Designing Health Messages: Approaches from Communication Theory and Public Health Practice [1 ed.] 0803953976, 9780803953970

Table of contents :
Contents
Preface
PART I: Theory-Driven Approaches to Health Message Design
1. Motivation to Attend to Health Messages: Presentation of Content and Linguistic Considerations • Roxanne Louiselle Parrott
2. Encouraging Risk Reduction: A Decision-Making Approach to Message Design • David R. Holtgräve, Barbara J. Tinsley, and Linda S. Kay
3. Moving People to Behavior Change: A Staged Social Cognitive Approach to Message Design • Edward W. Maibach and David Cotton
4. Fear Appeals in Health Promotion Campaigns: Too Much, Too Little, or Just Right? • Jerold L Hale and James Price Dillard
5. Thinking Positively: Using Positive Affect When Designing Health Messages • Jennifer L. Monahan
6. Designing Messages for Behavioral Inoculation • Michael Pfau
7. Reaching Young Audiences: Developmental Considerations in Designing Health Messages • Erica Weintraub Austin
8. Fishing for Success: Using the Persuasive Health Message Framework to Generate Effective Campaign Messages • Kim Witte
PART II: Audience-Centered Strategies for Health Message Design
9. Using Research to Inform Campaign Development and Message Design: Examples From the "America Responds to AIDS" Campaign • Glen J. Nowak and Michael J. Siska
10. Choosing Audience Segmentation Strategies and Methods for Health Communication • Michael D. Slater
11. The Gatekeeping Process: The Right Combinations to Unlock the Gates • John McGrath
12. Use of Database Marketing and Consumer-Based Health Communication in Message Design: An Example From the Office of Cancer Communications’ “5 a Day for Better Health” Program • R. Craig Lefebvre, Lynne Doner, Cecile Johnston, Kay Loughrey, George I. Balch, and Sharyn M. Sutton
PART III: Combining Theory and Practice: Additional Considerations
13. Supplementing Health Campaign Messages: Recent Developments in Informing Patients About Their Prescription Drugs • Sharon Lee Hammond
14. Enabling Health: Policy and Administrative Practices at a Crossroads • Roxanne Louiselle Parrott, Mary Louise Kahl, and Edward W. Maibach
Index
About the Contributors

Citation preview

DESIGNING HEALTH MESSAGES

This book is dedicated to Hilda Maibach and John Parrott, our partners in the journey.

DESIGNING HEALTH MESSAGES Approaches From Communication Theory and Public Health Practice

• Edward Maibach Rexanne Louiselle Parrott editors

®

S A G E Publications International Educational and Professional Thousand Oaks London New Delhi

Publisher

Copyright © 1995 by Sage Publications, Inc. All rights reserved. No part of this book m a y b e reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.

For information

address:

SAGE Publications, Inc. 2455 Teller Road T h o u s a n d Oaks, California 9 1 3 2 0 E-mail: [email protected] SAGE Publications Ltd. 6 Bonhill Street London EC2A 4PU United Kingdom SAGE Publications India Pvt. Ltd. M-32 Market Greater Kailash I New Delhi 110 048 India

Printed in the United States of America Library of Congress Cataloging-in-Publication Data Main entry under title: Designing health messages: Approaches from communication theory and public health practice / edited by Edward Maibach, Roxanne Louiselle Parrott. p. cm. Includes bibliographical references and index. ISBN 0-8039-5397-6. — ISBN 0-8039-5398-4 (pbk.) 1. Mass media in health education. 2. Health promotion. I. Maibach, Edward. II. Parrott, Roxanne. RA440.5.D46 1995 362.1 '014—dc20

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Sage Production Editor: Astrid Virding

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Contents

Preface

vii

PART I: Theory-Driven Approaches to Health Message Design 1. Motivation to Attend to Health Messages: Presentation of Content and Linguistic Considerations Roxanne Louiselle Parrott 2. Encouraging Risk Reduction: A Decision-Making Approach to Message Design David R. Holtgräve, Barbara J. Tinsley, and Linda S. Kay 3. Moving People to Behavior Change: A Staged Social Cognitive Approach to Message Design Edward W. Maibach and David Cotton 4. Fear Appeals in Health Promotion Campaigns: Too Much, Too Little, or Just Right? Jerold L Hale and James Price Dillard 5. Thinking Positively: Using Positive Affect When Designing Health Messages Jennifer L. Monahan 6. Designing Messages for Behavioral Inoculation Michael Pfau 7. Reaching Young Audiences: Developmental Considerations in Designing Health Messages Erica Weintraub Austin

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7

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65

81

99

114

8. Fishing for Success: Using the Persuasive Health Message Framework to Generate Effective Campaign Messages Kim Witte

PART II: Audience-Centered Strategies for Health Message Design 9. Using Research to Inform Campaign Development and Message Design: Examples From the "America Responds to AIDS" Campaign Glen J. Nowak and Michael J. Siska

145

167

169

10. Choosing Audience Segmentation Strategies and Methods for Health Communication Michael D. Slater

186

11. The Gatekeeping Process: The Right Combinations to Unlock the Gates John McGrath

199

12. Use of Database Marketing and Consumer-Based Health Communication in Message Design: An Example From the Office of Cancer Communications' "5 a Day for Better Health" Program R. Craig Lefebvre, Lynne Doner, Cecile Johnston, Kay Loughrey, George I. Balch, and Sharyn M. Sutton

217

PART III: Combining Theory and Practice: Additional Considerations

247

13. Supplementing Health Campaign Messages: Recent Developments in Informing Patients About Their Prescription Drugs Sharon Lee Hammond

249

14. Enabling Health: Policy and Administrative Practices at a Crossroads Roxanne Louiselle Parrott, Mary Louise Kahl, and Edward W. Maibach

270

Index

284

About the Contributors

299

Preface

"There is nothing so practical as a good theory." —Professor Kurt Lewin The Practical Theorist

T

h e o r y . T h e r e is n o o t h e r t e r m in t h e field of c o m m u n i c a t i o n t h a t i n s p i r e s s u c h p a s s i o n (positive a n d negative) a n d p r o v o k e s s u c h divisiveness. C o m m u n i c a t i o n r e s e a r c h e r s are often p a s s i o n a t e a b o u t , o n e m i g h t e v e n say love s t r u c k b y , t h e t h e o r i e s t h a t d r i v e their research. C o m m u n i c a t i o n p r a c t i t i o n e r s c a n b e equally p a s s i o n a t e a b o u t t h e o r y . U n f o r t u n a t e l y , t h e i r p a s sion often c o n c e r n s t h e irrelevance of t h e o r y t o t h e realities of t h e p r a c t i t i o n e r s ' w o r l d . T h e r e are c o m m u n i c a t i o n p r a c t i t i o n e r s w h o v a l u e t h e o r y ; h o w e v e r , t h e y often face skepticism o r o p p o s i t i o n at t h e h a n d s of t h e i r less a c a d e m i c a l l y o r i e n t e d colleagues. T h e o r y h a s also b e e n k n o w n t o p o l a r i z e t e a c h e r s a n d s t u d e n t s . Professors t e n d t o l e c t u r e in a b s t r a c t a b o u t t h e i m p o r t a n c e o f t h e o r y , w h e r e a s s t u d e n t s prefer c o n c r e t e g u i d a n c e o n h o w t o a c c o m p l i s h c o m m u n i c a t i o n objectives. 1

As c o m m u n i c a t i o n r e s e a r c h e r s w h o are d e e p l y i n v o l v e d in t h e p r a c t i c e of p u b l i c h e a l t h c o m m u n i c a t i o n , w e are c o n c e r n e d a b o u t t h e d i v i s i o n b e t w e e n t h e o r y a n d p r a c t i c e . T h e division is a false d i c h o t o m y t h a t s e r i o u s l y i n h i b i t s a d v a n c e m e n t o f t h e field of p u b l i c h e a l t h c o m m u n i c a t i o n . W e w h o l e h e a r t edly e m b r a c e P r o f e s s o r Lewin's a d a g e t h a t " t h e r e is n o t h i n g so p r a c t i c a l as a g o o d t h e o r y " ( M a r r o w , 1969). M o r e o v e r , w e believe t h a t c o m m u n i c a t i o n r e s e a r c h e r s , p r a c t i t i o n e r s , a n d s t u d e n t s alike will b e willing t o e m b r a c e t h a t a d a g e o n c e t h e field h a s a d v a n c e d s o m e " g o o d " t h e o r i e s , a n d o n c e t h e s e t h e o r i e s h a v e b e e n e x p l a i n e d in a m a n n e r t h a t m a k e s clear t h e i r v a l u e in practice. vii

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MESSAGES

F o r t u n a t e l y , theorists in t h e field of c o m m u n i c a t i o n a n d o t h e r r e l a t e d b e h a v i o r a l fields h a v e a d v a n c e d m a n y " g o o d " t h e o r i e s . T h e challenge n o w is t o e x p l a i n t h e s e t h e o r i e s in ways t h a t p r o v e their w o r t h . T h e r e a r e a n u m b e r of o b v i o u s r e a s o n s w h y p u b l i s h e d d i s c u s s i o n s of t h e o r y t e n d t o b e esoteric. T h e o r i s t s m a y c o n s i d e r s u c h e x p l a n a t i o n s t o b e a d i s t r a c t i o n from t h e i r w o r k . After all, c o m m u n i c a t i o n t h e o r i e s are c o n ceived in a b s t r a c t t e r m s to explain c o m m u n i c a t i o n processes a n d effects at a n a b s t r a c t level ( R e y n o l d s , 1971). It m a y also b e t h a t forces o p e r a t i v e in t o d a y ' s a c a d e m i c i n s t i t u t i o n s d i s c o u r a g e a c a d e m i c s ( w h o d o m o s t of t h e w r i t i n g ) from w r i t i n g a b o u t t h e practical implications of theory. For example, a c a d e m i c careers a r e generally elevated o n t h e basis o f a d v a n c i n g o r i g i n a l theories or disproving other peopled theories, not explaining a n d applying t h e o r i e s . S e c o n d , a c a d e m i c b o o k s a n d j o u r n a l s are b i a s e d against t h e overtly p r a c t i c a l b e c a u s e their reading audience is c o m p o s e d primarily of o t h e r academics, n o t p r a c t i c i n g professionals. M o r e o v e r , t h e s t a n d a r d f o r m a t in m o s t a c a d e m i c j o u r n a l s relegates d i s c u s s i o n s a b o u t t h e practical aspects o f t h e o r y t o t h e c o n c l u d i n g section of research articles. I n t r o d u c t o r y t e x t b o o k s are generally b r o a d l y inclusive, w h i c h i n h i b i t s t h e i r ability t o delve d e e p l y i n t o t h e o r y o r m a k e a n a d e q u a t e case for l i n k i n g t h e o r y t o p r a c t i c e . T h e r e m a y b e o t h e r r e a s o n s as well w h y s o few p r a c t i c a l e x p l a n a t i o n s of " g o o d " theories have been forthcoming. Rising t o t h e challenge of e x p l a i n i n g " g o o d " t h e o r i e s in a w a y t h a t p r o v e s t h e i r w o r t h is t h e first goal of this b o o k . T h e c o n t r i b u t i n g a u t h o r s in P a r t I ( T h e o r y - D r i v e n A p p r o a c h e s t o H e a l t h Message D e s i g n ) w e r e carefully selected b o t h for their e x u b e r a n c e a b o u t t h e c o m m u n i c a t i o n t h e o r i e s w i t h w h i c h t h e y w o r k , a n d for their interest in e x p l a i n i n g t h o s e t h e o r i e s in a w a y t h a t p r o v e s t h e i r w o r t h . T h e c o n t r i b u t i n g a u t h o r s w e r e directly a n d explicitly c h a l l e n g e d t o p r o v e K u r t L e w i n g adage b y laying b a r e t h e m e s s a g e design i m p l i c a t i o n s of t h e i r t h e o r i e s . As e d i t o r s , w e feel t h e y h a v e m e t t h e challenge, a n d in d o i n g so h a v e h o n o r e d t h e m e m o r y of Professor L e w i n , a f o u n d i n g m e m b e r of t h e a c a d e m i c field of c o m m u n i c a t i o n . M o r e o v e r , t h e s e c h a p t e r s s p e a k t o w h a t psychologist Albert B a n d u r a (1986) h a s called t h e u l t i m a t e test of a theory: w h e n a t h e o r y indicates m e t h o d s that are "capable of effecting significant c h a n g e s in h u m a n affect, t h o u g h t , a n d a c t i o n " (p. 3 ) . " G o o d " theories of h u m a n behavior a n d c o m m u n i c a t i o n processes p r o v i d e o n l y half t h e necessary i n f o r m a t i o n for effective h e a l t h m e s s a g e d e s i g n . T h e o t h e r half of t h e e q u a t i o n is a t h o r o u g h k n o w l e d g e of t h e target a u d i e n c e . A detailed, vivid k n o w l e d g e of t h e i n t e n d e d a u d i e n c e enables t h e m e s s a g e d e s i g n e r t o select a p p r o p r i a t e c o m m u n i c a t i o n objectives, t o create messages t h a t can a c c o m p l i s h t h o s e c o m m u n i c a t i o n objectives, t o c o n t e x t u a l i z e t h e

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messages p r o p e r l y , a n d t o deliver t h e messages t h r o u g h c o m m u n i c a t i o n c h a n n e l s f r e q u e n t e d a n d p r e f e r r e d b y m e m b e r s of t h e a u d i e n c e . T h e r e a r e m a n y ways t h a t message designers can a t t e m p t t o gain a t h o r o u g h k n o w l e d g e of t h e i r t a r g e t a u d i e n c e . S o m e of these a p p r o a c h e s a r e likely t o b e m o r e effective t h a n o t h e r s . T h e m o r e effective strategies are t h o s e t h a t s y s t e m a t i cally u s e r e s e a r c h b o t h t o identify t h e a u d i e n c e ( s ) a n d t o assess w h a t t h e a u d i e n c e c u r r e n t l y w a n t s , t h i n k s , feels, a n d d o e s r e g a r d i n g t h e h e a l t h issue. Ideally, this is a n o n g o i n g p r o c e s s t h r o u g h o u t t h e c a m p a i g n , w i t h t h e i n f o r m a t i o n fed f o r w a r d for t h e p u r p o s e of refining c a m p a i g n m e s s a g e s t o t h e c h a n g i n g s i t u a t i o n a n d n e e d s of t h e a u d i e n c e m e m b e r s . T h u s , t h e s e c o n d goal of this b o o k is to r e c o m m e n d a n d illustrate a series o f i n f o r m a t i o n g a t h e r i n g strategies from c o n t e m p o r a r y p u b l i c h e a l t h p r a c tice t h a t will e n a b l e a p p r o p r i a t e a u d i e n c e - c e n t e r e d c o m m u n i c a t i o n p l a n n i n g . T h e c o n t r i b u t i n g a u t h o r s in P a r t II ( A u d i e n c e - C e n t e r e d Strategies for H e a l t h M e s s a g e D e s i g n ) w e r e selected for t h e i r ability t o discuss a n d illust r a t e ( w i t h t h e i r o w n w o r k ) h e a l t h c o m m u n i c a t i o n p l a n n i n g activities t h a t p u t a face o n b o t h t h e target a u d i e n c e a n d o n i n t e r m e d i a r i e s w h o s t a n d b e t w e e n m e s s a g e p l a n n e r a n d target a u d i e n c e . As e d i t o r s , w e a r e e x t r e m e l y pleased b o t h w i t h t h e logical a n d practical n a t u r e of t h e p r o p o s e d a p p r o a c h e s , a n d w i t h t h e level of c o m p l e m e n t a r i t y a m o n g ideas a d v a n c e d in t h e s e c h a p t e r s . T h e s e c h a p t e r s will assist c o m m u n i c a t i o n p l a n n e r s at all levels in refining t h e i r a p p r o a c h e s t o message design a n d delivery. As previously indicated, o u r m o t i v a t i o n for editing this b o o k was t o a d v a n c e in clear t e r m s , a n d t o illustrate across a variety of p u b l i c h e a l t h p r o b l e m s , t h e o r y - g r o u n d e d a n d audience-centered approaches to health message d e sign. I n o u r m i n d s , t h e n e e d for this b o o k is so p r e s s i n g n o t b e c a u s e of t h e lack o f h e a l t h i n f o r m a t i o n in t h e i n f o r m a t i o n e n v i r o n m e n t , b u t b e c a u s e of t h e o v e r a b u n d a n c e of ineffectual i n f o r m a t i o n . B e y o n d t h e m y r i a d activities t h a t c a n b e c o n s t r u e d as s o m e f o r m of h e a l t h i n f o r m a t i o n c a m p a i g n (see R o g e r s 8c Storey [1987] for an excellent d i s c u s s i o n of w h a t c o n s t i t u t e s a n i n f o r m a t i o n c a m p a i g n ) , h e a l t h messages a r e pervasive in o u r s c h o o l s , h e a l t h care o r g a n i z a t i o n s , w o r k p l a c e s , a n d in all aspects of o u r m a s s m e d i a . M o r e over, Vice P r e s i d e n t Albert G o r e is l e a d i n g a n a t i o n w i d e c h a r g e t o e x p a n d dramatically o u r i n f o r m a t i o n e n v i r o n m e n t in t h e form of the N a t i o n a l I n f o r m a t i o n I n f r a s t r u c t u r e (i.e., t h e " i n f o r m a t i o n s u p e r h i g h w a y " ) , o n e m a j o r c o m p o n e n t of w h i c h will b e d e v o t e d t o h e a l t h i n f o r m a t i o n ( G o r e , 1 9 9 4 ) . N o t all o f t h i s h e a l t h i n f o r m a t i o n is specifically i n t e n d e d t o i m p r o v e t h e health of o u r citizens. N e w s a n d e n t e r t a i n m e n t p r o g r a m m i n g a b o u t h e a l t h , for e x a m p l e , m a y b e c r e a t e d w i t h little c o n c e r n a b o u t p e o p l e ' s h e a l t h . C o n versely, a vast a m o u n t of health information, including news, e n t e r t a i n m e n t , 2

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a n d a d v e r t i s i n g , is d e v e l o p e d w i t h h e a l t h i m p r o v e m e n t as a p r i m a r y o r s e c o n d a r y c o m m u n i c a t i o n objective. O u r c o n c e r n is t h a t t h e m a j o r i t y of t h e s e h e a l t h messages a r e p r o d u c e d in s u c h a h a p h a z a r d fashion as t o e n s u r e t h a t t h e y h a v e little or n o positive i m p a c t . By c r e a t i n g c l u t t e r in t h e h e a l t h i n f o r m a t i o n e n v i r o n m e n t , t h e y m a y actually h a v e a negative i m p a c t t o t h e e x t e n t t h a t t h e y interfere w i t h t h e relatively fewer w e l l - d e s i g n e d a n d wellc o m m u n i c a t e d h e a l t h messages. W e a r e e n c o u r a g e d b y p r e l i m i n a r y signs t h a t a c a d e m i c s in t h e field of c o m m u n i c a t i o n a r e b e c o m i n g m o r e c o n c e r n e d w i t h t h e o r y for t h e sake of p r a c t i c e (see Avery & Eadie, 1993; M o n a h a n & Collins-Jarvis, 1993). A m o n g o t h e r places, this c h a n g e can b e o b s e r v e d in t h e r a p i d l y e x p a n d i n g h e a l t h c o m m u n i c a t i o n section r o s t e r s of t h e I n t e r n a t i o n a l C o m m u n i c a t i o n Association a n d t h e Speech C o m m u n i c a t i o n Association, t h e t w o largest p r o f e s s i o n a l a s s o c i a t i o n s in t h e a c a d e m i c field of c o m m u n i c a t i o n . W e a r e e q u a l l y e n c o u r a g e d b y signs that c o m m u n i c a t i o n professionals at all levels are b e c o m i n g increasingly i n t e r e s t e d in p r o m o t i n g h e a l t h a n d o t h e r p r o s o c i a l o u t c o m e s (see M o n t g o m e r y [1990] a n d N a r i m a n [1993] for d i s c u s s i o n s a b o u t t h e e n t e r t a i n m e n t i n d u s t r y ) . T h e single m o s t s p e c t a c u l a r e x a m p l e of this t r e n d is t h e efforts over t h e p a s t d e c a d e of t h e P a r t n e r s h i p for a D r u g - F r e e America, a media industry consortium that produced and distributed app r o x i m a t e l y $1,000,000 w o r t h of public service advertising per day for several c o n s e c u t i v e years ( t h e 10th largest a d v e r t i s i n g c a m p a i g n in t h e c o u n t r y at t h a t t i m e ) . O u r h o p e is t h a t this b o o k will e n c o u r a g e t h e c o n t i n u e d d e v e l o p m e n t of these t r e n d s b y focusing m o r e h e a l t h c o m m u n i c a t i o n efforts o n theory-driven, audience-centered approaches.

