels such as print and mass media, including interactivity, multimedia capacity, and tailoring, all of which can increase message persuasiveness (Noar & Harrington, 2012).

Directions and Challenges for Future Research

There are numerous directions for future research that takes seriously and problematizes the design of persuasive health messages. This section addresses conceptual and methodological opportunities or challenges.

Conceptualization

First, the field would benefit from a clear, coherent, and comprehensive taxonomy to classify message characteristics. This article has referred to content, format, and structural dimensions, but that is a convenient rubric, not a theoretical one. Other authors use somewhat different dimensions (e.g., content, structure, and style; Shen & Bigsby, 2013) or have different opinions of which elements fall under each dimension (e.g., O’Keefe (2016) classifies message sidedness as a content dimension whereas this article considers it under structure).

Development of such a taxonomy would help persuasive message design researchers grapple with yet another challenge: managing the myriad of message elements. The number of elements that factor into message design is substantial, and it simply is not feasible to consider all of them (Cappella, 2006). However, all messages do embody these elements, either as variables (more or less of something, such as message sensation value) or as attributes (presence or absence of something, such as visual images). Slater, Peter, and Valkenburg (2015) have recently identified this challenge as one of message variability versus message heterogeneity. Message elements that researchers conceptually and operationally define and then either manipulate or measure in their studies are message variables; all other variation in the messages is heterogeneity. Having a comprehensive taxonomy would serve to sharpen the focus on message variability, helping researchers to not only identify elements of interest but also realize which elements are being neglected. Researchers could then direct their attention to developing more and better message design theories to investigate elements that matter and to explain how they influence outcome variables of interest, from increasing knowledge to effecting behavior change.

Although this article has not directly addressed audience characteristics that can be used to inform message design, such characteristics are of tremendous interest to persuasive health message design researchers. A plethora of such variables have been studied, including sensation seeking, need for cognition, regulatory focus, self-efficacy, issue involvement, prior knowledge, monitoring style, vested interest, and so on. Such individual difference variables can guide message content, structure, or format decisions, but to date, there is no comprehensive rubric to suggest when and how these variables should come into play. To be sure, specific models and theories provide such guidance (e.g., AMIE with sensation seeking and message sensation value), but the field would benefit from something both systematic and overarching.

Methodology

The field faces several methodological challenges. One arises from the rapid development of telecommunications technology and social media. Text messaging, for example, is a promising strategy for reaching people with health promotion messages (Head et al., 2013), and Twitter offers an effective means of reaching millions of people with disaster warning messages (Sutton et al., 2015). However, these channels present certain message constraints (e.g., length and font limitations) and sometimes introduce sources of message variability (e.g., smartphone versus limited function mobile phone) that may imperil message effects.

A second challenge is related to how researchers should design and conduct their studies and analyze their data to produce evidence that will contribute to “dependable generalizations” for the persuasive health message design literature. O’Keefe (2015) argues for five propositions to guide message design researchers: (1) vary message features in randomized trials using multiple-message designs (i.e., more than one message per condition), (2) describe results in terms of effect sizes and confidence intervals, not statistical significance, (3) use random effects, not fixed effects, when conducting analyses and meta-analyses, (4) treat attitude, behavioral intention, and behavior measures as equivalent when assessing the relativeness persuasiveness of messages (see O’Keefe, 2013), and (5) do not rely exclusively on published, English-language studies for meta-analyses.

A third challenge is to more systematically address questions of audiovisual effects in persuasive message design. The majority of published message design studies either do not include or do not manipulate the audio or visual elements, yet clearly these elements may have an effect, either on their own or interacting with another variable. To be sure, the importance of audiovisual effects has been acknowledged, especially in message sensation value research in which these elements are manipulated to obtain high or low sensation value levels (Donohew et al., 1998). Even within message sensation value research, though, there is a lack of theoretical grounding to guide the types of sounds and images that should be included and, in a systematic sense, how they should be manipulated. Persuasive health message design researchers have great opportunity to investigate the impact of audiovisual effects and perhaps would do well to turn to the advertising literature as a starting point (e.g., Messaris, 1997).

Primary Sources

There is no definitive “persuasive health message design” book. There are, however, several works that address major aspects of message design. This section presents a brief annotated bibliography of primary sources organized categorically into books and special issues of journals, followed by journal articles and book chapters.

Books and Special Issues of Journals

Cho, H. (Ed.) (2012). Health communication message design: Theory and practice. Los Angeles, CA: SAGE

. This edited volume is organized into two sections: theory-based message design and audience-centered message design. The theory section covers challenges inherent in using psychological theories to inform message design; using the integrated model of behavioral prediction and the extended parallel process model to guide message design; and using emotional appeals, inoculation, and narrative in persuasive health messaging. The audience factors covered are culture, identity, religiosity/spirituality, health literacy, fatalism, stages of change, and sensation seeking.