Intended Users of the Book T h i s b o o k w a s w r i t t e n w i t h a n u m b e r of a u d i e n c e s in m i n d . B o t h e d i t o r s a n d m a n y of t h e c h a p t e r c o n t r i b u t o r s teach a d v a n c e d u n d e r g r a d u a t e o r g r a d u a t e - l e v e l c o u r s e s in h e a l t h c o m m u n i c a t i o n , social m a r k e t i n g , a n d i n f o r m a t i o n c a m p a i g n s . S t u d e n t s in these a n d related c o u r s e s s h o u l d find t h e c h a p t e r s in this b o o k refreshingly d i r e c t a n d i n s t r u c t i v e . T h e s e c o n d a u d i e n c e is t h e large g r o u p of p u b l i c h e a l t h professionals w h o , as p a r t of t h e i r j o b r e q u i r e m e n t s , d e v e l o p h e a l t h messages o r c a m p a i g n s b u t w i t h o u t t h e b e n e f i t of h a v i n g h a d specific t r a i n i n g in h e a l t h c o m m u n i c a t i o n . A n e q u a l l y large a u d i e n c e is c o m m u n i c a t i o n professionals w h o , w i t h n o p u b l i c h e a l t h t r a i n i n g , find t h e m s e l v e s d i r e c t i n g o r assisting in t h e d e v e l o p m e n t of p u b l i c h e a l t h messages o r c a m p a i g n s . T h e final a u d i e n c e is c o m p o s e d of o u r

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a c a d e m i c colleagues in d e p a r t m e n t s of c o m m u n i c a t i o n , p u b l i c h e a l t h , a n d r e l a t e d areas. W e h o p e t h a t this v o l u m e ' s e m p h a s i s o n t h e p r a c t i c a l side of t h e o r y will g e n e r a t e n e w insights a n d i n s p i r a t i o n s . P a r t I of t h e b o o k ( T h e o r y - D r i v e n A p p r o a c h e s t o H e a l t h M e s s a g e D e s i g n ) o p e n s w i t h a c h a p t e r b y P a r r o t t t h a t b r o a d l y overviews variables t h a t affect a u d i e n c e m e m b e r s ' a t t e n t i o n t o h e a l t h messages, regardless of t h e i r level of i n v o l v e m e n t w i t h t h e t o p i c . Several l a n g u a g e - u s e p r i n c i p l e s a r e s u g g e s t e d for m a x i m i z i n g a t t e n t i o n t o h e a l t h messages, a n d c o n t e x t o f t h e m e s s a g e is d i s c u s s e d as a p o t e n t i a l m e c h a n i s m for h e i g h t e n i n g m e s s a g e effectiveness. I n t h e s e c o n d c h a p t e r H o l t g r ä v e , Tinsley, a n d Kay i n t r o d u c e P r o c h a s k a a n d D i C l e m e n t e ' s ( 1 9 8 4 ) stages of c h a n g e m o d e l , a n d d e m o n s t r a t e h o w p r i n c i ples d r a w n f r o m t h e b e h a v i o r a l d e c i s i o n - m a k i n g l i t e r a t u r e can b e u s e d t o h e l p m o v e p e o p l e t h r o u g h t h e initial stages. I n C h a p t e r 3, M a i b a c h a n d C o t t o n c o n t i n u e t h e d i s c u s s i o n b y p r e s e n t i n g a c o m p l e m e n t a r y a p p r o a c h t o m o v i n g p e o p l e t h r o u g h all five stages of c h a n g e u s i n g m e s s a g e design c o n s t r u c t s p r e s e n t e d in B a n d u r a ' s ( 1 9 8 6 ) social c o g n i t i v e t h e o r y . T h e s e t h r e e c h a p t e r s a d d r e s s t h e first t h e m e w i t h i n P a r t I o f t h e v o l u m e : h o w t o use b e h a v i o r a l t h e o r y t o o r g a n i z e m e s s a g e design d e c i s i o n s . T h e s u b s e q u e n t five c h a p t e r s a d d r e s s t h e s e c o n d t h e m e w i t h i n P a r t I: a p r e s e n t a t i o n of specific t h e o r y - g r o u n d e d c o n s i d e r a t i o n s in m e s s a g e d e s i g n . I n C h a p t e r 4, H a l e a n d Dillard initiate t h e t h e m e b y r e v i e w i n g t h e t h e o r y a n d findings o n t h e use of fear appeals in h e a l t h c a m p a i g n s , p r o v i d i n g insights o n intelligent use of this strategy. I n C h a p t e r 5, M o n a h a n e l a b o r a t e s t h e utility o f u s i n g t h e o t h e r e n d of t h e affective scale: positive feelings. In doing so, she presents a promising perspective o n an underutilized health c o m m u n i c a t i o n strategy. I n C h a p t e r 6, Pfau discusses a n d illustrates t h e i m p o r t a n c e of b e h a v i o r a l inoculation with (primarily) young audiences w h o demonstrate a predisp o s i t i o n t o a d o p t u n h e a l t h f u l practices. In C h a p t e r 7, A u s t i n c o m p l e t e s o u r c o n s i d e r a t i o n of y o u n g a u d i e n c e s b y m e t i c u l o u s l y r e v i e w i n g t h e d e v e l o p m e n t a l literature a n d m a k i n g s o m e b o l d message-related r e c o m m e n d a t i o n s . I n C h a p t e r 8, W i t t e r o u n d s o u t t h e s e c t i o n b y p r e s e n t i n g h e r o r i g i n a l t e m p l a t e for c a m p a i g n message design a n d d i s s e m i n a t i o n . W i t t e ' s a p p r o a c h , called t h e Persuasive H e a l t h Message F r a m e w o r k A p p r o a c h , utilizes p e r s u a s i o n t h e o r y a n d research t o p r o v i d e a d e c i s i o n t r e e o f c h o i c e p o i n t s a n d p a t h s for h e a l t h m e s s a g e d e s i g n e r s t o c o n s i d e r in specifying p l a n s a n d objectives. I n P a r t II o f t h e b o o k ( A u d i e n c e - C e n t e r e d Strategies for H e a l t h M e s s a g e D e s i g n ) , w e p r e s e n t four c h a p t e r s t h a t focus o n t h e d a t a g a t h e r i n g a n d

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r e l a t e d activities n e e d e d t o d e v e l o p effective h e a l t h messages. In C h a p t e r 9, N o w a k a n d Siska beautifully illustrate h o w a u d i e n c e a n d e v a l u a t i o n research can b e used t h r o u g h o u t t h e life span of a campaign. In C h a p t e r 10, Slater p r o vides a d e e p l y insightful l o o k at a u d i e n c e s e g m e n t a t i o n , a n d r e c o m m e n d s a p p r o a c h e s t o s e g m e n t a t i o n in b o t h h i g h - a n d l o w - r e s o u r c e s i t u a t i o n s . I n C h a p t e r 1 1 , M c G r a t h r e m i n d s u s t h a t a w h o l e cast of c h a r a c t e r s — g a t e k e e p e r s — t y p i c a l l y s t a n d b e t w e e n t h e message designer a n d t h e t a r g e t a u d i e n c e . Based o n his extensive e x p e r i e n c e , h e p r e s e n t s a series of i m p o r t a n t r e c o m m e n d a t i o n s t o enlist t h e h e l p of g a t e k e e p e r s . I n t h e final c h a p t e r of P a r t II, Lefebvre a n d colleagues illustrate t h a t t h e b r a v e n e w w o r l d of d a t a b a s e m a r k e t i n g can be h a r n e s s e d in service of greater goals t h a n selling dish soap. P a r t III ( C o m b i n i n g T h e o r y a n d Practice: A d d i t i o n a l C o n s i d e r a t i o n s ) consists of t w o c h a p t e r s t h a t a d d r e s s several a d d i t i o n a l issues t h a t h e a l t h m e s s a g e d e s i g n e r s o u g h t t o c o n s i d e r before a n d d u r i n g their d e s i g n activities. First, in C h a p t e r 13, H a m m o n d reviews steps t h a t h a v e b e e n t a k e n t o i n c r e a s e p a t i e n t s ' u n d e r s t a n d i n g of m e d i c a t i o n r e g i m e n s . T h e s e initiatives exemplify t h e i m p o r t a n c e of c o n s i d e r i n g h o w m e d i a a n d i n t e r p e r s o n a l c o m m u n i c a t i o n interface in t h e design of h e a l t h messages. T h e s e efforts also illustrate h o w m u l t i p l e m e d i a messages in t h e i n f o r m a t i o n e n v i r o n m e n t s u p p l e m e n t c a m p a i g n efforts, at t i m e s r e i n f o r c i n g b u t at o t h e r t i m e s c o n tradicting c a m p a i g n messages. In the final chapter, Parrott, Kahl, a n d M a i b a c h a c k n o w l e d g e t h e critical c o n s t r a i n t s i m p o s e d o n m e s s a g e d e s i g n e r s b y h e a l t h a n d o t h e r a d m i n i s t r a t i v e policies, e x p a n d i n g o n t h e ideas a b o u t gate k e e p i n g a d v a n c e d b y M c G r a t h in C h a p t e r 11. S u c h policies m a y facilitate o r i n h i b i t t h e design a n d delivery of h e a l t h c a m p a i g n s . M e s s a g e d e s i g n e r s s h o u l d c o n s i d e r t h e relevance a n d i m p l i c a t i o n s of t h e s e policies b e f o r e p r o c e e d i n g w i t h their message design activities. Finally, t h e s e 14 c h a p t e r s challenge e v e r y o n e i n v o l v e d in t h e c o n s t r u c t i o n of t h e h e a l t h i n f o r m a t i o n e n v i r o n m e n t t o p r a c t i c e t h e p r i n c i p l e s p r o v i d e d b y " g o o d t h e o r y . " D o i n g so will h a v e t w o i m p o r t a n t c o n s e q u e n c e s : It will h e l p e n a b l e o u r citizens t o live healthier a n d m o r e p r o d u c t i v e lives; a n d it will u l t i m a t e l y , t h r o u g h its i m p a c t o n s u b s e q u e n t r e s e a r c h a n d e v a l u a t i o n efforts, a d v a n c e o u r u n d e r s t a n d i n g of t h e m e c h a n i s m s a n d d y n a m i c s of effective p u b l i c h e a l t h c o m m u n i c a t i o n .

Notes 1. This point is nicely emphasized by the third definition of the term academic in Webster's (New Riverside) Dictionary: "not practical: theoretical."

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2. Universal service—that is, assuring all segments of society full access to the information superhighway through the use of subsidies—is a major tenet of the federal government's proposed plan. This provision is specifically intended to level the playing field between the information haves and have nots.

References Avery, R K., 8c Eadie, W. F. (1993). Making a difference in the real world. Journal of Communication, 43,174-179. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Gore, A. (1994, February 28). We're all going to be connected. The Wallstreet Journal, p. A15. Marrow, A. J. (1969). The practical theorist The life and work of Kurt Lewin. New York: Basic Books. Monahan, J. L., 8c Collins-Jarvis, L. (1993). The hierarchy of institutional values in the communication discipline. Journal of Communication, 43,150-157. Montgomery, K. (1990). Promoting health through entertainment television. In C. Atkins 8c L. Wallack (Eds.), Mass communication and public health (pp. 114-128). Newbury Park, CA: Sage. Nariman, H. (1993). Soap operas for change. New York: Praeger. Prochaska, J. O., 8c DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow-Jones-Irwin. Reynolds, P. D . (1971). A primer in theory construction. New York: Macmillan. Rogers, E., 8c Storey, J. D. (1987). Communication campaigns. In C. Berger 8c S. Chaffee (Eds.), Handbook of communication science (pp. 814-846). Newbury Park, CA: Sage.

PARTI

Theory-Driven Approaches to Health Message Design

T h e o p e n i n g a n d in m a n y ways t h e m a i n section of this b o o k a d d r e s s e s t h e o r y - d r i v e n a p p r o a c h e s t o h e a l t h message design. T h e o r y plays m a n y roles in h e l p i n g u s u n d e r s t a n d c o m m u n i c a t i o n p r o c e s s e s . T h e m o s t b a s i c r o l e o f t h e o r y in b e h a v i o r a l science involves d e s c r i p t i o n . O u r t h e o r i e s d e s c r i b e aspects of t h e c o m p l e x w o r l d in w h i c h w e live, a n d in d o i n g s o , render them m o r e comprehensible. Philosopher John Dewey c o m m e n t e d o n t h i s role of t h e o r y b y p r o p o s i n g t h e following q u e s t i o n as a test of t h e a d e q u a c y o f a t h e o r y : " D o e s it e n d in c o n c l u s i o n s w h i c h , w h e n t h e y a r e referred b a c k t o o r d i n a r y life e x p e r i e n c e s , r e n d e r t h e m m o r e significant, m o r e l u m i n o u s t o u s , a n d m a k e o u r dealings w i t h t h e m m o r e fruitful? O r d o e s it t e r m i n a t e in r e n d e r i n g t h e things of o r d i n a r y experience m o r e o p a q u e than they were before?" 1

A s e c o n d role of b e h a v i o r a l t h e o r y involves p r e d i c t i o n o f o u t c o m e s . P r e d i c t i v e t h e o r i e s e x t e n d descriptive t h e o r i e s t o t h e n e x t logical level b y s t a t i n g : "if X o c c u r s , t h e n Y is m o r e ( o r less) likely t o o c c u r . " T h i s is said t o

1

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b e a h i g h e r role of t h e o r y b e c a u s e t h e p r o c e s s of p o s t u l a t i n g a n d p r o v i n g r e l a t i o n s h i p s a m o n g a n t e c e d e n t s a n d o u t c o m e s confers a n even g r e a t e r d e g r e e of c o m p r e h e n s i b i l i t y to t h e w o r l d a r o u n d us. Yet a n o t h e r goal of t h e o r y , in a d d i t i o n to d e s c r i p t i o n a n d p r e d i c t i o n , is e x p l a n a t i o n . A l t h o u g h theories t h a t p r e d i c t r e l a t i o n s h i p s a m o n g variables a r e often h i g h l y heuristic, g e n e r a t i n g v o l u m e s of testable h y p o t h e s e s a n d r e s e a r c h , t h e s e t h e o r i e s d o n o t necessarily explain w h y "If X o c c u r s t h e n Y is m o r e (or less) likely." T h e o r i e s t h a t are able to a n s w e r t h e q u e s t i o n " w h y " create greater u n d e r s t a n d i n g . T h e y a r e often necessary t o a t t a i n yet a n o t h e r goal of t h e o r y — t h e ability to p r e s c r i b e effective i n t e r v e n t i o n s . T h e final role of t h e o r y w e will discuss involves p r e s c r i p t i o n . P r e s c r i p t i v e t h e o r i e s b u i l d o n t h e o t h e r t w o roles of t h e o r y b y e x t e n d i n g t h e m t o t h e final logical level: "X can b e m a d e m o r e likely t o o c c u r b y d o i n g A, B, a n d C, w h i c h , in t u r n , will m a k e Y m o r e ( o r less) likely to o c c u r . " S u c h u n d e r s t a n d i n g confers t h e greatest degree of c o m p r e h e n s i b i l i t y . It is t h e difference b e t w e e n u n d e r s t a n d i n g t h a t apples are g o o d food, u n d e r s t a n d i n g t h a t a p p l e trees g r o w f r o m a p p l e seeds, a n d u n d e r s t a n d i n g t h a t a n a p p l e tree will b e a r t h e m o s t fruit w h e n p r o p e r l y w a t e r e d , fertilized, a n d p r u n e d . T h e latter d e g r e e of c o m p r e h e n s i o n is clearly m o r e useful t o t h o s e p e o p l e c o n c e r n e d w i t h regularly p u t t i n g food o n t h e table. T h e p r e s c r i p t i v e f u n c t i o n of t h e o r y , needless t o say, is t h e central c o n c e r n of this section. T h e m a i n challenge issued t o c o n t r i b u t i n g a u t h o r s in this section was t o e x p l o r e t h e prescriptive value of b e h a v i o r a l t h e o r i e s . All a u t h o r s r e s p o n d e d t o o u r challenge. M a n y of t h e m even t o o k t h e a s s i g n m e n t o n e step farther. T h e y i n t e g r a t e d their d e s c r i p t i o n of t h e t h e o r i e s we a s k e d t h e m t o a d d r e s s w i t h d e s c r i p t i o n s of o t h e r t h e o r i e s , a n d in d o i n g so, t h e y e x t e n d e d t h e p r e s c r i p t i v e v a l u e of t h e original t h e o r i e s in i m p o r t a n t ways. In C h a p t e r 1, P a r r o t t explores linguistic t h e o r i e s a d v a n c e d in t h e fields of c o m m u n i c a t i o n a n d p s y c h o l o g y t h a t c o n t e n d t h a t w o r d c h o i c e m a t t e r s . She b u i l d s t h e case t h a t p a r t i c u l a r w o r d c h o i c e s lead m e m b e r s of t h e t a r g e t a u d i e n c e t o recognize s o m e c o n c e p t s as m o r e central o r i m p o r t a n t t o focus o n t h a n o t h e r s . T h e p r e s c r i p t i v e value of these t h e o r i e s is seen in P a r r o t t ' s r e c o m m e n d a t i o n s for g u i d i n g t h e selection of t h e exact w o r d s t o m a x i m i z e a u d i e n c e a t t e n t i o n to t h e critical message content. P a r r o t t extends t h e p r e s c r i p tive value of linguistic t h e o r i e s b y i n t e g r a t i n g t h e m w i t h t h e o r i e s t h a t specify w h i c h f o r m s of m e d i a p r e s e n t a t i o n s evoke t h e m o s t active t h o u g h t p r o cesses. T h e i n t e g r a t i o n p r o v i d e s significant i n s i g h t i n t o w h y p e o p l e a t t e n d to a n d b e c o m e m o r e involved with s o m e health messages t h a n o t h e r s , even w h e n t h e messages d o n o t initially a p p e a r t o b e p e r s o n a l l y relevant.

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3

In C h a p t e r 2, H o l t g r ä v e , Tinsley, a n d Kay e x a m i n e c e r t a i n key b e h a v i o r a l decision-making constructs. Moreover, they extend the prescriptive value o f t h e s e c o n s t r u c t s b y e x a m i n i n g t h e m w i t h i n t h e c o n t e x t of P r o c h a s k a a n d D i C l e m e n t e ' s stage of b e h a v i o r c h a n g e f r a m e w o r k . T h e i r d i s c u s s i o n c e n t e r s o n d e c i s i o n - m a k i n g processes at t h e early ( d e c i s i o n - o r i e n t e d ) p h a s e s o f t h e b e h a v i o r c h a n g e p r o c e s s . T h e result is a n i l l u m i n a t i n g set of r e c o m m e n d a tions o n h o w t o m o v e target a u d i e n c e m e m b e r s t h r o u g h early b e h a v i o r c h a n g e stages ( P r e c o n t e m p l a t i o n a n d C o n t e m p l a t i o n ) . In C h a p t e r 3 , M a i b a c h a n d C o t t o n explain t h e p r e s c r i p t i v e v a l u e of key c o n s t r u c t s f r o m B a n d u r a ' s social cognitive t h e o r y . M o r e o v e r , following t h e a p p r o a c h p r e s e n t e d in C h a p t e r 2, t h e y e x a m i n e t h e s e c o n s t r u c t s in a stages o f b e h a v i o r c h a n g e c o n t e x t . T h e d i s c u s s i o n g r a n t s t h e r e a d e r a significant o p p o r t u n i t y t o u n d e r s t a n d a n a u d i e n c e m e m b e r ' s e x p e r i e n c e at e a c h stage of the b e h a v i o r c h a n g e process. Explicit g u i d a n c e is given, b y stage of b e h a v i o r c h a n g e , r e g a r d i n g w h i c h social cognitive c o n s t r u c t s a r e likely t o b e m o s t influential, a n d r e c o m m e n d a t i o n s are m a d e r e g a r d i n g h o w t o m o s t reliably i n f l u e n c e t h o s e c o n s t r u c t s . T h e d i s c u s s i o n is a d i r e c t c o m p l e m e n t t o t h a t p r e s e n t e d i n C h a p t e r 2. In C h a p t e r 4, H a l e a n d Dillard p r o v i d e a c o m p r e h e n s i v e review a n d i n t e g r a t i o n of t h e t h e o r e t i c a l perspectives a d v a n c e d t o e x p l a i n t h e r o l e of u s i n g n e g a t i v e affect in h e a l t h m e s s a g e design. Fear a p p e a l s h a v e historically b e e n aligned w i t h health campaigns, p e r h a p s because s o m e of t h e classic e x a m p l e s are so indelibly i m p r i n t e d in t h e m i n d s of p e r s o n s e x p o s e d t o t h e m . I n a d d i t i o n , i n d i v i d u a l s h a v e often b e e n p r e s u m e d t o p e r f o r m b e h a v i o r s r e p r e s e n t e d as b e i n g in t h e i r o w n b e s t h e a l t h i n t e r e s t s if t h e y u n d e r s t a n d t h e d i r e c o n s e q u e n c e s associated w i t h failure t o d o s o . As H a l e a n d D i l l a r d illustrate, s u c h a s s u m p t i o n s m a y b e m i s l e a d i n g , w h e r e a s o t h e r p r i n c i p l e s m o r e a p p r o p r i a t e l y a n d frequently lead t o i n t e n d e d o u t c o m e s . In c o m p a r i n g a n d c o n t r a s t i n g t h e s e issues, H a l e a n d Dillard p r o v i d e an excellent synthesis o f u n d e r s t a n d i n g t o g u i d e t h e p r a g m a t i c c o n s i d e r a t i o n s o f h e a l t h message designers. I n C h a p t e r 5, M o n a h a n takes u p w h e r e H a l e a n d D i l l a r d leave off, d i s cussing the o b v e r s e — t h a t is, t h e role of using positive affect in health m e s s a g e d e s i g n . As she d u l y n o t e s , this a p p r o a c h is far t o o often n e g l e c t e d w h e n health campaigners are considering h o w to present the content of health i n f o r m a t i o n t o a n a u d i e n c e . H e r review of t h e o r y a n d r e s e a r c h r e l a t i n g t o t h e i m p a c t of p r o m o t i n g benefits associated w i t h b e h a v i o r leads t o M o n a h a n ' s identification of ways t o e n c o m p a s s this k n o w l e d g e in t h e c o n s t r u c t i o n of h e a l t h messages. M o r e o v e r , M o n a h a n c o m p a r e s a n d c o n t r a s t s v a r i e d

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a p p r o a c h e s t o utilizing positive affect, each w i t h its o w n s t r e n g t h s a n d weaknesses. In C h a p t e r 6, Pfau e x a m i n e s t h e issue of a d o l e s c e n t s m o k i n g p r e v e n t i o n a n d a r g u e s t h a t , w h e n t a r g e t i n g c h i l d r e n a n d early a d o l e s c e n t s , a p p r o p r i a t e messages a r e t h o s e t h a t positively reinforce existing b e h a v i o r , n o t t h o s e t h a t a t t e m p t t o p e r s u a d e c h i l d r e n t o o p p o s e a h e a l t h risk b e h a v i o r . H e specifically e x a m i n e s t h e t h e o r e t i c a l r a t i o n a l e for o n e a p p r o a c h t o p r i m a r y p r e v e n t i o n t h r o u g h positive r e i n f o r c e m e n t : b e h a v i o r a l i n o c u l a t i o n . Pfau p r e sents a n explicit set of t h e o r y - d r i v e n r e c o m m e n d a t i o n s for t h e c r e a t i o n of inoculation a n d booster messages. This chapter is a n i m p o r t a n t c o m p l e m e n t t o M a i b a c h a n d C o t t o n ' s c h a p t e r o n social cognitive a p p r o a c h e s b e c a u s e it focuses o n t h e d e v e l o p m e n t of abilities a n d c o n f i d e n c e t o resist e x p e r i m e n t i n g w i t h a n d a d o p t i n g risk b e h a v i o r s . In C h a p t e r 7, t a k i n g u p w h e r e Pfau left off, A u s t i n integrates a vast a n d d i v e r g e n t set of literatures o n d e v e l o p m e n t a l t h e o r y a n d y o u t h a u d i e n c e s . H e r d e v e l o p m e n t a l stage-specific review gives r e a d e r s t h e m e a n s t o u n d e r s t a n d t h e c o g n i t i o n s , m o t i v a t i o n s , s o u r c e s of influence, m e d i a use h a b i t s , a n d a v a r i e t y of o t h e r i m p o r t a n t m e s s a g e design c o n s i d e r a t i o n s for c h i l d r e n in six age g r o u p s ( 0 - 5 , 5 - 7 , 7 - 1 0 , 1 0 - 1 3 , 1 3 - 1 6 , a n d over 16). Austin's t h o r o u g h review p r e s e n t s a n d defends four i m p o r t a n t message design r e c o m m e n d a t i o n s for y o u t h a u d i e n c e s : start early; s e g m e n t a n d target b y age g r o u p a n d e n v i r o n m e n t a l differences; strive for c o n s i s t e n t messages f r o m a v a r i e t y of s o u r c e s o v e r a l o n g p e r i o d of t i m e ; a n d e m p h a s i z e giving c h i l d r e n c o n t r o l a n d o w n e r s h i p of their o w n destinies. I n C h a p t e r 8, W i t t e p r o p o s e s a t r a n s t h e o r e t i c a l m o d e l t o g u i d e h e a l t h m e s s a g e d e s i g n e r s ' a c t i o n s . In a d d i t i o n to i n t e g r a t i n g diverse b e h a v i o r change theories, Witte's model provides a step-by-step guide to the process of d e s i g n i n g h e a l t h messages. As s u c h , it is a n i m p o r t a n t b r i d g e t o t h e s e c o n d s e c t i o n of this b o o k . T h e m o d e l e m p h a s i z e s t h e i n t e r r e l a t i o n s h i p s a m o n g decisions m a d e a b o u t selecting t h e c o n t e n t of a message based o n t h e p a r t i c u l a r a u d i e n c e for w h o m t h e message is d e s i g n e d , in c o n j u n c t i o n w i t h t h e s o u r c e a n d c h a n n e l selection. T h e specific e x a m p l e s u s e d for illustration in these c h a p t e r s a r e largely d r a w n f r o m t h e p e r s o n a l experiences of t h e a u t h o r s . T h e e x a m p l e s a d d r e s s a w i d e v a r i e t y of h e a l t h p r o m o t i o n issues i n c l u d i n g t h e p r e v e n t i o n of c a n c e r , s u b s t a n c e use, A I D S , a n d accidents. T h e r e a d e r can t h u s benefit b o t h f r o m t h e a u t h o r s ' efforts t o i n t e g r a t e a n d e x t e n d t h e o r y i n t o p r e s c r i p t i o n s for

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5

h e a l t h m e s s a g e d e s i g n , a n d b y seeing t h e s e p r e s c r i p t i o n s i l l u s t r a t e d in a p p l i c a t i o n t o " r e a l - w o r l d " e x a m p l e s a l o n g t h e way.

Note 1. Dewey, J. (1929). Experience and nature. New York: Norton.

1

Motivation to Attend to Health Messages PRESENTATION OF CONTENT A N D LINGUISTIC CONSIDERATIONS

ROXANNE LOUISELLE PARROTT

Mass media can be extremely powerful in involving audiences with the abstract matters of health in exciting personalized ways and in so involving people they can become quite capable of affording insights that might produce ameliorative actions ultimately. —Mendelsohn (1968, p. 136)

D

espite M e n d e l s o h n ' s (1968) p r o m i s e r e g a r d i n g m e d i a ' s p o t e n t i a l t o positively affect p e o p l e ' s b e h a v i o r s in r e l a t i o n t o h e a l t h , e v i d e n c e suggests t h a t m a n y m e d i a t e d h e a l t h messages fall s h o r t of a t t a i n i n g t h i s goal. T h e failure o c c u r s , in p a r t , b e c a u s e of t h e ways t h a t p e o p l e p r o c e s s i n f o r m a t i o n o n c e t h e y h a v e b e e n e x p o s e d t o it (Levy 8c W i n d a h l , 1985). T h i s c h a p t e r discusses a u d i e n c e i n f o r m a t i o n p r o c e s s i n g , a n d p r o p o s e s specific p r e s e n t a t i o n of c o n t e n t a n d linguistic a p p r o a c h e s t o i n c r e a s e i n d i v i d u a l s ' m e n t a l effort t o p r o c e s s h e a l t h messages.

Audience Attention Levels C a m p a i g n t h e o r i s t s a n d r e s e a r c h e r s generally agree t h a t after e x p o s u r e t o a message, a u d i e n c e a t t e n t i o n comprises the n e x t stage in r e s p o n s e ( M c G u i r e , 1 9 8 9 ) . T h e a t t e n t i o n a n a u d i e n c e gives t o a m e s s a g e m a y b e c o n c e p t u a l i z e d a l o n g a c o n t i n u u m (Langer, 1978). At o n e e n d of t h e c o n t i n u u m , t h e

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a u d i e n c e pays very little a t t e n t i o n , a passive o r m i n d l e s s r e s p o n s e . At t h e o t h e r e n d of t h e c o n t i n u u m , listeners a t t e n d a great deal, a n active o r mindful response: Audience Attention Mindless/Passive

Mindful/Active

A n i m p o r t a n t p r e d i c t o r of t h e a m o u n t of cognitive effort an a u d i e n c e exerts t o a t t e n d messages is t h e audience's level of i n v o l v e m e n t with t h e t o p i c of t h e m e s s a g e (Petty 8c C a c i o p p o , 1986). I n v o l v e m e n t has b e e n c o n c e p t u a l ized in a n u m b e r of ways (see Pfau 8c P a r r o t t , 1993), w i t h e a c h p r o m o t i n g active i n f o r m a t i o n p r o c e s s i n g via a c e n t r a l r o u t e ( B o r g i d a 8c H o w a r d - P i t ney, 1983; Petty, C a c i o p p o , 8c G o l d m a n , 1981). A n a u d i e n c e w h o is i n v o l v e d w i t h t h e t o p i c of c a n c e r p r e v e n t i o n , for e x a m p l e , will actively seek, a t t e n d , a n d p r o c e s s messages a b o u t cancer p r e v e n t i o n ( J o h n s o n , M e i s c h k e , G r a u , 8c J o h n s o n , 1992). T h i s has also b e e n referred t o as t o p - d o w n i n f o r m a t i o n p r o c e s s i n g , w h i c h o c c u r s w h e n an i n d i v i d u a l ' s goal or c o n s c i o u s a w a r e n e s s leads t o active p r o c e s s i n g ( G r e e n , Lightfoot, B a n d y , 8c B u c h a n a n , 1985; P a r k 8c S m i t h , 1989). U n i n v o l v e d a u d i e n c e s , o n t h e o t h e r h a n d , p r o c e s s inform a t i o n in a passive fashion, w h i c h has b e e n c o n c e p t u a l i z e d t o o c c u r via a peripheral route: Information Processing Passive/Peripheral

Active/Central Top-down

P e r i p h e r a l i n f o r m a t i o n p r o c e s s i n g lacks t h e active a w a r e n e s s , c o m p r e h e n s i o n , a n d evaluation of a r g u m e n t s to s u p p o r t positions (Petty, C a c i o p p o , 8c S c h u m a n n , 1983). A l t h o u g h relatively e n d u r i n g a t t i t u d e a n d b e h a v i o r f o r m a t i o n , change, a n d reinforcement occur via b o t h active a n d passive m o d e s of i n f o r m a t i o n p r o c e s s i n g ( P e c h m a n n 8c Stewart, 1989), t h e h e a l t h m e s s a g e d e s i g n e r ' s goal often is t o p r o m p t active t h o u g h t in a passive a u d i e n c e . Message designers thus should reckon with how, when, a n d w h y people e x p o s e d t o h e a l t h messages m i g h t b e m o t i v a t e d t o switch t o m o r e active r a t h e r t h a n a u t o m a t i c message p r o c e s s i n g , as well as w h e n a n d h o w t o m o t i v a t e m o r e active v e r s u s passive t h o u g h t .

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9

"Switching Cognitive Gears": Invoking Active Thought For t h e m o s t p a r t , i n d i v i d u a l s rely o n a u t o m a t i c p r o c e s s i n g o f h e a l t h i n f o r m a t i o n , d e p e n d i n g o n past knowledge o r experience with similar m e s sages t o assign m e a n i n g a n d i n t e r p r e t a t i o n t o a p r e s e n t m e s s a g e ( C h a n o w i t z 8c L a n g e r , 1981). O n e d o e s n o t h a v e to exert m u c h effort t o b e e x p o s e d t o h e a l t h m e s s a g e s , as p o p u l a r television p r o g r a m s , b o t h e n t e r t a i n m e n t a n d e d u c a t i o n a l , deal w i t h h e a l t h topics ( L a r s o n , 1991), a n d c o m m e r c i a l c a m p a i g n e r s m a k e h e a l t h claims in relation t o t h e i r p r o d u c t s t o p r o m o t e sales ( M a i b a c h , 1991). T h i s i n f o r m a t i o n d i s s e m i n a t i o n o c c u r s s i m u l t a n e o u s l y w i t h m o r e t r a d i t i o n a l m e d i a a n d i n t e r p e r s o n a l f o r m s , s u c h as p u b l i c service a n n o u n c e m e n t s (PSAs) p r e s e n t e d via p o s t e r s , p a m p h l e t s , r a d i o , a n d television (e.g., F r e i m u t h , H a m m o n d , Edgar, 8c M o n a h a n , 1990); a n d p h y s i c i a n r e c o m m e n d a t i o n s delivered face t o face a n d over t h e t e l e p h o n e ( P a r r o t t , G r e e n e , 8c P a r k e r , 1992). T h e m o d e of m e s s a g e p r e s e n t a t i o n m a y affect i n f o r m a t i o n p r o c e s s i n g , as e v i d e n c e suggests t h a t p e o p l e e x p e n d m o r e c o g n i t i v e effort t o p r o c e s s p r i n t messages t h a n television m e s s a g e s ( C h a i k e n 8c Eagly, 1976). T h i s a s s u m e s , h o w e v e r , t h a t a n a u d i e n c e h a s a l r e a d y d e c i d e d t o a t t e n d t h e p r i n t message; o n e c a n n o t actively exert effort t o p r o c e s s a message that o n e simply chooses to ignore. A n u m b e r of t h e o r i e s a d d r e s s t h e differences b e t w e e n active a n d passive c o g n i t i v e f u n c t i o n i n g a n d w h y individuals actively o r passively p r o c e s s i n f o r m a t i o n (e.g., B e h r m a n , M o s c o v i t c h , 8c M o z e r , 1991; P e t t y 8c C a c i o p p o , 1986). Less research h a s a d d r e s s e d h o w t o m o t i v a t e i n d i v i d u a l s t o m o v e f r o m t h e passive t o t h e active m o d e ( P a r k 8c S m i t h , 1989; Reeves 8c T h o r s o n , 1986). L o u i s a n d S u t t o n (1991) h a v e b e g u n a s y s t e m a t i c p r o g r a m of r e s e a r c h t o identify c o n d i t i o n s t h a t e n c o u r a g e p e o p l e t o e n t e r a n active p r o c e s s i n g m o d e , p r o m p t i n g b o t t o m - u p a t t e n t i o n a l p r o c e s s i n g in c o n t r a s t t o t o p d o w n processing: Information Processing Passive/Peripheral

Active/Central Bottom-up Top-down

L o u i s a n d S u t t o n ' s m o d e l of " s w i t c h i n g cognitive g e a r s " p o s i t s t h a t i n d i v i d u a l s a r e m o t i v a t e d t o b e c o m e actively cognitively e n g a g e d : 1. w h e n p r e s e n t a t i o n o f c o n t e n t is u n u s u a l , unfamiliar, or novel;

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2. when presentation of content represents a discrepancy between expectations and reality; and 3. when an external or internal request causes an individual to deliberately initiate an increased level of conscious attention (Louis & Sutton, 1991). E a c h c o n d i t i o n will b e e x a m i n e d w i t h i n a f r a m e w o r k of h e a l t h m e s s a g e design a n d of m o t i v a t i n g p e o p l e t o a t t e n d h e a l t h messages actively, via b o t t o m - u p information processing.

UNUSUAL, UNFAMILIAR, AND NOVEL PRESENTATION OF C O N T E N T C o n s i d e r t h e following message, w h i c h a p p e a r s o n t h e b a c k p a g e of a p a m p h l e t titled, "It's N e v e r T o o Early t o S t o p Skin C a n c e r . . . o r T o o L a t e " ( T h e Skin C a n c e r F o u n d a t i o n , 1985): Know the signs of skin cancer • A skin growth that increases in size and appears pearly, translucent, tan, brown, black or multicolored. • A mole, birthmark or beauty mark that changes color increases in size or thickness changes in texture is irregular in outline • A spot or growth that continues to itch, hurt, crust, scab, erode or bleed. • An open sore or wound on the skin that does not heal or persists for more than four weeks, or heals and then reopens. If you have any of these symptoms, see your doctor. Now. Clearly, t h e goal of this m e s s a g e is t o e d u c a t e r e a d e r s a b o u t t h e p h y s i c a l s y m p t o m s of skin cancer, w h i c h , if o b s e r v e d , s h o u l d lead a p e r s o n t o seek a p h y s i c i a n for c o n s u l t . For this e d u c a t i o n to o c c u r , h o w e v e r , a n i n d i v i d u a l m u s t o b t a i n t h e b r o c h u r e , r e a d it, a n d p a y e n o u g h a t t e n t i o n t o c o m p r e h e n d a n d r e t a i n i n f o r m a t i o n t h a t m a y o r m a y n o t b e p e r s o n a l l y r e l e v a n t at t h e time. T h e m a t e r i a l c o n t a i n e d in the skin cancer m e s s a g e m a y b e u n f a m i l i a r t o t h e r e a d e r , b u t t h e m e t h o d o f p r e s e n t a t i o n is a h i g h l y familiar o n e : a l e n g t h y a n d d r y clinical e x p o s i t i o n c o n t a i n i n g w o r d s t h a t are n o t c o m m o n l y u s e d b y m o s t p e o p l e . E v e r y o n e has seen n u m e r o u s h e a l t h b r o c h u r e s t h a t l o o k j u s t like this m e s s a g e . Louis a n d S u t t o n ' s (1991) first c o n d i t i o n t o p r o m o t e

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11

active i n f o r m a t i o n p r o c e s s i n g — p r e s e n t t h e c o n t e n t in a n u n u s u a l w a y — i s lacking in this m e s s a g e . Because p r i n t e d h e a l t h m e s s a g e s are often factual, s t r a i g h t f o r w a r d , clinical directives, positive affect a p p e a l s (see C h a p t e r 5 in this v o l u m e ) m a y garner m o r e attention. N o o n e feels positively a b o u t c a n c e r in g e n e r a l , b u t a p r i n t m e s s a g e c o u l d b e d e s i g n e d t o p r o m o t e p o s i t i v e feelings in relation t o t h e b e h a v i o r b e i n g p r o m o t e d , b y a n o p e n i n g s t a t e m e n t c o n s t r u c t e d in t h e following fashion: " K n o w i n g t h e s e signs o f skin c a n c e r gives p e o p l e o n e m o r e w a y t o safeguard t h e i r h e a l t h . " A u d i e n c e m e m b e r s feel positively a b o u t h a v i n g t h e ways a n d m e a n s t o c o n t r o l t h e i r o w n wellb e i n g , b u t h e a l t h messages t o o s e l d o m explicitly e m p h a s i z e this as a r e a s o n t o p r o c e s s i n f o r m a t i o n actively. Messages c a n also b e d e s i g n e d t o i n v o k e a sense o f p e r s o n a l responsibility, w h i c h h a s b e e n s h o w n t o m o t i v a t e p e o p l e t o p r o c e s s i s s u e - r e l e v a n t a r g u m e n t s ( P e t t y 8c C a c i o p p o , 1986) b u t is n o t f r e q u e n t l y f o u n d in p r e s e n t a t i o n s of h e a l t h c o n t e n t : " K n o w i n g t h e s e signs of skin cancer helps friends a n d families to detect the disease early for t h e m selves a n d t h e i r loved o n e s . " A n o t h e r w a y t o p r e s e n t t h e c o n t e n t in a n u n u s u a l w a y is t o explicitly state a b a s i c m o t i v e t o a t t e n d r a t h e r t h a n stating a clinical directive: " K n o w i n g t h e s e signs of skin c a n c e r can h e l p y o u d e t e c t a n y u n u s u a l skin c o n d i t i o n s b e f o r e t h e y b e c o m e a serious h e a l t h p r o b l e m . " Each of t h e s e o p e n i n g s w o u l d b e n o v e l in c o m p a r i s o n t o h o w t h e message p r e s e n t l y o p e n s , a n d so t h e y s h o u l d i n v o k e m o r e active p r o c e s s i n g . T o k e e p t h e a u d i e n c e ' s a t t e n t i o n , t h e rest of t h e c o n t e n t s h o u l d b e revised to present the i n f o r m a t i o n in an u n u s u a l fashion r e l e v a n t t o a u d i e n c e n e e d s . U n u s u a l m o d e s of p r i n t e d h e a l t h messages s h o u l d also b e c o n s i d e r e d b y m e s s a g e d e s i g n e r s w h o seek t o trigger m o r e active t h o u g h t a b o u t specific h e a l t h m a t t e r s t h r o u g h t h e u n u s u a l p r e s e n t a t i o n of c o n t e n t . A m o n g t h e m o r e novel print media currently being used to disseminate health messages is t h e c o m i c b o o k ( P a r r o t t , in p r e s s - a ) . The Amazing Spiderman c o m i c s , for e x a m p l e , h a v e d e v o t e d a n u m b e r of issues t o t h e d e v e l o p m e n t of stories in w h i c h t h e m a i n c h a r a c t e r p r o m o t e s a w a r e n e s s a b o u t h e a l t h m a t t e r s . In o n e issue (McDuffie, 1993a), S p i d e r m a n discusses d r u g use a n d a b u s e w i t h several t e e n a g e b o y s . I n a n o t h e r (McDuffie, 1993b), t h e m a i n c h a r a c t e r p r o m o t e s w e a r i n g h e l m e t s w h e n cycling. T h r o u g h t h e m e d i u m o f c o m i c b o o k s , t h e h e a l t h m e s s a g e m a y take o n a c o n v e r s a t i o n a l r a t h e r t h a n d i d a c t i c t o n e . M o r e p e r s o n a l m a t t e r s , s u c h as strategies t o deal w i t h p e e r p r e s s u r e t o use drugs, m a y b e addressed. Although an audience m e m b e r does n o t actually h a v e an i n t e r p e r s o n a l r e l a t i o n s h i p w i t h a fictional c h a r a c t e r , a u d i e n c e m e m b e r s often feel as t h o u g h t h e y h a v e f o r m e d s u c h social r e l a t i o n s h i p s (Pfau, 1990). By i n v o k i n g these a l r e a d y f o r m e d parasocial r e l a t i o n s h i p s w i t h c o m i c