Harrington, N. G. (Ed.) (2015). Message design in health communication research [Special issue]. Health Communication, 30(2), 103–207

. This special issue offers 10 original articles addressing a wide range of message design concerns. Topics include specifying evidentiary requirements for message design effects, emotional flow in messages, conceptual ambiguities in perceived message effectiveness, terse messaging via Twitter in crisis situations, communication nonaccommodation in family conversations about end-of-life, narrative health messaging, a social cognitive theory-based approach to message design, temporal framing and consideration of future consequences, and designing messages for dissemination.

Maibach, E., & Parrott, R. L. (Eds.) (1995). Designing health messages: Approaches from communication theory and public health practice. Thousand Oaks, CA: SAGE

. This edited book is organized into three sections: theory-driven approaches to health message design, audience-centered strategies for health message design, and considerations for combining theory and practice. The theory section addresses issues related to message content and linguistics, decision-making, social cognition, fear appeals, positive affect, behavioral inoculation, audience development, and a persuasive health message framework. The audience section addresses using formative, process, impact, and outcome evaluation research; audience segmentation strategies and methods; the gatekeeping process; and using marketing databases in campaign design.

Noar, S. M., & Harrington, N. G. (Eds.) (2012). eHealth applications: Promising strategies for behavior change. New York: Routledge

. This edited book addresses message design in the context of electronic technology-based interventions. It is organized into three sections: historical and conceptual foundations, eHealth applications, and practice implications and future directions. The chapters on eHealth applications address Internet-based and virtual interactive interventions, avatars and digital game use for health behavior change, and computer-tailored, mobile phone-based, text messaging, and interactive voice response technology for health interventions.

Roberto, A. J. (Ed.) (2013). The extended parallel process model: Two decades later [Special issue]. Health Communication, 28(1), 1–99

. This special issue offers nine original articles that consider how the EPPM has been used and has evolved in the 20 years since its development. Articles address theoretical issues inherent in the EPPM, including threat and efficacy perceptions and ratios, and various applications of the model in health communication contexts, including workplace safety and adolescent substance abuse prevention.

Journal Articles and Book Chapters

Hosman, L. A. (2002). Language and persuasion. In J. P. Dillard & M. Pfau (Eds.), The persuasion handbook: Developments in theory and practice (pp. 371–390). Thousand Oaks, CA: SAGE

. This chapter reviews literature on language variations and language use in persuasion. Language variations comprise phonological, syntactical, and lexical levels of language; language use involves pragmatics, power of speech, and standard versus nonstandard language.

O’Keefe, D. J. (2003). Message properties, mediating states, and manipulation checks: Claims, evidence, and data analysis in experimental persuasive message effects research. Communication Theory, 13(3), 251–274

. This article presents two major claims. First, to advance understanding of message effects, research must focus on the intrinsic features of messages, not their psychological effects. Second, a focus on intrinsic message features renders manipulation checks as such unnecessary; however, such data can be used to explore psychological states that may mediate message effects.

O’Keefe, D. J. (2013). The relative persuasiveness of different message types does not vary as a function of the persuasive outcome assessed: Evidence from 29 meta-analyses of 2,062 effect sizes for 13 message variations. Communication Yearbook, 37, 221–249

. This article investigates whether or not there are differences in persuasive message effect sizes for attitudes, behavioral intentions, and behaviors. A meta-analytic reanalysis of 29 meta-analyses that investigated 13 message variations revealed no systematic significant differences in effect sizes across dependent variables; that is, the relative effectiveness of a message variable (e.g., gain/loss framing, fear appeal strength, conclusion explicitness) does not vary across attitude, behavioral intention, and behavior.

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. This chapter reviews the literature on the nature of evidence and the effects of its use, including increasing persuasiveness and enhancing credibility. It presents three conditions for using evidence effectively: Audiences must be aware that evidence has been presented, they must cognitively process the evidence, and they must perceive the evidence to be legitimate. The chapter concludes with extensive recommendations for future research on evidence.

Further Reading

Cappella, J. N. (2006). Integrating message effects and behavior change theories: Organizing comments and unanswered questions. Journal of Communication, 56, S265–S279.Find this resource:

Dillard, J. P., & Pfau, M. (Eds.). (2002). The persuasion handbook: Developments in theory and practice. Thousand Oaks, CA: SAGE.Find this resource:

Hovland, C. I., Janis, I. L., & Kelley, H. H. (1953). Communication and persuasion: Psychological studies of opinion change. New Haven, CT: Yale University Press.Find this resource:

O’Keefe, D. J. (2016). Persuasion: Theory and research (3d ed.). Los Angeles, CA: SAGE.Find this resource:

Petty, R. E., & Cacioppo, J. T. (1986). Communication and persuasion: Central and peripheral routes to attitude change. New York: Springer-Verlag.Find this resource:

Slater, M. D., Peter, J., and Valkenburg, P. M. (2015). Message variability and heterogeneity: A core challenge for communication research. Communication Yearbook, 39, 2–31.Find this resource:

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