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b o o k c h a r a c t e r s , o p p o r t u n i t i e s o c c u r to reinforce h e a l t h y b e h a v i o r s w h i l e a t t e m p t i n g t o c h a n g e u n h e a l t h y b e h a v i o r s . T h e finding t h a t u n u s u a l , u n f a miliar, a n d n o v e l p r e s e n t a t i o n s of c o n t e n t p r o m o t e m o r e active m e s s a g e p r o c e s s i n g m a y also explain w h y a u d i e n c e s a t t e n d a n d r e m e m b e r h e a l t h i n f o r m a t i o n p r e s e n t e d in television soap o p e r a s a n d s i t u a t i o n c o m e d i e s ( L a r s o n , 1991). Yet a n o t h e r w a y to p r e s e n t skin c a n c e r i n f o r m a t i o n in a n o v e l fashion is to have a c h a r a c t e r o n a p r i m e - t i m e s i t u a t i o n c o m e d y o r a d a y t i m e s o a p o p e r a s u d d e n l y n o t i c e a m o l e t h a t h a s c h a n g e d in c o l o r a n d t e x t u r e a n d is i n c r e a s i n g in size. T h e c h a r a c t e r ' s visit to a p h y s i c i a n p r o v i d e s a n o p p o r t u n i t y to m o d e l t h e a p p r o p r i a t e b e h a v i o r a l r e s p o n s e a n d for c o n v e r s a t i o n s t o o c c u r in w h i c h family a n d friends, in a d d i t i o n t o m e d i c a l professionals, discuss t h e c h a r a c t e r ' s skin cancer. T h e s e n o v e l m e t h o d s of p r e s e n t i n g h e a l t h i n f o r m a t i o n also p r o v i d e o p p o r t u n i t i e s explicitly t o a d d r e s s p o t e n t i a l l y p r i v a t e topics. T h e very n a t u r e of t h e s o a p o p e r a p r o v i d e s a n excellent setting for t h e c h a r a c t e r t o reveal p e r s o n a l d o u b t s a n d c o n c e r n s , t h e s a m e o n e s an a u d i e n c e m e m b e r m i g h t hesitate t o reveal t o a p h y s i c i a n b e c a u s e of t h e i r sensitive n a t u r e ( P a r r o t t , in p r e s s - b ) . I n relation t o skin c a n c e r , i n d i v i d u a l s m a y b e c o n c e r n e d a b o u t t h e s c a r r i n g t h a t c o u l d result f r o m h a v i n g a skin c a n c e r r e m o v e d b u t hesitate t o express s u c h a c o n c e r n in t h e fear t h a t it seems vain o r i n a p p r o p r i a t e . T h e s o a p o p e r a c h a r a c t e r , h o w e v e r , c o u l d express this s a m e c o n c e r n a n d p r o v i d e t h e o p p o r t u n i t y for his o r h e r physician to explain h o w s e l d o m s u r g e r y is necessary t o t r e a t a skin c a n c e r a n d h o w m i n i m a l scarring is likely t o b e if s u r g e r y is n e e d e d . In s u m , n o v e l c o n t e n t , s i t u a t i o n s in w h i c h t o p r e s e n t c o n t e n t , o r m o d e s t o deliver c o n t e n t p r o v i d e m e a n s t o p r o m p t p e o p l e t o e n g a g e in m o r e active t h o u g h t a b o u t h e a l t h messages. H e a l t h m e s s a g e d e s i g n e r s s h o u l d c o n s i d e r n o v e l ways t o i n t r o d u c e h e a l t h i n f o r m a t i o n , p a r t i c u l a r l y w h e n t h e i n f o r m a t i o n t o b e p r e s e n t e d deal? w i t h m a t t e r s t h a t m i g h t b e c o n s i d e r e d sensitive o r p o t e n t i a l l y private: Information Processing Passive/Peripheral

Active/Central Bottom-up Top-down • Novel/unusual: = Information = Mode of delivery = Situation

Content and Linguistic

Considerations

13

DISCREPANT OR UNEXPECTED PRESENTATION OF C O N T E N T A s e c o n d c o n d i t i o n t h a t Louis a n d S u t t o n (1991) identify as a m e a n s t o m o t i v a t e a n a u d i e n c e ' s active t h o u g h t is t h e p r e s e n t a t i o n of c o n t e n t t h a t is d i s c r e p a n t o r u n e x p e c t e d . Based o n p r e v i o u s e x p e r i e n c e o r o b s e r v a t i o n , individuals form expectations a b o u t w h a t health messages will say a n d w h e r e p a r t i c u l a r h e a l t h messages will a p p e a r . T h e s e e x p e c t a t i o n s p r o v i d e p e o p l e w i t h t h e o p p o r t u n i t y t o t h i n k a n d b e h a v e in r e s p o n s e t o t h e c o n t e n t o r t h e s e t t i n g in a n a u t o m a t i c fashion (Langer, 1985; Langer, Blank, 8c C h a n o w i t z , 1978). W h e n a n a c t u a l message is i n c o n s i s t e n t w i t h w h a t is e x p e c t e d , active t h o u g h t is triggered. C o n s i d e r messages a b o u t e x p o s u r e t o t h e s u n as o n e e x a m p l e of h o w d i s c r e p a n t p r e s e n t a t i o n of c o n t e n t invokes t h o u g h t . For y e a r s , e x p o s u r e t o s u n l i g h t w a s p r o m o t e d as a m e a n s t o e n h a n c e h e a l t h , specifically in r e l a t i o n t o o b t a i n i n g a d e q u a t e a m o u n t s of vitamin D . In recent years, e x p o s u r e t o t h e s u n is m o r e likely t o b e criticized in t e r m s of t h e d a m a g e t h a t s u c h e x p o s u r e causes t o t h e skin. F o r a u d i e n c e s w h o h a v e b e e n e x p o s e d t o b o t h m e s s a g e s , t h e d i s c r e p a n c y is likely t o p r o d u c e m o r e t h o u g h t a b o u t t h e latter m e s s a g e t h a n w o u l d o c c u r in t h e a b s e n c e of e x p o s u r e t o t h e f o r m e r m e s s a g e . T h e t h o u g h t s g e n e r a t e d m a y , h o w e v e r , lead t o t h e d e v e l o p m e n t of c o u n t e r a r g u m e n t s t o t h e d i s c r e p a n t message (see C h a p t e r 6 in this v o l u m e ) , so m e s s a g e designers m u s t consider all possible o u t c o m e s associated with active t h o u g h t a b o u t a d i s c r e p a n t m e s s a g e t o p r e d i c t t h e a u d i e n c e ' s m o s t likely r e s p o n s e . M e s s a g e s a b o u t c o n d o m s are also likely t o h a v e a s s o c i a t i o n s in t h e m i n d s of m a n y a u d i e n c e m e m b e r s w h o h a v e b e e n e x p o s e d t o p r e v i o u s m e s s a g e s t h a t p r o m o t e c o n d o m use t o p r e v e n t v e n e r e a l disease. As a m e t h o d t o r e d u c e t h e s p r e a d of H I V , messages t h a t p r o m o t e c o n d o m u s e m a y i n v o k e m o r e active t h o u g h t for audiences w h o have already b e e n exposed t o m e s s a g e s a b o u t c o n d o m s a n d sexually t r a n s m i t t e d diseases t h a n in a u d i e n c e m e m b e r s w h o h a v e n o t h a d s u c h e x p o s u r e . I n this i n s t a n c e , a u d i e n c e m e m b e r s m a y well b e able t o assimilate r a t h e r t h a n c o n t r a s t t h e i n f o r m a t i o n , for a l t h o u g h t h e i n f o r m a t i o n is u n e x p e c t e d in view of earlier l e a r n i n g , t h e i n f o r m a t i o n d o e s n o t disagree w i t h w h a t has already b e e n l e a r n e d . F o r a u d i e n c e m e m b e r s w h o use c o n d o m s as a m e t h o d t o p r e v e n t v e n e r e a l disease, a w a r e n e s s t h a t c o n d o m s r e d u c e t h e s p r e a d of H I V m a y reinforce b e h a v i o r . I n relation t o expectations for health messages a b o u t skin cancer a n d A I D S , message designers should consider, too, h o w and where audience m e m b e r s expect to b e exposed to such messages (or t o p u r c h a s e t h e p r o d u c t s p r o m o t e d

14

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APPROACHES

in t h e m e s s a g e s — s u n s c r e e n a n d c o n d o m s ) . T h e s e h e a l t h messages a r e m o s t likely expected to be p a r t of public service a n n o u n c e m e n t s (PSAs) a n d c o m m e r c i a l c a m p a i g n e r s ' displays in d r u g stores. W h a t if, h o w e v e r , f a r m e r s — w h o a r e a c c u s t o m e d t o e n c o u n t e r i n g h e a l t h messages a b o u t f a r m injuries at f e e d s t o r e s — s u d d e n l y also find messages a b o u t skin c a n c e r in feedstores. T h e s e u n e x p e c t e d messages, a l t h o u g h similar t o skin c a n c e r p r e v e n t i o n m e s s a g e s , w h i c h t h e y h a v e b e e n e x p o s e d t o in t h e i r p h y s i c i a n s ' offices, a r e m o r e likely t o g e n e r a t e active t h o u g h t . S o m e fast food r e s t a u r a n t s h a v e i n t r o d u c e d salads a n d skin-free b r o i l e d c h i c k e n s a n d w i c h e s i n t o their m e n u s , partially in r e s p o n s e t o t h e p u b l i c ' s request for such food fare. This, however, provides all c o n s u m e r s with u n e x p e c t e d m e s s a g e s a b o u t n u t r i t i o n a l o p t i o n s t h a t p r o m o t e m o r e active t h o u g h t a b o u t e a t i n g choices a n d health. C o n s u m e r s e x p e c t t o e n c o u n t e r m e s s a g e s a b o u t t h e r e s t a u r a n t ' s " h e a l t h y , " "beefy," "juicy" b u r g e r s — t h e y d o n o t e x p e c t messages a b o u t fat a n d cholesterol in r e l a t i o n t o fast food. If c o n s u m e r s c o m e t o expect s u c h messages in r e s t a u r a n t s as p a r t of t h e i n f o r m a t i o n p r o v i d e d a b o u t t h e m e n u , h o w e v e r , this will r e d u c e t h e effectiveness of t h e i r p r e s e n c e to m o t i v a t e active t h o u g h t . T h e " M e a t - o u t " c a m p a i g n takes a d v a n t a g e of this m e t h o d of i n v o k i n g m o r e c o n s c i o u s t h o u g h t in relation t o t h e c a m p a i g n ' s goal of g e t t i n g i n d i v i d u a l s t o eat less m e a t (Pfau & P a r r o t t , 1993). T h e a n n u a l d a t e for " T h e G r e a t A m e r i c a n M e a t - o u t " falls o n t h e first d a y of s p r i n g , w i t h c a m p a i g n e r s ' messages i n t e n t i o n a l l y i n v o k i n g t h o u g h t s a b o u t n e w life. S u c h t h o u g h t s a r e d i s c r e p a n t w i t h messages t h a t also discuss t h e d e s t r u c t i o n of life t h a t e a t i n g m e a t r e q u i r e s . M o r e o v e r , t h e c a m p a i g n e r s solicit p a r t i c i p a t i o n f r o m r e s t a u r a n t s w h o agree t o p o s t messages a b o u t " M e a t - o u t " a n d p r o v i d e m e a t l e s s m e n u s o n t h e first d a y of s p r i n g . Because s u c h messages a r e i n c o n s i s t e n t w i t h p e o p l e ' s e x p e c t a t i o n s for r e s t a u r a n t s ' m e n u s , t h e y s h o u l d p r o d u c e m o r e active t h o u g h t a b o u t t h e issues s u r r o u n d i n g t h e c a m p a i g n . In s u m , w h e n a h e a l t h m e s s a g e d e s i g n e r ' s goal is t o i n v o k e active t h o u g h t , in a d d i t i o n t o c o n s i d e r i n g n o v e l p r e s e n t a t i o n s of c o n t e n t , d i s c r e p a n t or u n e x p e c t e d messages s h o u l d be c o n s i d e r e d . C o n s i d e r a t i o n s h o u l d also b e given t o t h e settings in w h i c h h e a l t h messages a n d p r o d u c t s are usually delivered a n d w h e t h e r or n o t to e x p a n d these. Designers m a y w a n t to i n c l u d e settings w h e r e o n e k i n d of h e a l t h message a n d / o r p r o d u c t is e x p e c t e d , a n d still o t h e r messages are salient, a n d p r o d u c t s s h o u l d b e u s e d , b u t n e i t h e r a r e available:

Content and Linguistic

Considerations

15

Information Processing Passive/Peripheral

Active/Central Bottom-up Top-down • Unexpected/discrepant: = Information = Mode of delivery = Situation

EXTERNAL OR INTERNAL REQUESTS TO ATTEND L o u i s a n d S u t t o n ' s (1991) t h i r d c o n d i t i o n t o p r o m o t e active m e s s a g e p r o c e s s i n g — u s e of a n e x t e r n a l o r i n t e r n a l r e q u e s t t o a t t e n d — i s e x t r e m e l y r e l e v a n t for h e a l t h m e s s a g e design. E x t e r n a l r e q u e s t s a r e o v e r t s t a t e m e n t s b y a m e s s a g e s o u r c e t h a t explicitly o r implicitly tell a n a u d i e n c e t o i n c r e a s e t h e i r a t t e n t i o n t o t h e m e s s a g e (e.g., " L o o k i n g for t h e a n s w e r t o fast w e i g h t loss? Pay a t t e n t i o n to this."). Internal requests are a message receiver's p s y chological o r physiological response to message stimuli, w h i c h p r o d u c e s a selfc o m m a n d to attend. Although novel or unexpected messages m a y p r o d u c e a c o m m a n d t o a t t e n d , s o m e linguistic f o r m s a n d w o r d choices facilitate t h e r e a c t i o n in a u d i e n c e s regardless of w h e t h e r o r n o t t h e c o r e m e s s a g e c o n t e n t is n o v e l o r u n e x p e c t e d . By s t i p u l a t i n g w h a t l a n g u a g e f e a t u r e s p r o m p t external or internal requests to attend, message designers m a y intentionally c o n s t r u c t c o n t e n t t o take a d v a n t a g e of t h e s e r e l a t i o n s h i p s . N o v e l o r u n e x pected messages might be c o m b i n e d with these suggestions to further facilitate c o n s c i o u s c o n s i d e r a t i o n of m e s s a g e c o n t e n t . E x t e r n a l r e q u e s t s t o increase c o n s c i o u s a t t e n t i o n o c c u r m o s t d i r e c t l y in t h e f o r m of a c o m m a n d t o t h e a u d i e n c e : Now hear this. Pay attention to what's coming next. Don't let anything interrupt this message. Stop whatever else is going on, and get on over here. T h e s e e x a m p l e s o f explicit e x t e r n a l r e q u e s t s t o i n c r e a s e c o n s c i o u s a t t e n t i o n w e r e all t a k e n directly f r o m a single r a d i o s h o w a i r e d in A t l a n t a , G e o r g i a , o n e m o r n i n g . T h e r e is n o t h i n g u n u s u a l a b o u t t h e a p p r o a c h . I n fact, if a s k e d , p e o p l e s e e m m o r e likely t o r e p o r t t h a t t h e s e m e s s a g e s a n n o y t h e m t h a n t o r e p o r t t h a t t h e y increase a t t e n t i o n . Yet, L o u i s a n d S u t t o n ' s review ( 1 9 9 1 ) p o s i t s t h a t s u c h messages o r i e n t t h e listener t o a t t e n d t o t h e c o n t e n t t h a t

THEORY-DRIVEN

16

APPROACHES

follows. E x t e r n a l requests m a y also b e c o n s t r u c t e d in t h e f o r m of a q u e s t i o n w i t h v a r y i n g levels of directness: Is everyone listening for information about the upcoming flu season? (Implicit: If not, please do.) How many listeners know what to do when faced with someone who has an alcohol or drug problem? (Implicit: Pay attention to find out.) M a n y c a m p a i g n messages are f o r m e d a r o u n d s u c h q u e s t i o n s , w h i c h facilitate increased audience attention. W h e r e a s d e s i g n i n g messages t h a t direct a u d i e n c e s t o " P a y a t t e n t i o n t o t h e u p c o m i n g a n n o u n c e m e n t " exemplifies t h e use of e x t e r n a l cues t o att e n d , i n t e r n a l r e q u e s t s t o a t t e n d m a y also b e triggered b y i n t e n t i o n a l m e s sage d e s i g n . I n t e r n a l requests to a t t e n d are a u d i e n c e m e m b e r s ' p r o m p t s t o t h e m s e l v e s t o " p a y m o r e a t t e n t i o n " t o t h e c o n t e n t of a m e s s a g e in r e a c t i o n t o w h a t they have heard. In o n e sense, all of the m e t h o d s described t o increase active t h o u g h t p r o d u c e s u c h a r e s p o n s e . H o w e v e r , an analysis of t h e f o r m e r m e t h o d s t h a t p r o d u c e active r e s p o n s e s in listeners leads t o t h e identification of m a c r o t h e m e s o r r e a s o n s for t h e a u d i e n c e m e m b e r s ' cognitive effort, s u c h as t h e use of novel, d i s c r e p a n t , or u n e x p e c t e d i n f o r m a t i o n , a n d o v e r t c o m m a n d s t o a t t e n d . Message designers s h o u l d also e x a m i n e t h e m a n y m i c r o level d e c i s i o n s t h a t m u s t be m a d e , as t h e s e a v e n u e s p r o v i d e o t h e r m e a n s t o m o t i v a t e a u d i e n c e s t o process i n f o r m a t i o n actively. P e r h a p s m o s t critically, m e s s a g e d e s i g n e r s m u s t decide w h a t w o r d s t o use in c o n s t r u c t i n g c o n t e n t . I n t e r n a l r e q u e s t s t o a t t e n d m a y o c c u r in r e s p o n s e t o t h e precise w o r d s selected t o design h e a l t h messages. N u m e r o u s m e s s a g e design r e s e a r c h e r s r e c o m m e n d a v o i d i n g a m b i g u o u s l a n g u a g e in t h e design of h e a l t h messages (Siegel, 1988). O n e r e a s o n for this r e c o m m e n d a t i o n is t h a t these m e s s a g e s are likely t o be m i s u n d e r s t o o d b y audiences. Phrases such as multiple partners a n d sexual activity c a r r y m o r e t h a n o n e m e a n i n g . M o r e o v e r , t o p e r s o n a l i z e h e a l t h messages, t h e selection of s o m e w o r d s v e r s u s o t h e r s creates p s y c h o logical d i s t a n c e b e t w e e n t h e message a n d t h e a u d i e n c e . T h e l a n g u a g e c o n s t r u c t of verbal i m m e d i a c y p r o v i d e s insights a b o u t h o w t o a v o i d d i s t a n c i n g t h e m e s s a g e f r o m t h e a u d i e n c e . Verbal immediacy is defined as t h e d e g r e e of directness between a c o m m u n i c a t o r a n d the objects or events a b o u t w h i c h h e or she is c o m m u n i c a t i n g , as d e t e r m i n e d b y p r o n o u n c h o i c e , v e r b tense, object referents, a n d the context of language use (Wiener 8c M e h r a b i a n , 1968). I m m e d i a c y increases s e n s o r y s t i m u l a t i o n ( A n d e r s o n , 1985), w i t h verbal i m m e d i a c y facilitating a message receiver's a w a r e n e s s of i n f o r m a t i o n c o n -

Content and Linguistic

Considerations

17

t a i n e d in u t t e r a n c e s b u t n o t necessarily asserted in t h e d i s c o u r s e ( W i e n e r 8c M e h r a b i a n , 1968). N o n i m m e d i a t e language c o m m u n i c a t e s avoidance, w h e r e as i m m e d i a t e language c o m m u n i c a t e s approachability, e n h a n c i n g t h e a t t e n t i o n given t o issues ( H e s s 8c Gossett, 1974) o r p e r s o n s ( K u i k e n , 1981). W i e n e r a n d M e h r a b i a n (1968) h a v e identified several categories o f s p e e c h t h a t c o m m u n i c a t e avoidance versus approachability. F o u r forms t h a t s h o u l d b e c o n s i d e r e d w h e n e v a l u a t i n g t h e i m m e d i a c y of l a n g u a g e u s e will b e d i s c u s s e d in r e l a t i o n t o d e s i g n i n g h e a l t h messages. Denotative Speäfiäty. D e n o t a t i v e l y specific s p e e c h explicitly states t h e agent, object, a n d / o r action in a message ( W i e n e r 8c M e h r a b i a n , 1968). M e s s a g e d e s i g n e r s m u s t d e c i d e b e t w e e n t h e use of i m m e d i a t e w o r d s t h a t m a k e explicit references t o specific a g e n t s , objects, o r a c t i o n s — o r n o n i m m e d i a t e w o r d s t h a t refer t o general categorical a g e n t s , objects, a n d a c t i o n s . I n t h e s t a t e m e n t s , " Y o u s h o u l d w e a r s u n s c r e e n t o p r o t e c t y o u r skin f r o m t h e s u n " v e r s u s " P e o p l e s h o u l d w e a r s u n s c r e e n t o p r o t e c t their skin from t h e s u n , " t h e first p e r s o n p r o n o u n specifically designates a n explicit a g e n t in reference t o t h e a c t i o n , w h e r e a s t h e s e c o n d s e n t e n c e c o n t a i n s a categorical class for t h e a g e n t in reference t o t h e a c t i o n . T h e u s e of d e n o t a t i v e l y specific l a n g u a g e e n h a n c e s t h e a t t e n t i o n given t o t h e m e s s a g e b y p e r s o n a l i z i n g a n d simplifying t h e message: T h e listener d o e s n o t h a v e t o c o n s i d e r w h e t h e r o r n o t t h e message is relevant b e c a u s e t h e m e s s a g e c o n t a i n s trigger w o r d s t h a t state its relevance. S i m p l e r m e s s a g e s h a v e b e e n f o u n d t o b e p r o c e s s e d w i t h m o r e cognitive effort t h a n a r e c o m p l e x m e s s a g e s , as e v i d e n c e d b y t h e l o n g e r r e a c t i o n t i m e s t h a t result f r o m e x p o s u r e t o s i m p l e versus c o m p l e x messages (Reeves 8c T h o r s o n , 1986). T h i s m a y b e d u e t o s u c h messages triggering p e r c e p t i o n s of p e r s o n a l r e s p o n sibility, for e x a m p l e , w h i c h have b e e n f o u n d t o facilitate active t h o u g h t ( L a n g e r 8c R o d i n , 1976), or t h e use of self-references, w h i c h i n c r e a s e p e r suasive effectiveness of a p p e a l s ( B u r n k r a n t 8c U n n a v a , 1989). C o n s i d e r t h e following m e s s a g e , w h i c h a p p e a r s in a skin c a n c e r b r o c h u r e p u b l i s h e d b y t h e A m e r i c a n C a n c e r Society (1985):

H O W IS SKIN CANCER TREATED?

Physicians have several different methods to choose from depending o n the size of the skin cancer, position on the body and risks to the patient. Mainly they are surgery, electrical current, radiation therapy, and freezing. Sometimes a combination of therapies are used. Afterward, if the extent of the defect warrants it, some form of plastic surgery may be used to improve appearance.

18

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Physicians, methods, a n d nsks are all e x a m p l e s of use of categorical t e r m s . T h e first t w o s t a t e m e n t s can b e stated m o r e specifically in t h e following way: " Y o u r dermatologist m a y choose surgery, electrical current, radiation t h e r a p y , o r freezing, or s o m e c o m b i n a t i o n of these t o treat y o u r skin c a n c e r . " T h i s d e n o t a t i v e l y specific w o r d i n g m o r e explicitly a n d s i m p l y i n f o r m s t h e r e a d e r of t h e t y p e o f physician to see for t r e a t m e n t of skin cancer. I n a d d i t i o n , t h e self-reference ( " y o u r " ) triggers active i n f o r m a t i o n p r o c e s s i n g b y clarifying t h e a u d i e n c e ' s r e l a t i o n s h i p t o t h e message; t h e revised m e s s a g e also c o n c i s e ly identifies t h e " m e t h o d s " o f t r e a t m e n t . M o r e explicit i n f o r m a t i o n a b o u t t h e " r i s k s " t h a t physicians c o n s i d e r in o r d e r t o m a k e a t r e a t m e n t d e c i s i o n w o u l d r e d u c e t h e l i k e l i h o o d t h a t a p a t i e n t will reach u n w a r r a n t e d c o n c l u s i o n s in this r e g a r d . "Risks," in o t h e r w o r d s , m a y a p p e a r o m i n o u s a n d act as a b a r r i e r to t h o u g h t a b o u t t h e m e s s a g e . I n s u m , t o i n v o k e m o r e c o n s c i o u s t h o u g h t a b o u t a verbal message, m e s s a g e d e s i g n e r s s h o u l d select m o r e d e n o t a t i v e l y specific language. 1

Spatial Immediacy. A s e c o n d form of speech t h a t m a y b e u s e d t o e n h a n c e v e r b a l i m m e d i a c y is t h e use of d e m o n s t r a t i v e s , s u c h as this, these, a n d here in contrast to use of that, those, a n d there ( W i e n e r 8c M e h r a b i a n , 1968). M o r e over, t h e i n t r o d u c t i o n of adverbial clauses w i t h where o r o t h e r w o r d s a n d p h r a s e s d e n o t i n g physical o r spatial s e p a r a t i o n d e t r a c t s f r o m i m m e d i a c y of e x p r e s s i o n . E x a m i n e these messages: Message A: "This is your brain . . . This is your brain on drugs . . . Any questions?" Message B: "That was a person's brain . . . That was a person's brain after using drugs . . . Any questions?" T h e w i d e l y d i s s e m i n a t e d v e r s i o n c o n t a i n e d in M e s s a g e A is b o t h spatially i m m e d i a t e a n d d e n o t a t i v e l y specific. I n c o n t r a s t , Message Β s e e m s less p e r s o n a l , involving, o r explicit. T h e use of spatially i m m e d i a t e d e m o n s t r a tives e n h a n c e s t h e a t t e n t i o n given t o a verbal m e s s a g e . Temporal Immediacy. A t h i r d f o r m of l a n g u a g e use t h a t e n h a n c e s verbal i m m e d i a c y is t h e selection of p r e s e n t tense verbs in reference t o p r e s e n t events ( W i e n e r 8c M e h r a b i a n , 1968). A n u m b e r of r e s e a r c h e r s s t u d y i n g t h e effects of l a n g u a g e use d u r i n g t h e r a p e u t i c e n c o u n t e r s h a v e f o u n d t h a t v e r b t e n s e affects p e r c e p t i o n s of context: " T h e v e r b tenses, as c o n t e x t m a r k e r s ,

Content and Linguistic

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19

will f u n c t i o n a t a n o u t - o f - a w a r e n e s s level a n d b e vitally i m p o r t a n t t o t h e t h e r a p i s t w h o wishes t o deal w i t h t h e overall c o n t e x t of t h e i n t e r a c t i o n " ( P h o e n i x 8c L i n d e m a n , 1982, p . 8 ) . R e s e a r c h o n l e a r n i n g h a s d e m o n s t r a t e d t h a t l e a r n i n g is i m p a i r e d if i n structional material misdirects attention, with one m e t h o d of misdirecting a t t e n t i o n b e i n g t o u s e i n a p p r o p r i a t e v e r b t e n s e (Sweller, C h a n d l e r , T i e r n e y , 8c C o o p e r , 1990). M e s s a g e Β a b o v e is also t e m p o r a l l y n o n i m m e d i a t e , f u r t h e r i n h i b i t i n g t h e l i k e l i h o o d t h a t an a u d i e n c e will u n d e r s t a n d a n d r e m e m b e r t h e vivid verbal m e t a p h o r , even w h e n the visual image of an egg frying r e m a i n s c o n s t a n t , a n d o n l y t h e w o r d s selected t o c o n v e y t h e m e s s a g e c h a n g e . U s e of temporally immediate language generates an internal request to attend. Qualifiers. O n e final t y p e of l a n g u a g e t h a t d e s i g n e r s s h o u l d c o n s i d e r w h e n e v a l u a t i n g t h e i m m e d i a c y of a message is use o f qualifiers, t h e w o r d s o r p h r a s e s t h a t express u n c e r t a i n t y ( W i e n e r 8c M e h r a b i a n , 1968). S u c h w o r d s as perhaps, may, maybe, a n d possibly all i n t r o d u c e r o o m for d o u b t . Similarly, p h r a s e s s u c h as it could be a n d it might be suggest u n c e r t a i n t y . T h e following m e s s a g e from t h e G e o r g i a D e p a r t m e n t o f H u m a n R e s o u r c e s ' W I C P r o g r a m a n d t h e Office of N u t r i t i o n in t h e b r o c h u r e , Good Beginnings for Having a Healthy Baby, exemplifies such use: "Avoid eating l a u n d r y starch, c o r n s t a r c h , d i r t , clay, flour, chalk, a n d ashes b e c a u s e t h e y m a y b e h a r m f u l . " A m o n g m a n y r u r a l w o m e n in s o m e S o u t h e a s t e r n states, t h e p r a c t i c e o f e a t i n g w h i t e d i r t o r clay is c o m m o n , w i t h t h e c o n s u m p t i o n b e i n g related t o a n e m i a (Beasley, 1993). Yet, the message that appears in the W I C b r o c h u r e is qualified t h r o u g h t h e use of may a n d a p p e a r s unlikely t o m o t i v a t e m a n y p r e g n a n t w o m e n t o give t h e m e s s a g e o r t h e i r b e h a v i o r , if t h e y a r e e a t i n g d i r t , a s e c o n d t h o u g h t . A v o i d use of qualifiers t o facilitate a t t e n t i o n t o a h e a l t h m e s s a g e . In s u m , t o m o t i v a t e a u d i e n c e s t o a t t e n d h e a l t h m e s s a g e s c o n s c i o u s l y a n d actively, c o n s i d e r a t i o n s h o u l d b e given t o t h e selection of specific s p e e c h i n d i c e s t o trigger i n t e r n a l r e q u e s t s t o a t t e n d :

Information Processing Passive/Peripheral

Active/Central Bottom-up Top Top-down • Immediate language = Denotatively specific = Spatially immediate = Temporally immediate = Without qualifiers

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T h e s e f o r m s of l a n g u a g e use p r o v i d e t h e m e a n s n o t o n l y t o i n c r e a s e a w a r e ness b u t to p r o m p t behavioral change as well. O n e s t u d y that e x a m i n e d a d u l t s ' u n d e r s t a n d i n g of skin c a n c e r ' s causes f o u n d t h a t an i m m e d i a t e m e s s a g e i n c r e a s e d a w a r e n e s s m o r e t h a n a n o n i m m e d i a t e m e s s a g e ( P a r r o t t , 1993). A n o t h e r s t u d y d e m o n s t r a t e d that college students increased c o n d o m use after receiving a n i m m e d i a t e message p r o m o t i n g A I D S p r e v e n t i o n , b u t s t u d e n t s w h o received t h e n o n i m m e d i a t e message d e m o n s t r a t e d n o differences in use (Saisslin & P a r r o t t , 1993).

Conclusion T h e desire t o discover w h a t m o t i v a t e s p e o p l e to b e h a v e o r n o t to b e h a v e in their o w n best h e a l t h interests has p u z z l e d a n d i n s p i r e d r e s e a r c h e r s from m a n y disciplines for m a n y years (e.g., Glanz, Kirscht, & R o s e n s t o c k , 1 9 8 1 ; T a l k i n g t o n , 1978; W e b b , 1980; Zifferblatt, 1975). At t i m e s , p e o p l e i n t e n tionally seek i n f o r m a t i o n a b o u t h e a l t h m a t t e r s , a g o a l - o r i e n t e d activity t h a t is likely t o b e associated w i t h c o n s c i o u s a t t e n t i o n a n d t h e e x e r t i o n of m e n t a l effort t o w a r d t h e e n d of satisfying a p a r t i c u l a r n e e d . U n f o r t u n a t e l y , t h e g o a l - o r i e n t e d n e e d for h e a l t h i n f o r m a t i o n m o s t often o c c u r s b e c a u s e i n d i v i d u a l s or s o m e o n e t h e y k n o w a c q u i r e a n illness o r disease t h a t m i g h t h a v e b e e n p r e v e n t e d h a d t h e y actively p r o c e s s e d i n f o r m a t i o n earlier. In o r d e r t o facilitate active t h o u g h t a b o u t h e a l t h messages in t h e a b s e n c e of a p e r c e i v e d n e e d , several guidelines s h o u l d b e c o n s i d e r e d , as d e v e l o p e d in this c h a p t e r , in r e l a t i o n t o p r e s e n t a t i o n of c o n t e n t a n d linguistic variables t h a t m o t i v a t e c o g n i t i v e effort: 1. Use novel messages, settings, and media to present health messages. 2. Consider discrepant and unexpected messages, settings, and media to present traditional health messages. 3. Instruct the audience to pay attention to the message. 4. Construct health messages in a denotatively specific manner. 5. Choose spatially immediate demonstratives. 6. Use temporally immediate speech. 7. Avoid the use of qualifiers in relation to establishing a need to change behaviors; instead, identify the probabilities associated with specific outcomes of certain behaviors.

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21

As a r e s u l t of c o n s i d e r i n g t h e s e m a t t e r s , M e n d e l s o h n ' s ( 1 9 6 8 ) p r o m i s e r e g a r d i n g m e d i a ' s p o t e n t i a l t o affect p e o p l e ' s b e h a v i o r s positively in r e l a t i o n t o h e a l t h will m o r e often b e a t t a i n e d .

Note 1. Moreover, as the message appears, the use of the personal pronoun they in reference to surgery, electrical current, radiation therapy, and freezing may be misinterpreted in reference to "risks to the patient," due to the location of the pronoun in relation to methods versus risks. They, as the message reads, modifies the risks to the patient—undoubtedly not the intended meaning of the writer.

References American Cancer Society. (1985). Fry now: Pay later (No. 2611-LE). New York: Author. Anderson, P. A. (1985). Nonverbal immediacy in interpersonal communication. In A. W. Siegman & S. Feldstein (Eds.), Multichannel integrations of nonverbal behavior (pp. 105-128). Hillsdale, NJ: Lawrence Erlbaum. Beasley, D. (1993, January 9). Trying to stop a dirty habit: Macon doctor behind drive against unhealthy, age-old craving for kaolin. Atlanta Journal & Constitution, p. B2. Behrman, M., Moscovitch, M., 8c Mozer, M. C. (1991). Directing attention to words and nonwords in normal subjects and in a computational model: Implications for neglect dyslexia. Cognitive Neuropsychology, 3, 213-248. Borgida, E., 8c Howard-Pitney, B. (1983). Personal involvement and the robustness of perceptual salience effects. Journal of Personality and Sodal Psychology, 45, 560-570. Burnkrant, R. E., 8c Unnava, H. R. (1989). Self-referencing: A strategy for increasing processing of message content. Personality and Social Psychology Bulletin, 15, 628-638. Chaiken, S., 8c Eagly, A. H. (1976). Communication modality as a determinant of message persuasiveness and message comprehensibility. Journal of Personality and Social Psychology, 34, 605-614. Chanowitz, B., 8c Langer, Ε. J. (1981). Premature cognitive commitment. Journal of Personality and Social Psychology, 41, 1051-1063. Freimuth, V. S., Hammond, S. L., Edgar, T., 8c Monahan, J. L. (1990). Reaching those at risk: A content-analytic study of AIDS PSAs. Communication Research, 17, 775-991. Glanz, Κ., Kirscht, J. P., 8c Rosenstock, I. M. (1981). Linking research and practice in patient education for hypertension. Medical Care, 19, 141-152. Green, S. K., Lightfoot, Μ. Α., Bandy, C , 8c Buchanan, D. R. (1985). A general model of the attribution process. Basic and Applied Social Psychology, 6, 159-179. Hess, A. K., 8c Gossett, D. (1974). Nixon and the media: A study of non-immediacy in newspaper editorials as reflective of geographical attitude differences. Psychobgical Reports, 34, 1055-1058. Johnson, J. D., Meischke, H., Grau, J., 8c Johnson, S. (1992). Cancer-related channel selection. Health Communication, 4, 183-196.

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Kuiken, D. (1981). Nonimmediate language style and inconsistency between private and expressed evaluations. Journal ofExperimental Social Psychology, 17, 183-196. Langer, Ε. J. (1978). Rethinking the role of thought in social interaction. In J. H. Harvey, W. J. Ickes, 8c R. F. Kidd (Eds.), New directions in attribution research (Vol. 2, pp. 35-58). Hillsdale, NJ: Lawrence Erlbaum, Langer, Ε. J. (1985). Playing the middle against both ends: The usefulness of adult cognitive activity as a model for cognitive activity in childhood and old age. In S. R. Yussen (Ed.), The growth of reflection in children (pp. 267-285). New York: Academic Press. Langer, Ε., Blank, Α., & Chanowitz, Β. (1978). The mindlessness of ostensibly thoughtful action: The role of "placebic" information in interpersonal interaction. Journal of Personality and Social Psychology, 36, 635-642. Langer, Ε. J., 8c Rodin, J. (1976). The effects of choice and enhanced personal responsibility for the aged: A field experiment in an institutional setting. Journal of Personality and Social Psychology, 34, 191-198. Larson, M. S. (1991). Health-related messages embedded in prime-time television entertainment. Health Communication, 3, 175-184. Levy, M. R., 8c Windahl, S. (1985). The concept of audience activity. In Κ. E. Rosengren, L. A. Wenner, 8c P. Palmgreen (Eds.), Media gratifications research: Current perspectives (pp. 109-122). Beverly Hills, CA: Sage. Louis, M. R., 8c Sutton, R. I. (1991). Switching cognitive gears: From habits of mind to active thinking. Human Relations, 44, 55-76. Maibach, E. (1991). Selling prevention: A public health communication perspective. Cosmetics & Toiletries, 106, 39-40. McDuffie, D. (1993a, February). Hit and run. In T. DeFalco (Ed.), The amazing Spiderman, 1-3, pp. 1-30. McDuffie, D. (1993b, February). Skating on thin ice. In T. DeFalco (Ed.), The amazing Spiderman, 1-1, pp. 1-30. McGuire, W. J. (1986). The myth of massive media impact: Savagings and salvagings. In G. Comstock (Ed.), Public communication and behavior (Vol. 1, pp. 173-257). Newbury Park, CA: Sage. McGuire, W. J. (1989). Theoretical foundations of campaigns. In R. E. Rice 8c C. K. Atkin (Eds.), Public communication campaigns (2nd ed.) (pp. 43-66). Newbury Park, CA: Sage. Mendelsohn, H. (1968). Which shall it be: Mass education or mass persuasion for health? American Journal of Public Health, 58, 131-137. Park, C. W., 8c Smith, D. C. (1989). Product-level choice: A top-down or bottom-up process? Journal of Consumer Research, 16, 289-299. Parrott, R. (1993). Adults' knowledge, perceptions of vulnerability, and outcome expectations: A formative evaluation. Manuscript submitted for publication. Parrott, R. (in press-a). Comic book heroes battle a tough enemy in AIDS. In L. K. Fuller (Ed.), Media-mediated AIDS: Messages about transmission and risk. Amherst, MA: Human Resource Development Press. Parrott, R. (in press-b). Topic and person-centered "sensitive subjects": Managing barriers to disclosure about health. In L. K. Fuller 8c L. M. Shilling (Eds.), Communicating about communicable diseases. Amherst, MA: Human Resource Development Press. Parrott, R., Greene, K., 8c Parker, R. (1992). Negotiating child health care routines through paediatrician-parent conversations. Journal ofLanguage and Social Psychology, 11,35-45. Pechmann, C , 8c Stewart, D. W. (1989). The multidimensionality of persuasive communications: Theoretical and empirical foundations. In P. Cafferata 8c A. M. Tybout (Eds.),

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Considerations

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Cognitive and affective responses to advertising (pp. 31-56). Lexington, MA: Lexington Books. Petty, R. E., & Cacioppo, J. T. (1986). The elaboration likelihood model of persuasion. Advances in Experimental Social Psychology, 19, 123-205. Petty, R. E., Cacioppo, J. T., 8c Goldman, R. (1981). Personal involvement as a determinant of argument-based persuasion. Journal of Personality and Social Psychology, 37,1915-1926. Petty, R. E., Cacioppo, J. T., 8c Schumann, D. (1983). Central and peripheral routes to advertising effectiveness: The moderating role of involvement. Journal of Consumer Research, 10, 135-146. Pfau, Μ. (1990). A channel approach to television influence. Journal of Broadcasting and Electronic Media, 34, 195-214. Pfau, Μ., 8c Parrott, R. (1993). Persuasive communication campaigns. Needham Heights, MA: Allyn 8c Bacon. Phoenix, V. G., 8c Lindeman, M. L. (1982). Language patterns and therapeutic change. In R. D. Pietro (Ed.), Linguistics and the professions: Proceedings of the second annual Delaware Symposium on Language Studies (pp. 3-11). Norwood, NJ: Ablex. Reeves, B., 8c Thorson, E. (1986). Watching television: Experiments on the viewing process. Communication Research, 13, 343-361. Saisslin, R., 8c Parrott, R. (1993). Use of verbal immediacy to personalize an AIDS message: Effects on college students' condom use. Manuscript under review. Siegel, Κ. (1988). Public education to prevent the spread of HIV infection. New York State Journal of Medicine, 88, 642-646. Skin Cancer Foundation. (1985). It's never too early to stop skin cancer ...or too late. New York: Skin Cancer Foundation. Sweller, J., Chandler, P., Tierney, P., 8c Cooper, M. (1990). Cognitive load as a factor in the structuring of technical material. Journal of Experimental Psychology, 119, 176-192. Talkington, D. R. (1978). Maximizing patient compliance by shaping attitudes of self-directed health care. The Journal of Family Practice, 6, 591-595. Webb, P. A. (1980). Effectiveness of patient education and psychosocial counseling in promoting compliance and control among hypertensive patients. The Journal of Family Practice, 10, 1047-1055. Wiener, M., 8c Mehrabian, A. (1968). Language within language: Immediacy, a channel in verbal communication. New York: Appleton-Century-Crofts. Zifferblatt, S. M. (1975). Increasing patient compliance through the applied analysis of behavior. Preventive Medicine, 4, 173-182.

2

Encouraging Risk Reduction A DECISION-MAKING APPROACH TO MESSAGE DESIGN

DAVID R. HOLTGRÄVE BARBARA J. TINSLEY LINDA S. KAY

D

ecisions a r e m a d e in t h e h o p e t h a t t h e y will result in g o o d o u t c o m e s (Yates, 1990). H o w e v e r , s h o r t - t e r m benefits (e.g., t h e p e r c e i v e d pleasu r e of h a v i n g sex w i t h o u t a c o n d o m ) s o m e t i m e s a r e c h o s e n o v e r l o n g - t e r m benefits (e.g., a r e d u c e d probability of developing AIDS with consistent c o n d o m use). O t h e r times, t h e effort required t o m a k e a decision m a y b e o v e r w h e l m i n g , a n d p e o p l e m a y elect s i m p l y n o t t o d e c i d e (e.g., s o m e o n e m a y c h o o s e t o d o w h a t e v e r their sexual p a r t n e r w a n t s t o d o r e g a r d i n g c o n d o m u s e ) . O n o t h e r o c c a s i o n s , p e o p l e m i g h t arrive at very different d e c i s i o n s j u s t b e c a u s e t h e y h e a r identical i n f o r m a t i o n w o r d e d in slightly different ways (e.g., a c o u p l e m i g h t disagree o n t h e usefulness of c o n d o m s because o n e p e r s o n h a s h e a r d a r e p o r t t h a t c o n d o m s are 9 8 % effective against H I V t r a n s m i s s i o n , w h e r e a s t h e o t h e r has h e a r d t h a t c o n d o m s h a v e a 2 % failure r a t e ) . T h e s t u d y of these a n d related p h e n o m e n a is the d o m a i n of the field ofbehavioral d e c i s i o n m a k i n g ( B D M ) (Arkes 8c H a m m o n d , 1986; D a w e s , 1988; H o g a r t h , 1987; H o g a r t h 8c R e d e r , 1986; v o n W i n t e r f e l d t 8c E d w a r d s , 1986; Yates, 1990). AUTHORS' NOTE: The authors thank J. Carlos Rivero, Rob Hamm, Ann Bostrom, Caryn Christensen, and the editors for insightful theoretical discussions and commentary. Although the original empirical research on environmental decision making described herein was funded wholly or in part by the United States Environmental Protection Agency under assistance agreement #CR817465 to the University of Oklahoma while David R. Holtgräve was a faculty member there in the Clinical Decision Making Program, Department of Family Medicine, it may not necessarily reflect the views of the Agency and no official endorsement should be inferred.

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B D M is largely c o n c e r n e d w i t h t h e cognitive processes b y w h i c h h u m a n s perceive, s t r u c t u r e , a n d evaluate alternative c o u r s e s of a c t i o n . It goes far b e y o n d t h e relatively simplistic cost-benefit c o m p o n e n t s i n c l u d e d in t h e h e a l t h belief m o d e l , t h e t h e o r y of r e a s o n e d action a n d p r o t e c t i o n m o t i v a t i o n t h e o r y (for a c o m p a r i s o n of t h o s e t h e o r i e s , see W e i n s t e i n , 1993). B D M r e s e a r c h i n c l u d e s t h e s t u d y of risk p e r c e p t i o n , p r o b l e m s t r u c t u r i n g , c o n s e q u e n c e ( o u t c o m e ) valuation, probability j u d g m e n t , a n d heuristics a n d biases. T h e last a r e a c o n s i d e r s h o w p e o p l e use cognitive s h o r t c u t s in t h e i r d e c i s i o n m a k i n g a n d h o w t h e i r j u d g m e n t displays c o n s i s t e n t biases ( K a h n e m a n , Slovic, & Tversky, 1982). A l t h o u g h m u c h effort in t h e B D M field h a s b e e n e x p e n d e d in d e v e l o p i n g descriptive t h e o r i e s of h o w p e o p l e actually do m a k e d e c i s i o n s ( C a m e r e r , 1992; L o p e s , 1990; Yates, 1 9 9 0 , 1 9 9 2 ) , n o n e h a s g a i n e d u n i v e r s a l a c c e p t a n c e . For t h a t r e a s o n , this c h a p t e r d o e s n o t p u t f o r t h o n e particular descriptive B D M theory, b u t rather draws broadly o n t h e B D M literature.

CHAPTER OVERVIEW In t h i s c h a p t e r , w e take from t h e B D M l i t e r a t u r e t h e o r e t i c a l c o n s t r u c t s a n d e m p i r i c a l lessons t h a t can b e u s e d t o g u i d e a n d i m p r o v e t h e d e v e l o p m e n t of h e a l t h c o m m u n i c a t i o n messages. H e r e w e m o d i f y a n d u p d a t e F i s c h h o f f s ( 1 9 8 9 b ; Fischhoff, B o s t r o m , 8c Q u a d r e l , 1993) s u r v e y of B D M r e s e a r c h for u s e in risk c o m m u n i c a t i o n c a m p a i g n s , e m p h a s i z e d e v e l o p m e n tal c o n s i d e r a t i o n s , a n d c o m b i n e t h e B D M lessons w i t h a stage of b e h a v i o r c h a n g e f r a m e w o r k . A stage of b e h a v i o r c h a n g e f r a m e w o r k is i m p o r t a n t t o u s e b e c a u s e , at best, c o m m u n i c a t i o n c a m p a i g n s will c a u s e p e o p l e t o m a k e incremental movements toward behavior change, and various B D M cons t r u c t s a r e m o r e a p p r o p r i a t e for use at p a r t i c u l a r stages of t h e s e i n c r e m e n t a l steps ( P r o c h a s k a , D i C l e m e n t e , 8c N o r c r o s s , 1992). It is also i m p o r t a n t t o c o n s i d e r d e v e l o p m e n t a l issues b e c a u s e it h a s b e e n s h o w n t h a t child a n d a d o l e s c e n t d e c i s i o n m a k i n g differ from a d u l t d e c i s i o n m a k i n g ( B a r o n 8c B r o w n , 1 9 9 1 ; Fischhoff, 1992; H o l t g r ä v e , Tinsley, 8c Kay, in p r e s s ) ; h o w e v e r , d e v e l o p m e n t a l B D M d a t a is less available t h a n d a t a o n a d u l t s . This material is covered in three major sections below. First, stage of c h a n g e m o d e l s a r e briefly reviewed. S e c o n d , specific B D M c o n s t r u c t s a r e d e s c r i b e d that can be used by communication campaigns to help m o v e audience m e m b e r s f r o m o n e stage of b e h a v i o r c h a n g e t o t h e n e x t . T h e s e a r e a c c o m p a n i e d b y e x a m p l e s , m o s t of w h i c h are related t o H I V p r e v e n t i o n m e s s a g e s . D e v e l o p m e n t a l issues are also c o v e r e d t h r o u g h o u t this s e c t i o n w h e n e v e r

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r e l e v a n t d a t a is available. T h e final section gives c o n c l u s i o n s a n d d e s c r i b e s a p r o p o s e d research a g e n d a .

Stage Models of Behavior Change N o n s t a g e t h e o r i e s a n d m o d e l s of p r e v e n t i v e b e h a v i o r (e.g., t h e h e a l t h belief m o d e l , t h e o r y of r e a s o n e d a c t i o n , a n d p r o t e c t i o n m o t i v a t i o n t h e o r y ) view b e h a v i o r c h a n g e o r a d o p t i o n as m o v e m e n t a l o n g a single c o n t i n u u m of a c t i o n . T h e y a s s u m e t h a t t h e relative p r o b a b i l i t y of a p e r s o n t a k i n g a c t i o n is a m a t h e m a t i c a l function of t h a t i n d i v i d u a l ' s a t t i t u d e s a n d beliefs. W h i c h factors a r e i n c l u d e d in this f u n c t i o n , h o w t h e y are w e i g h t e d , a n d their i n t e r a c t i o n s a r e a s s u m e d t o b e c o n s t a n t from t h e t i m e o n e l e a r n s of a t h r e a t t o t h e t i m e a c t i o n is t a k e n ( W e i n s t e i n , 1988). In c o n t r a s t , stage m o d e l s view b e h a v i o r c h a n g e as a series of a c t i o n s or e v e n t s . T h e s e m o d e l s allow researchers t o detect m o v e m e n t t o w a r d a b e h a v ior c h a n g e a m o n g p e o p l e w h o h a v e n o t yet a t t a i n e d t h e b e h a v i o r c h a n g e . In a d d i t i o n , investigators can see t h e influence of factors at t h e b e g i n n i n g a n d t h r o u g h - o u t t h e c h a n g e process, r a t h e r t h a n e x p e c t i n g all factors t o i m p a c t t h e e n d p r o d u c t of actual b e h a v i o r c h a n g e or a d o p t i o n ( P r o c h a s k a et al., 1992; W e i n s t e i n & S a n d m a n , 1992). A c c o r d i n g to W e i n s t e i n (1988), a stage t h e o r y suggests t h a t (a) p e o p l e at different stages in t h e c h a n g e p r o c e s s b e h a v e in qualitatively d i s t i n c t ways, a n d (b) t h e i n t e r v e n t i o n s n e e d e d t o m o v e p e o p l e t o w a r d t h e d e s i r e d b e h a v ior vary b y stage. T h u s , an effective p r o g r a m in o n e situation m a y b e i n a p p r o p r i a t e in a n o t h e r ( C a t a n i a , Kegeles, 8c C o a t e s , 1990; P r o c h a s k a et al., 1992; W e i n s t e i n 8c S a n d m a n , 1992). T h r e e of t h e stage m o d e l s c u r r e n t l y in u s e a r e t h e A I D S risk r e d u c t i o n m o d e l ( A R R M ) ( C a t a n i a , Kegeles, 8c C o a t e s , 1992), t h e p r e c a u t i o n a d o p t i o n process ( P A P ) ( W e i n s t e i n , 1988; W e i n s t e i n 8c S a n d m a n , 1992), a n d t h e stages of c h a n g e m o d e l ( D i C l e m e n t e 8c P r o c h a s k a , 1985; P r o c h a s k a et a l , 1992; B a r a n o w s k i , 1992-1993). W e h a v e c h o s e n t o elaborate h e r e o n the stages of change (SOC) m o d e l a n d to use it as the f r a m e w o r k for t h e selected B D M c o n s t r u c t s b e c a u s e of t h e extensive t e s t i n g of t h e m o d e l a n d t h e w e a l t h of e m p i r i c a l d a t a t h a t s u p p o r t it. T h e S O C m o d e l , d e r i v e d from diverse theories of p s y c h o t h e r a p y , p r o poses five stages: Precontemplative (PC)—not recognizing the p r o b l e m o r t h e n e e d t o c h a n g e ; Contemplative (C)—seriously thinking about the problem a n d t h e possibility of c h a n g e ; Preparation (P)—making a c o m m i t m e n t to c h a n g e a n d t a k i n g steps t o p r e p a r e for t h a t c h a n g e ; Action (A)—successful modification of behavior for a period of from 1 day to 6 m o n t h s ; a n d Mainte-

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nance (M)—continuation of c h a n g e from 6 m o n t h s t o an i n d e f i n i t e p e r i o d . R e s e a r c h h a s s h o w n t h a t relapse a n d recycling t h r o u g h t h e stages of b e h a v i o r c h a n g e h a p p e n s often as individuals t r y t o s t o p o r c h a n g e p a r t i c u l a r b e h a v iors. T h e r e f o r e , t h e original m o d e l of linear p r o g r e s s i o n t h r o u g h t h e stages w a s m o d i f i e d t o a spiral m o d e l . T h e factors a n d processes t h a t h e l p i n d i v i d u a l s p r o g r e s s t h r o u g h t h e stages of b e h a v i o r c h a n g e v a r y f r o m stage t o stage. F o r e x a m p l e , c o n s c i o u s n e s s raising, e m o t i o n a l a r o u s a l , a n d e n v i r o n m e n t a l r e e v a l u a t i o n a r e influential processes for m o v i n g p e o p l e f r o m P C t o C, a n d d e c i s i o n a l b a l a n c e a n d self-reevaluation a r e i m p o r t a n t for m o v e m e n t f r o m C t o Ρ ( D i C l e m e n t e 8c P r o c h a s k a , 1985; D i C l e m e n t e , 1993; P r o c h a s k a et al., 1992). W e i n s t e i n a n d S a n d m a n (1992) c o n c l u d e t h a t , " k n o w i n g w h i c h factor o n e w o u l d like t o c h a n g e is n o t t h e s a m e as k n o w i n g h o w t o c h a n g e it" ( p . 180). I n this c h a p t e r w e p r o p o s e u s i n g B D M lessons n o t o n l y t o i n d i c a t e w h i c h factors t o c h a n g e , b u t also t o p r o v i d e i m p o r t a n t i n s t r u c t i o n o n " h o w t o " c h a n g e t h e s e factors.

The Influence of Behavioral Decision-Making Constructs on Progression Through Stages of Change MOVING FROM THE PRECONTEMPLATIVE T O C O N T E M P L A T I V E STAGE: LESSONS F R O M B D M C o n s c i o u s n e s s raising, o n e of t h e c h a n g e p r o c e s s e s f o u n d t o u n d e r l i e m o v e m e n t f r o m P C t o C, is defined as i n c r e a s i n g i n f o r m a t i o n a b o u t oneself a n d a p a r t i c u l a r p r o b l e m b e i n g faced ( P r o c h a s k a et al., 1992). A n i n c r e a s e d p e r c e p t i o n of p e r s o n a l risk b y p e o p l e e n g a g e d in p o t e n t i a l l y risky b e h a v i o r s ( w h i c h m a y i n c l u d e t h e a b s e n c e o f a p r e v e n t i v e b e h a v i o r ) easily fits w i t h i n this d e f i n i t i o n , a n d p o i n t s t o four c o n s t r u c t s from t h e B D M l i t e r a t u r e t h a t are especially relevant a n d compelling: (a) D i m e n s i o n a l M o d e l s of Risk P e r c e p t i o n a n d Risk C o m p a r i s o n s , (b) C u m u l a t i v e a n d " O n e - S h o t " P r o b a b i l i t y J u d g m e n t s , (c) Q u a l i t a t i v e a n d Q u a n t i t a t i v e P r o b a b i l i t y T e r m s , a n d ( d ) t h e F r a m i n g Effect. T h e s e c o n c e p t s , all of w h i c h relate t o level o f p e r c e i v e d risk, c a n b e e m p l o y e d b y d e s i g n e r s of h e a l t h messages t o foster m o v e m e n t f r o m t h e P C t o C stage of b e h a v i o r c h a n g e . Dimensional Models and Risk Comparisons. Scientists, policy m a k e r s , a n d risk analysts often t h i n k of risk as t h e objective p r o b a b i l i t y t h a t s o m e h a r m will c o m e t o a p e r s o n e x p o s e d t o a p a r t i c u l a r h a z a r d ( C o h r s s e n 8c C o v e l l o ,

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1989; Fischhoff, W a t s o n , 8c H o p e , 1990). Empirical B D M research, h o w e v e r , h a s s h o w n t h a t lay p e o p l e h a v e a m u c h richer w a y of c o n c e p t u a l i z i n g risk. I n w e l l - r e p l i c a t e d research, Slovic a n d colleagues h a v e s h o w n t h a t p e o p l e categorize diverse risks i n t o a t a x o n o m y defined b y several d i m e n s i o n s ( K r a u s 8c Slovic, 1988; Slovic, Fischhoff, 8c Lieh ten stein, 1990; Yates 8c S t o n e , 1992). A l t h o u g h t h e r e is s o m e c o n t r o v e r s y over t h e exact set of d i m e n s i o n s u s e d b y lay p e r s o n s in categorizing risks ( H o l t g r ä v e 8c W e b e r , 1993; N a t i o n a l Research Council, 1989), there is general a g r e e m e n t that at least t h e following m a j o r d i m e n s i o n s a r e involved: v o l u n t a r i n e s s , d r e a d , c o n t r o l , k n o w l e d g e , c a t a s t r o p h i c p o t e n t i a l , novelty, a n d e q u i t y ( K r a u s 8c Slovic, 1988). C e r t a i n characteristics lead to h i g h e r p e r c e i v e d risk: i n v o l u n t a r i n e s s , h i g h level of d r e a d , lack of c o n t r o l , l o w level of k n o w l e d g e , h i g h c a t a s t r o p h i c p o t e n t i a l , h i g h level of novelty, a n d low level of e q u i t y ( N a t i o n a l R e s e a r c h C o u n c i l , 1989). It is often a r g u e d t h a t p e o p l e reject c o m p a r i s o n s of risks t h a t possess very different d i m e n s i o n s of risk (National Research Council, 1989). For i n s t a n c e , p e o p l e m a y b e c o m e a n g r y w h e n their i n v o l u n t a r y e x p o s u r e t o m a n - m a d e o u t d o o r air p o l l u t a n t s is c o m p a r e d t o v o l u n t a r y e x p o s u r e from cigarette s m o k e . S u c h a c o m p a r i s o n is seen as c o m p a r i n g a p p l e s w i t h o r a n g e s , a n d m a y also b e seen as a n a t t e m p t at m a n i p u l a t i o n . W h e n a t a r g e t a u d i e n c e perceives m a n i p u l a t i o n , t h e c o m m u n i c a t o r m a y b e p e r c e i v e d as u n t r u s t w o r t h y a n d t h e messages d i s m i s s e d ( N a t i o n a l Research C o u n c i l , 1989). H e n c e , t h e m o s t i m p o r t a n t lesson for h e a l t h m e s s a g e d e s i g n e r s t o d r a w f r o m t h e risk p e r c e p t i o n literature is t h a t only risks with similar dimensional profiles should be compared in communication campaigns. H e a l t h c o m m u n i c a t o r s m a y e n c o u r a g e p e o p l e t o m o v e from t h e P C t o C stage of b e h a v i o r c h a n g e b y i n c r e a s i n g t h e risk p e r c e i v e d t o b e associated w i t h a p a r t i c u l a r b e h a v i o r a n d b y m a k i n g c o m p a r i s o n s w i t h activities w i d e l y r e g a r d e d b y society as risky. I n a p p r o p r i a t e c o m p a r i s o n s , h o w e v e r , m a y b e rejected b y the audience or have other undesirable or u n i n t e n d e d consequences. M e s s a g e d e s i g n e r s m u s t take care t o elicit o r locate t h e risk d i m e n s i o n profiles of activities t h a t t h e y w o u l d like t o c o m p a r e in their c o m m u n i c a t i o n s . For i n s t a n c e , a message designer c o n s t r u c t i n g a n H I V p r e v e n t i o n c a m p a i g n m i g h t b e t e m p t e d to c o m p a r e H I V risks a n d e p i d e m i o l o g i c a l statistics t o o t h e r S T D risks a n d statistics. W e m u s t ask, h o w e v e r , w h e t h e r t h e risk d i m e n s i o n profiles of H I V a n d o t h e r STDs a r e a d e q u a t e l y similar. It w o u l d s e e m t h a t these t w o types of risk differ m a i n l y o n four d i m e n s i o n s : dread, control, catastrophic potential, a n d novelty. H I V infection, at p r e s e n t , leads t o a fatal c o n s e q u e n c e . T h i s is largely n o t t h e case for o t h e r S T D s . H I V is t h e r e f o r e likely t o b e seen as a m o r e dreaded

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risk. H I V a n d o t h e r STDs can b o t h b e a v o i d e d via careful a v o i d a n c e of h i g h - r i s k b e h a v i o r s . H o w e v e r , o t h e r S T D s can b e m u c h m o r e r e a d i l y t r e a t e d t h a n can H I V infections. H e n c e , t h e r e is less control associated w i t h H I V infection. A l t h o u g h basic e p i d e m i o l o g y tells us t h a t H I V a n d o t h e r S T D s c a n b e t r a n s m i t t e d widely, a n H I V e p i d e m i c w o u l d result in d e a t h for a g r e a t e r p r o p o r t i o n of t h e p o p u l a t i o n t h a n w o u l d , say, a syphilis e p i d e m i c . Therefore, H I V infection has greater catastrophic potential H I V infection has a r r i v e d o n t h e p u b l i c h e a l t h h o r i z o n w i t h i n t h e p a s t several years; o t h e r S T D s h a v e b e e n k n o w n for c e n t u r i e s . So, H I V infection is a m o r e novel risk than other STDs. Overall, H I V infection is a m o r e dreaded, less controllable, m o r e catastrophic, a n d m o r e novel h e a l t h risk t h a n o t h e r S T D s . T h e risk p e r c e p t i o n m o d e l w o u l d p r e d i c t , t h e r e f o r e , t h a t p e o p l e are m o r e likely t o r a t e H I V i n f e c t i o n s as a g r e a t e r risk t h a n o t h e r S T D s . A b e t t e r c o m p a r i s o n t o H I V risks m i g h t b e d r i v i n g u n d e r t h e influence of d r u g s o r a l c o h o l . I n e b r i a t e d r i v i n g h a s m o r e in c o m m o n w i t h H I V infection risk in t e r m s of d r e a d a n d c o n t r o l t h a n d o o t h e r S T D s . H e n c e , a l t h o u g h a n i m p e r f e c t c o m p a r i s o n , it m a y b e v i e w e d ( p e r h a p s surprisingly) as a m o r e acceptable risk c o m p a r i s o n t h a n a c o m p a r i s o n of H I V a n d o t h e r S T D s . T h e N a t i o n a l Research C o u n c i l ( 1 9 8 9 ) p r o v i d e s o t h e r e x a m p l e s of p o o r a n d " b e t t e r " risk c o m p a r i s o n s . T h e r e a r e o t h e r c o n s i d e r a t i o n s w h e n devising risk c o m p a r i s o n s ( N a t i o n a l R e s e a r c h C o u n c i l , 1989; R o t h , M o r g a n , Fischhoff, Lave, 8c B o s t r o m , 1990; Slovic, K r a u s , 8c Covello, 1990). O n e i m p o r t a n t c o n s i d e r a t i o n is t h a t t h e r e a r e i n d i v i d u a l differences in t h e w a y p e o p l e use d i m e n s i o n s in t h e i r risk p e r c e p t i o n s ( H o l t g r ä v e 8c W e b e r , 1993). A n i m p o r t a n t i n d i v i d u a l difference is t h e age a n d d e v e l o p m e n t a l status of t h e a u d i e n c e m e m b e r s . Risk p e r c e p t i o n of a d o l e s c e n t s , for e x a m p l e , is highly i n f l u e n c e d b y d i m e n s i o n s r e l a t e d t o p e r c e i v e d social n o r m s ( B e n t h i n , Slovic, 8c Severson, 1992). T h i s is a n i m p o r t a n t difference from a d u l t d i m e n s i o n a l m o d e l s . Cumulative and One-Shot Probability Judgments. T h e B D M literature c o n t a i n s empirical evidence that people have difficulty processing p r o b a b i l i s t i c i n f o r m a t i o n . T h e y often o v e r w e i g h t small p r o b a b i l i t i e s a n d u n d e r w e i g h t large o n e s (Slovic, Fischhoff, 8c L i c h t e n s t e i n , 1990), h a v e t r o u b l e revising p r o b a b i l i t y j u d g m e n t s in light of n e w i n f o r m a t i o n ( H o g a r t h , 1987; T v e r s k y 8c K a h n e m a n , 1 9 8 2 b ) , a n d o v e r e s t i m a t e t h e p r o b a b i l i t y of e a s y - t o - i m a g i n e e v e n t s ( H o g a r t h , 1987; Sox, Blatt, H i g g i n s , 8c M a r t o n , 1988; T v e r s k y 8c K a h n e m a n , 1982a). Even w h e n p r o v i d e d with a t r u e probability of an event o c c u r r i n g o n c e f r o m o n e opportunity, people have trouble estimating the cumulative probability

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t h a t t h e e v e n t will o c c u r o n c e over m a n y o p p o r t u n i t i e s . T h i s w a s strikingly d e m o n s t r a t e d w h e n Linville, Fischhoff, a n d Fischer (Fischhoff, 1989a) a s k e d college s t u d e n t s for t h e p r o b a b i l i t y t h a t H I V w o u l d b e t r a n s m i t t e d b e t w e e n a h e t e r o s e x u a l c o u p l e , o n e of w h o m is H I V positive, in 1 i n s t a n c e of u n p r o t e c t e d sexual i n t e r c o u r s e . T h e y asked similar q u e s t i o n s specifying sex w i t h a n d w i t h o u t c o n d o m use, a n d specifying m a l e - t o - f e m a l e o r f e m a l e - t o m a l e t r a n s m i s s i o n . T h e y t h e n asked t h e s e q u e s t i o n s again b u t for 10 sexual e n c o u n t e r s ( n o t 1), a n d again for 100 sexual e n c o u n t e r s . A s s u m i n g as c o r r e c t t h e subjects' e s t i m a t e s for t r a n s m i s s i o n o n 1 sexual e n c o u n t e r , t h e subjects m a d e gross u n d e r e s t i m a t e s of t h e c u m u l a t i v e p r o b a b i l i t y of t r a n s m i s s i o n after 10 a n d 100 e n c o u n t e r s . Similar findings h a v e b e e n o b t a i n e d in studies related t o seat belt use a n d c o n t r a c e p t i v e failure (Fischhoff, 1989a). For h e a l t h m e s s a g e designers, t h e i m p o r t a n t lesson is t h a t people tend to underestimate cumulative risks. If t h e c o m m u n i c a t i o n d e s i g n e r w i s h e s t o m o v e s o m e o n e f r o m t h e P C t o C stage of b e h a v i o r c h a n g e , e m p h a s i z i n g c u m u l a t i v e p r o b a b i l i t i e s w o u l d b e m o r e useful t h a n e m p h a s i z i n g single i n c i d e n t p r o b a b i l i t i e s . For i n s t a n c e , a message related t o H I V p r e v e n t i o n m i g h t a v o i d m e n t i o n i n g t h a t t h e p r o b a b i l i t y of t r a n s m i s s i o n of H I V in a single i n c i d e n t of u n p r o t e c t e d sexual i n t e r c o u r s e is q u i t e low. R a t h e r t h e m e s s a g e s h o u l d e m p h a s i z e t h a t over t i m e , after a n u m b e r of u n p r o t e c t e d sexual e n c o u n t e r s , t h e p r o b a b i l i t y of c o n t r a c t i n g H I V infection rises t o n e a r l y 1. For e x a m p l e , a message t o a g r o u p of p e r s o n s e n g a g e d in h i g h - r i s k b e h a v i o r m i g h t state, " T h i n k of t h e t i m e s t h a t y o u are likely t o h a v e sex in t h e n e x t 2 years. Every o n e of t h o s e t i m e s t h a t y o u d o n ' t u s e a c o n d o m , y o u i n c r e a s e y o u r c h a n c e s of getting H I V , t h e A I D S v i r u s . Before y o u k n o w it, unsafe sex will catch u p w i t h y o u , a n d y o u will b e c o m e H I V infected. So w h y n o t p r o t e c t yourself a n d start u s i n g c o n d o m s n o w . M a k e c o n d o m s a h a b i t . " A l t h o u g h w e k n o w of n o s u p p o r t i n g e m p i r i c a l d a t a o n t h e effectiveness of s u c h a m e s s a g e in t h e H I V a r e n a , s i m i l a r m e s s a g e s h a v e b e e n f o u n d effective in t h e seatbelt usage l i t e r a t u r e (Fischhoff, 1989a; Slovic, Fischhoff, 8c L i c h t e n s t e i n , 1978). Qualitative and Quantitative Probabilities. Aside from the nightly w e a t h e r forecast, p e o p l e t e n d t o c o m m u n i c a t e a b o u t p r o b a b i l i s t i c c o n c e p t s u s i n g w o r d s i n s t e a d of n u m b e r s . R a t h e r t h a n saying, " T h e r e is a 1 0 % c h a n c e t h a t I will get this j o b , " p e o p l e t e n d t o say s o m e t h i n g like, "It is unlikely t h a t I will get this j o b . " T h e use of s u c h qualitative t e r m s t o refer t o q u a n t i t a t i v e concepts involves m u c h imprecision. Imprecision in c o m m u n i c a t i o n s a b o u t p r o b a b i l i s t i c t e r m s can lead t o c o n f u s i o n a n d even conflict.

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Several r e s e a r c h e r s h a v e a t t e m p t e d t o u n d e r s t a n d exactly w h a t p e o p l e m e a n w h e n t h e y u s e qualitative p r o b a b i l i t y e x p r e s s i o n s ( B r y a n t 8c N o r m a n , 1980; Mostellor 8c Youtz, 1990; Spedden 8c Ryan, 1992). These studies generally find t h a t t h e r e is great d i s a g r e e m e n t a b o u t w h a t n u m e r i c a l values s h o u l d b e l i n k e d w i t h p a r t i c u l a r verbal e x p r e s s i o n s . I n d e e d , t h e e r r o r b a r s a r o u n d t h e m e a n q u a n t i t a t i v e values given for a m a j o r i t y of v e r b a l e x p r e s s i o n s s p a n t h e v a l u e 5 0 % . T h i s is i m p o r t a n t b e c a u s e it m e a n s t h a t s o m e o n e h e a r i n g a t e r m s u c h as possibly w o u l d n o t k n o w w h e t h e r t o b e t t h a t t h e e v e n t in q u e s t i o n will o r will n o t o c c u r . T h e r e f o r e , b e f o r e u s i n g a qualitative e x p r e s s i o n of u n c e r t a i n t y (see C h a p t e r 1 in this v o l u m e ) , c o m m u n i c a t i o n d e s i g n e r s s h o u l d consult the qualitative probability literature to find the (range of) quantitative equivalents t h a t h a v e b e e n e x p r e s s e d b y research subjects. F u r t h e r , given t h e b r o a d r a n g e of d i s a g r e e m e n t typically e x p r e s s e d b y subjects o v e r t h e q u a n t i t a t i v e m e a n i n g of s o m e qualitative phrases, message designers should consider providing both qualitative and quantitative expressions so as t o m a k e t h e i r m e a n i n g clear. As a n e x a m p l e of m e s s a g e design i n t e n d e d t o m o v e p e o p l e f r o m P C t o C, c o n s i d e r a h y p o t h e t i c a l H I V p r e v e n t i o n street o u t r e a c h w o r k e r w h o w i s h e s t o c o n v e y t o a n injection d r u g - u s i n g p o p u l a t i o n t h a t — w h e n u s e d c o r r e c t l y — b l e a c h kills H I V w i t h a p r o b a b i l i t y of m o r e t h a n .99. T h e o u t r e a c h w o r k e r also n e e d s t o c o n v e y t h a t highly i m p r o p e r u s a g e of bleach c a n d r o p t h e p r o b a b i l i t y of bleach killing H I V t o less t h a n .20 (these a r e illustrative n u m b e r s o n l y ) . T h e research l i t e r a t u r e indicates t h a t virtually always a n d high probability h a v e average q u a n t i t a t i v e p r o b a b i l i t y m e a n i n g s relatively n e a r .99 ( B r y a n t 8c N o r m a n , 1980) a n d t h a t t h e p h r a s e s unlikely, doubtful, a n d low probability are c o n s i s t e n t w i t h a p r o b a b i l i t y v a l u e o f .20 w i t h s o m e a u d i e n c e s ( B r y a n t 8c N o r m a n , 1980). If i n t r a v e n o u s d r u g u s e r s u n d e r s t a n d t h e s e t e r m s in t h e s a m e w a y as o t h e r a u d i e n c e s , t h e street o u t r e a c h w o r k e r c a n u s e t h e qualitative t e r m s t o s u p p l e m e n t a n d e m p h a s i z e t h e n u m e r i c a l probabilistic information. Framing Effects. T h e f r a m i n g effect refers t o t h e p h e n o m e n o n in w h i c h subjects r e s p o n d differently t o e q u i v a l e n t verbal s t i m u l i w h e n t h e s t i m u l i a r e w o r d e d differently (Elstein, 1987). I n a classic s t u d y , M c N e i l , P a u k e r , Sox, a n d T v e r s k y (1982) asked b o t h p a t i e n t s a n d p h y s i c i a n s w h e t h e r t h e y w o u l d prefer surgical o r r a d i a t i o n t r e a t m e n t for l u n g c a n c e r . All subjects received i n f o r m a t i o n a b o u t t h e p o t e n t i a l c o n s e q u e n c e s of t h e t w o t h e r a p i e s . T h e subjects, h o w e v e r , w e r e r a n d o m l y assigned t o receive e i t h e r (a) inform a t i o n p r e s e n t e d as survival statistics, o r (b) i n f o r m a t i o n p r e s e n t e d as

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m o r t a l i t y statistics. O f c o u r s e , a 5-year survival rate of, say, 3 0 % is e q u i v a l e n t t o a 5-year mortality rate of 7 0 % . Both patient a n d physician subjects receiving s u r v i v a l - f r a m e d i n f o r m a t i o n h a d different expressed p r e f e r e n c e s a m o n g t h e r a p y m o d a l i t i e s t h a n d i d t h o s e receiving t h e m o r t a l i t y frame. T h i s difference in p r e f e r e n c e s b e t w e e n frames is startling b e c a u s e t h e o n l y t h i n g t h a t c h a n g e d b e t w e e n t h e t w o scenarios w a s t h e w o r d i n g — t h e u n d e r l y i n g inform a t i o n c o n v e y e d was t h e s a m e . Even u s i n g s o m e w h a t different s t i m u l i , r e s e a r c h e r s h a v e f o u n d this " f r a m i n g effect" t o b e q u i t e r o b u s t (Elstein, 1987; Fischhoff, 1989a; Tversky 8c K a h n e m a n , 1974, 1986). T h e implications for c o m m u n i c a t i o n designers are clear. W h a t m a y a p p e a r t o b e arbitrary choices of wording—even alternative wording with the same underlying meaning—can have profound impacts in terms of the decisions and behaviors they elicit irom t h e target a u d i e n c e . T h e message d e s i g n e r m a y o p t t o use t h e f r a m e t h a t seems m o s t likely t o elicit t h e d e s i r e d b e h a v i o r . For i n s t a n c e , s u p p o r t e r s of c o n d o m use in H I V p r e v e n t i o n m i g h t craft messages t o u t i n g c o n d o m success rates, w h e r e a s critics of c o n d o m usage m i g h t t o u t failure rates. A 9 5 % success rate is e q u a l t o a 5 % failure rate, b u t messages t h a t u s e o n l y o n e o r t h e o t h e r of these statistics are likely to lead t o different b e h a v i o r a l r e s p o n s e s . Fischhoff (1989a) d e m o n s t r a t e d t h a t p e o p l e receiving c o n d o m i n f o r m a t i o n f r a m e d as success rates w e r e m o r e likely t o r e p o r t t h a t t h e y w o u l d use c o n d o m s t h a n subjects receiving e q u i v a l e n t failure r a t e i n f o r m a t i o n . C l i e n t s ' r e s p o n s e s t o v a r i o u s frames s h o u l d b e tested in form a t i v e e v a l u a t i o n . F u r t h e r , if message receivers perceive t h a t t h e y h a v e b e e n given o n l y o n e frame as a m e a n s of m a n i p u l a t i o n , t h e m a n e u v e r m a y backfire a n d t h e receivers m a y c o m e t o d i s t r u s t t h e m e s s a g e s o u r c e s .

MOVING FROM THE CONTEMPLATIVE T O P R E P A R A T I O N STAGE: LESSONS F R O M B D M M o v e m e n t from C t o Ρ involves a p e r s o n d e v e l o p i n g a n d c o m m i t t i n g t o a c o u r s e of a c t i o n , a p r o c e s s t h a t necessarily i n c l u d e s selection a m o n g o p t i o n s (i.e., a t i p p i n g of t h e decisional b a l a n c e t o w a r d o n e o p t i o n ) . T h r e e B D M c o n c e p t s t h a t deal w i t h o p t i o n selection are p a r t i c u l a r l y c o m p e l l i n g : (a) D e c i s i o n - M a k i n g Perspective, (b) T i m e H o r i z o n , a n d (c) I m p o r t a n c e A s s e s s m e n t of D e c i s i o n - M a k i n g Factors. T h e s e t h r e e aspects of h e a l t h d e cision m a k i n g can in s o m e w a y b e influenced b y c o m m u n i c a t i o n c a m p a i g n messages. Decision -Making Perspective. For p u b l i c health w o r k e r s , t h e d e c i s i o n of w h e t h e r o r n o t t o s m o k e m a y s e e m to h a v e o n e a n d o n l y o n e o b v i o u s l y right

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a n s w e r . T h e " r i g h t " choice m a y n o t s e e m q u i t e so t r a n s p a r e n t t o a s m o k e r , however. Perhaps s o m e o n e hears an antismoking message b u t does n o t r e s p o n d b e c a u s e cigarettes a r e a s o u r c e of p e r c e i v e d c o m f o r t in a life w i t h few o t h e r s o u r c e s of positive influence. I n a n o t h e r h e a l t h area, P i n k e r t o n a n d A b r a m s o n ( 1 9 9 2 ) h a v e d i s c u s s e d u n d e r w h a t c o n d i t i o n s unsafe sexual b e h a v i o r m a y actually s e e m perfectly r a t i o n a l t o t h e p a r t i c i p a n t s . In t h e case of r a d o n testing, S v e n s o n a n d Fischhoff (1985) h a v e d r a w n a decision tree f r o m t h e p e r s p e c t i v e of social policy m a k e r s a n d a n o t h e r from t h e p e r s p e c t i v e of a n i n d i v i d u a l h o m e o w n e r . T h e t w o decision trees are q u i t e different, a n d i n s p e c t i o n of t h e m m a k e s it clear t h a t conflicts b e t w e e n policy m a k e r s a n d h o m e o w n e r s c o u l d easily arise over this issue, b e c a u s e q u i t e different issues a n d s t r u c t u r e s a r e i n c o r p o r a t e d in t h e trees. W h e n d e c i s i o n analysis is u s e d in t h e n o r m a t i v e sense, o n e of t h e v e r y first steps in t h e analysis is t o o u t l i n e t h e d e c i s i o n - m a k i n g p e r s p e c t i v e . In c o m m u n i c a t i o n c a m p a i g n s , message designers need to elicit and address the decision-making perspective of the message recipients, b e a r i n g in m i n d t h a t t h e d e s i g n e r ' s p e r s p e c t i v e is n o t necessarily t h e s a m e as t h e m e s s a g e r e c i p i e n t ' s p e r s p e c t i v e . T h i s elicitation takes place d u r i n g p e r i o d s of f o r m a t i v e r e s e a r c h ; t h e n messages are d e s i g n e d t o h e l p t h e client c h o o s e an o p t i o n t h a t will m o v e h i m o r h e r f r o m t h e C to Ρ stage of b e h a v i o r c h a n g e . As a c o n c r e t e e x a m p l e of e n c o u r a g i n g p e o p l e t o c h a n g e t h e i r d e c i s i o n m a k i n g perspective, consider a counselor providing ongoing, o n e - o n - o n e b e h a v i o r c h a n g e c o u n s e l i n g t o a m a l e client, recently t e s t e d H I V s e r o p o s i tive, w h o is c o n s i d e r i n g c o n s i s t e n t c o n d o m use b u t has yet t o c o m m i t t o this c o u r s e of a c t i o n . This c o n t i n u e d failure t o use c o n d o m s c o n s i s t e n t l y w i t h p e r s o n s of u n k n o w n H I V s e r o s t a t u s is clearly of c o n c e r n . In o r d e r t o h e l p t h e client m o v e from t h e C to Ρ stage of c o n d o m u s e , t h e c o u n s e l o r s h o u l d a t t e m p t t o assess t h e client's d e c i s i o n - m a k i n g p e r s p e c t i v e . If t h e client is u s i n g h i m s e l f as t h e referent p o i n t in his d e c i s i o n - m a k i n g p e r s p e c tive, h e m a y t h i n k t h a t b e c a u s e h e is already infected, t h e r e is little benefit in u s i n g c o n d o m s , b u t t h e r e is m a i n l y t h e financial cost a n d p e r c e i v e d p o t e n t i a l physical a n d social d i s c o m f o r t of c o n d o m usage. In s u c h a case, t h e c o u n s e l o r has at least t w o o p t i o n s . O n e is t o t r y t o shift t h e client's p e r s p e c t i v e t o t h a t of t h e sexual p a r t n e r s of u n k n o w n s e r o s t a t u s . As a s e c o n d o p t i o n , if t h e client refuses t o a c k n o w l e d g e a n o t h e r d e c i s i o n m a k i n g p e r s p e c t i v e , t h e c o u n s e l o r can w o r k w i t h i n t h e client's o w n p e r s p e c tive t o t i p t h e b a l a n c e of p e r c e i v e d costs, benefits, a n d p r o b a b i l i t i e s r e l a t e d to c o n d o m use and n o n u s e .

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Time Horizon. W h e t h e r c o n s c i o u s l y o r s u b c o n s c i o u s l y c o n s t r u c t e d , all d e c i s i o n s are m a d e , in p a r t , b y t a k i n g i n t o a c c o u n t t h e t i m e h o r i z o n o v e r w h i c h c o n s e q u e n c e s are to b e c o n s i d e r e d . For i n s t a n c e , p e o p l e in a v e r y stable e n v i r o n m e n t m a y c o n s i d e r t h e l o n g - t e r m h e a l t h effects of possible H I V infection w h e n m a k i n g a d e c i s i o n a b o u t w h e t h e r o r n o t t o use a c o n d o m w i t h a n e w sexual p a r t n e r of u n k n o w n H I V s e r o s t a t u s . If, h o w e v e r , a p e r s o n lives in an area w h e r e h o m i c i d e a n d other death rates are so high t h a t life e x p e c t a n c y is n u m b e r e d in years r a t h e r t h a n d e c a d e s , o r h a s t o p r o c u r e food a n d shelter o n a d a y - t o - d a y basis, t h e n c o n d o m use m a y s e e m s u p e r fluous. B D M research has s h o w n t h a t p e o p l e in actuality d o h a v e q u i t e different p l a n n i n g h o r i z o n s (Kirsch, N i j k a m p , & Z i m m e r m a n n , 1988; M c G r a t h , 1988; S v e n s o n , 1991; Vlek 8c K e r e n , 1992). H e a l t h m e s s a g e d e s i g n e r s need to incorporate message recipients' time horizon(s) into health communication. By h e l p i n g t h e client t o take o n a different t i m e h o r i z o n o r b y w o r k i n g w i t h i n t h e client's c u r r e n t t i m e h o r i z o n , m e s s a g e d e s i g n e r s can assist m o v e m e n t f r o m t h e C t o Ρ stage. For e x a m p l e , an H I V p r e v e n t i o n c o u n s e l o r can assess a n a d o l e s c e n t client's t i m e h o r i z o n b y i n q u i r i n g a b o u t w h e t h e r t h e client typically m a k e s p l a n s for t h e n e x t day, week, m o n t h , year, several years o r d e c a d e s ( o r a c o m b i n a t i o n of s u c h p l a n s ) . It m a y b e d i s c o v e r e d t h a t t h e client usually c o n s i d e r s activities for t h e n e x t m o n t h or t w o b u t s e l d o m c o n s i d e r s events t a k i n g place in t h e n e x t school year. W i t h this s h o r t t i m e h o r i z o n it s e e m s unlikely t h a t H I V infection w o u l d b e a m a j o r c o n c e r n of t h e client. T h e c o u n s e l o r m i g h t therefore p r o b e to see w h e t h e r t h e client h a s a n y d r e a m s for certain o c c u p a t i o n s . P e r h a p s t h e client h a s t h o u g h t a b o u t b e i n g a p h y s i c i a n , b u t feels t h a t is so far o u t in t h e f u t u r e it will p r o b a b l y n e v e r b e achieved. In this case t h e c o u n s e l o r m i g h t t r y t o focus t h e client o n c o n s i d e r i n g this o c c u p a t i o n a l d r e a m , t h e r e b y l e n g t h e n i n g t h e client's t i m e h o r i z o n . O n l y after t h e t i m e h o r i z o n h a s b e e n s t r e t c h e d will it m a k e sense t o c o n s i d e r t h e issue of c o n d o m use for H I V infection p r e v e n t i o n , w h i c h is a n issue r e q u i r i n g l o n g - t e r m t h o u g h t . O f c o u r s e , t h e client's t i m e h o r i z o n m i g h t n o t b e easily c h a n g e d . If t h e client c o n t i n u e s t o focus o n s h o r t - t e r m issues, t h e c o u n s e l o r will n e e d t o m a k e c o n d o m use a s h o r t - t e r m issue. For instance, it m a y m a k e sense to talk a b o u t c o n d o m s as a g u a r d against o t h e r STDs a n d u n i n t e n d e d p r e g n a n c y in t h e n e a r t e r m . Assessment of Importance of Decision-Making Factors. P e o p l e m a y differ in t h e choices t h e y m a k e a b o u t h e a l t h b e h a v i o r s b e c a u s e t h e y v a l u e o r w e i g h t t h e i m p o r t a n c e of various decision-making factors differently. M e t h o d s h a v e

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b e e n d e v e l o p e d for s t u d y i n g h o w p e o p l e access a n d use i n f o r m a t i o n a c r o s s m u l t i p l e factors w h e n m a k i n g decisions ( C a r r o l l 8c J o h n s o n , 1990; F o r d , Schmitt, S c h e c h t m a n , H u l t s , 8c Doherty, 1989; M o n t g o m e r y 8c Svenson, 1989). T h e B D M l i t e r a t u r e also c o n t a i n s w e l l - d e v e l o p e d n o r m a t i v e a n d d e s c r i p t i v e t h e o r i e s of h o w p e o p l e take i n t o a c c o u n t m u l t i p l e o u t c o m e factors in t h e i r decision m a k i n g , t h e m o s t famous theory being m u l t i - a t t r i b u t e utility t h e o r y ( M A U T ) ( v o n W i n t e r f e l d t 8c E d w a r d s , 1986). I n a simplified e x a m p l e , a s s u m e t h a t t h e r e are four factors relevant t o t h e decision a b o u t w h e t h e r o r n o t t o u s e c o n d o m s w i t h a c a s u a l sex p a r t n e r : (a) d i s e a s e p r o t e c t i o n , ( b ) physical c o m f o r t , (c) cost, a n d (d) p a r t n e r ' s r e a c t i o n . O n e p e r s o n m i g h t u s e c o n d o m s b e c a u s e h e p u t t h e m o s t w e i g h t o n t h e disease p r o t e c t i o n factor. If s o m e o n e else p u t m o s t of t h e i m p o r t a n c e w e i g h t i n g o n physical c o m f o r t , h e m i g h t c h o o s e n o t t o use c o n d o m s . For p u r p o s e s of c o m m u n i c a t i o n c a m p a i g n s , it is useful t o d e t e r m i n e w h a t i m p o r t a n c e w e i g h t s p e o p l e place o n t h e factors in a given d e c i s i o n - m a k i n g p r o b l e m a n d incorporate the factors with the highest importance weights into the message. W e will describe very briefly o u r success in u s i n g t h i s strategy in t h e d e s i g n a n d e v a l u a t i o n of a recycling e d u c a t i o n c u r r i c u l u m (for m o r e details, consult Holtgräve 8cTinsley, 1993; Holtgräve, Tinsley, 8c Kay, in p r e s s ) . Before a s s e m b l i n g t h e c u r r i c u l u m , extensive f o r m a t i v e r e s e a r c h w a s c o n ducted to u n d e r s t a n d h o w children and adolescents m a k e decisions a b o u t recycling. W e s u r v e y e d 1,278 s t u d e n t s , 731 f r o m O k l a h o m a City, O k l a h o m a , a r e a schools a n d t h e rest from Riverside, California, a r e a s c h o o l s . I n o n e p o r t i o n of t h e survey, students rated t h e i m p o r t a n c e of 41 different factors o n their decision m a k i n g a b o u t p u t t i n g t r a s h in a recycling c o n t a i n e r r a t h e r t h a n a g a r b a g e can. T h e s t u d e n t s r a t e d each factor f r o m 0 if it w a s n o t a t all i m p o r t a n t in t h e i r decision m a k i n g u p t o a 10 if t h e factor is t h e m o s t i m p o r t a n t in their decision m a k i n g . T h e 41 factors c o v e r e d s u c h d o m a i n s as t h e feelings of various people (e.g., family, friends, a n d teachers) a n d o t h e r features of recycling, s u c h as (a) h a b i t , (b) difficulty, (c) benefits t o h u m a n h e a l t h , wildlife, a n d t h e e n v i r o n m e n t , (d) p r o b l e m s t h a t arise f r o m failure t o recycle, a n d (e) financial benefits. T h e results o b t a i n e d w e r e r e m a r k a b l y stable w i t h o n l y slight differences seen across cities a n d grades. T h e m o s t i m p o r t a n t factors in recycling d e c i s i o n m a k i n g i n c l u d e d c o n c e r n s a b o u t wildlife, h e a l t h , t h e e n v i r o n m e n t , n a t u r a l r e s o u r c e s , r e d u c i n g t h e a m o u n t of garbage in d u m p s , a n d t h e o p i n i o n of e n v i r o n m e n t a l g r o u p s ( n o t necessarily in t h a t o r d e r ) . T h e s e 6 factors, r a t h e r t h a n all 41 relevant factors, were stressed p r o m i n e n t l y in t h e recycling e d u c a t i o n a l c u r r i c u l u m t h a t was i m p l e m e n t e d in s o m e schools in t h e Riverside,

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California, area. T h e c u r r i c u l u m m e t with a favorable evaluation in t e r m s of s h o r t - t e r m a t t i t u d e a n d self-reported recycling b e h a v i o r c h a n g e ( H o l t g r ä v e 8cTinsley, 1993).

Conclusions and Research Agenda T h e B D M l i t e r a t u r e also c o n t a i n s c o n s t r u c t s a n d findings r e l e v a n t t o p r o g r e s s i o n t h r o u g h t h e later stages of t h e b e h a v i o r c h a n g e p r o c e s s (P t o A a n d A t o Μ ) , as well as t o p r e v e n t i n g possible relapse from a n y stage t o a p r e v i o u s o n e . H o w e v e r , space c o n s t r a i n t s d o n o t p e r m i t a detailed c o v e r a g e here. Rather, we simply note that B D M researchers have concerned t h e m selves w i t h h o w p e o p l e m a k e s e q u e n t i a l choices (e.g., C o o m b s , D a w e s , 8c Tversky, 1981; F o r d et al., 1989; H u t c h i s o n , 1986), m a k e d e c i s i o n s in real t i m e (e.g., H o l t g r ä v e , 1990), a n d use feedback in their decision m a k i n g (e.g., H a m m o n d , Stewart, B r e h m e r , 8c S t e i n m a n n , 1986). T h e s e c o n s t r u c t s a r e r e l e v a n t t o message designers a t t e m p t i n g t o h e l p clients " s p i r a l " t h r o u g h t h e r e m a i n i n g stages of b e h a v i o r c h a n g e . A l t h o u g h i m p o r t a n t B D M discoveries h a v e b e e n m a d e t h a t a r e of c o n s i d erable utility for t h e design of h e a l t h c o m m u n i c a t i o n c a m p a i g n s , more research is clearly n e e d e d in at least t h e following areas. First, t h e r e is a n e e d for f u r t h e r empirical testing of t h e utility of B D M for m e s s a g e d e s i g n . Alt h o u g h it w o u l d b e difficult t o d e m o n s t r a t e directly t h a t B D M is m o r e useful t h a n a n a t h e o r e t i c a l a p p r o a c h t o message design ( H o c h b a u m , S o r e n s o n , 8c Lorig, 1992; v a n Ryn 8c H e a n e y , 1992), it w o u l d b e possible t o test further t h e effectiveness of B D M - b a s e d messages for c h a n g i n g a u d i e n c e m e m b e r s ' behaviors. S e c o n d , it w a s stated a b o v e t h a t d e v e l o p m e n t a l c o n s i d e r a t i o n s are i m p o r t a n t in B D M , b u t this is a relatively n e w area of B D M s t u d y a n d f u r t h e r w o r k is n e e d e d ( B a r o n 8c B r o w n , 1991). For i n s t a n c e , t h e effectiveness of t e a c h i n g g e n e r a l d e c i s i o n - m a k i n g skills as p a r t of h e a l t h c o m m u n i c a t i o n c a m p a i g n s t a r g e t e d t o w a r d a d o l e s c e n t s s h o u l d b e e v a l u a t e d . T h i r d , t h e r e is a n e e d t o e v a l u a t e t h e relative effectiveness of persuasive c a m p a i g n s t o t h o s e d e s i g n e d t o e n g a g e t h e client in a d e c i s i o n - m a k i n g p a r t n e r s h i p (Ballard-Reisch, 1990). A n o t h e r fruitful a r e a of research w o u l d b e c o m p a r i n g t h e effectiveness of d e c i s i o n a i d i n g devices for client d e c i s i o n m a k i n g ( d e D o m b a l , 1988; Shortliffe, 1990; W a t s o n 8c B u e d e , 1987) t o t h e effectiveness of p e r s u a s i v e campaigns.

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In c o n c l u s i o n , w e h a v e d e m o n s t r a t e d t h e p o t e n t i a l a n d utility o f B D M constructs for designing m o r e effective health messages a n d h o p e such c o n s i d e r a t i o n s will b e e n c o m p a s s e d in c a m p a i g n p l a n n e r s ' r e p e r t o i r e .

References Arkes, H. R., & Hammond, K. R. (1986). Judgment and decision making An interdisciplinary reader. Cambridge: Cambridge University Press. Ballard-Reisch, D. S. (1990). A model of participative decision making for physician-patient interaction. Health Communication, 2, 91-104. Baranowski, T. (1992-1993). Beliefs as motivation influences at stages in behavior change. International Quarterly of Community Health Education, 13, 3-29. Baron, J., 8c Brown, R. V. (1991). Teaching decision making to adolescents. Hillsdale, NJ: Lawrence Erlbaum. Benthin, A. C , Slovic, P., 8c Severson, H. (1992). A psychometric study of adolescent risk perception. Unpublished manuscript, Decision Research, Eugene, OR. Bryant, G. D., 8c Norman, G. R. (1980). Expressions of probability: Words and numbers. The New England Journal of Medicine, 302,411. Camerer, C. F. (1992). Recent tests of generalizations of expected utility theory. In W. Edwards (Ed.), Utility theories: Measurements and applications (pp. 207-251). Boston: Kluwer Academic. Carroll, J. S., 8c Johnson, E. J. (1990). Decision research: A field guide. Newbury Park, CA: Sage. Catania, J. A.,Kegeles,S. M., 8cCoates,T. J. (1990). Towards an understanding of risk behavior: An AIDS risk reduction model (ARRM). Health Education Quarterly, 17, 53-72. Cohrssen, J. J., 8c Covello, V. T. (1989). Risk analysis: A guide to analyzing health and environmental risk (NTIS No. PB89-137772). Washington, DC: Executive Office of the President's Council on Environmental Quality. Coombs, C. H., Dawes, R. M., 8c Tversky, A. (1981). Mathematical psychology: An elementary introduction. Ann Arbor, MI: Mathesis Press. Dawes, R. M. (1988). Rational choice in an uncertain world. San Diego, CA: Harcourt Brace Jovanovich. de Dombai, F. T. (1988). Computer-aided diagnosis of acute abdominal pain: The British experience. In J. Dowie 8c A. Elstein (Eds.), Professional judgment: A reader in clinical decision making (pp. 196-199). Cambridge: Cambridge University Press. DiClemente, C. C. (1993). Changing addictive behaviors: A process perspective. Current Directions in Psychological Science, 2, 101-106. DiClemente, C. C , 8c Prochaska, J. O. (1985). Processes and stages of self-change: Coping and competence in smoking behavior change. In S. Shiftman 8c T. A. Willis (Eds.), Coping and substance abuse (pp. 319-343). San Diego, CA: Academic Press. Elstein, A. S. (1987). Cognitive processes in clinical inference and decision making. In D. C. Turk 8c P. Salovey (Eds.), Reasoning, inference and judgment in clinical psychology (pp. 17-50). New York: Free Press/Macmillan. Fischhoff, Β. (1989a). Making decisions about AIDS. In V. M. Mays, G. W. Albee, 8c S. F. Schneider (Eds.), Primary prevention of AIDS (pp. 168-205). Newbury Park, CA: Sage.

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Fischhoff, B. (1989b). Risk: A guide to controversy. In National Research Council, Improving risk communication (pp. 211-319). Washington, DC: National Academy Press. Fischhoff, B. (1992). Risk taking: A developmental perspective. In J. F. Yates (Ed.), Risk taking behavior (pp. 133-162). Chichester, England: John Wiley. Fischhoff, B., Bostrom, Α., 8c Quadrel, M. J. (1993). Risk perception and communication. Annual Review of Public Health, 14, 183-203. Fischhoff, B., Watson, S. R., 8c Hope, C. (1990). Defining risk. In T. S. Glickman 8c M. Gough (Eds.), Readings in risk (pp. 30-41). Washington, DC: Resources for the Future. Ford, J. K., Schmitt, Ν., Schechtman, S. L., Hults, Β. M., 8c Doherty, M. L. (1989). Process tracking methods: Contributions, problems 8c neglected research questions. Organizational Behavior and Human Decision Processes, 43, 75-117. Hammond, K. R, Stewart, T. R., Brehmer, Β., 8c Steinmann, D. Ο. (1986). Social judgment theory. In H. R. Arkes 8c K. R. Hammond (Eds.), Judgment and decisionmaking: An interdisciplinary reader (pp. 56-76). Cambridge: Cambridge University Press. Hochbaum, G. M., Sorenson, J. R., 8c Lorig, K. (1992). Theory and health education in practice. Health Education Quarterly, 19, 295-314. Hogarth, R. M. (1987). Judgement and choice (2nd ed.). Chichester, England: John Wiley. Hogarth, R. M., 8c Reder, M. W. (1986). Rational choice: The contrast between economics and psychology. Chicago: University of Chicago Press. Holtgräve, D. R. (1990). Constructing models of dynamic choice behavior. In K. Borcherding, Ο. I. Larichev, 8c D. M. Messick (Eds.), Contemporary issues in decision-making (pp. 409428). Amsterdam: Elsevier Science (North-Holland). Holtgräve, D. R., 8cTinsley, B. J. (1993). Risk communication, recycling and young people (Cooperative Agreement No. 817465). Washington, DC: Environmental Protection Agency. Holtgräve, D. R, Tinsley, B. J., 8c Kay, L. S. (in press). Heuristics, biases and environmental health risk analysis. In L. Heath, F. Bryant, J. Edwards, E. Henderson, J. Myers, E. Posavac, Y. Suarez-Balcazar, 8c R. S. Tindale (Eds.), Applications of heuristics and biases in social issues. New York: Plenum. Holtgräve, D. R., 8c Weber, E. U. (1993). Dimensions of risk perception for financial and non-financial stimuli. Risk Analysis, 13, 553-558. Hutchison, J. W. (1986). Discrete attribute models of brand switching. Marketing Science, 5, 350-371. Kahneman, D., Slovic, P., 8c Tversky, A. (1982). Judgment under uncertainty: Heuristics and biases. Cambridge: Cambridge University Press. Kirsch, G., Nijkamp, P., 8c Zimmermann, Κ. (1988). The formulation time preferences in a multidisciplinary perspective. Berlin: WZB-Publications. Kraus, Ν., 8c Slovic, P. (1988). Taxonomic analysis of perceived risk: Modeling individual and group perceptions within homogeneous hazard domains. Risk Analysis, 8, 435-455. Lopes, L. L. (1990). Re-modeling risk aversion: A comparison of Bernoullian and rank dependent value approaches. In G. M. von Furstenberg (Ed.), Acting under uncertainty: Multidisciplinary conceptions (pp. 267-299). Boston: Kluwer. McGrath, J. E. (1988). Introduction: The place of time in social psychology. In J. E. McGrath (Ed.), The social psychology of time: New perspectives (pp. 7-20). Newbury Park, CA: Sage. McNeil, B. J., Pauker, S. G., Sox, H. C , 8c Tversky, A. (1982). On the elicitation for preferences for alternative therapies. The New England Journal of Medicine, 306, 1259-1262. Montgomery, H., 8c Svenson, O. (Eds.). (1989). Process and structure in human decision making. Chichester, England: John Wiley.

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Mostellor, F., & Youtz, C. (1990). Quantifying probabilistic expressions. Statistical Science, 5, 2-34. National Research Council. (1989). Improving risk communication. Washington, DC: National Academy Press. Pinkerton, S. D., 8c Abramson, P. R. (1982). Is risky sex rational? The Journal of Sex Research, 29,561-568. Prochaska, J. O., DiClemente, C. C , 8c Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114. Roth, E., Morgan, M. G., Fischhoff, Β., Lave, L., 8c Bostrom A. (1990). What do we know about making risk comparisons? Risk Analysis, 10, 375-388. Shortliffe, Ε. H. (1990). Clinical decision-support systems. In Ε. H. Shortliffe 8c L. E. Perrealt (Eds.), Medical informatics: Computer applications in health care (pp. 466-502). Reading, MA: Addison-Wesley. Slovic, P., Fischhoff, Β., 8c Lichtenstein, S. (1978). Accident probabilities and seatbelt usage: A psychological perspective. Accident Analysis and Prevention, 10, 281-285. Slovic, P., FischhofF, B., 8c Lichtenstein, S. (1990). Rating the risk. In T. S. Glickman 8c M. Gough (Eds.), Readings in risk (pp. 61-75). Washington, DC: Resources for the Future. Slovic, P., Kraus, Ν., 8c Covello, V. T. (1990). Comment: What should we know about making risk comparisons? Risk Analysis, 10, 389-392. Sox, H. C , Blatt, Μ. Α., Higgins, Μ. C , 8cMarton, Κ. Ι. (1988). Medical decision making. Boston: Butterworths. Spedden, S. E., 8c Ryan, P. B. (1992). Probabilistic connotations of carcinogen hazard classifications: Analysis of survey data for anchoring effects. Risk Analysis, 12, 535-541. Svenson, O. (1991). The time dimension in perception and communication of risk. In R. E. Kasperson 8c P.J.M. Stallen (Eds.), Communicating risks to the public (pp. 263-285). Dordrecht, the Netherlands: Kluwer. Svenson, O., 8c Fischhoff, Β. (1985). Levels of environmental decisions: A case study of radiation in Swedish homes. Journal of Environmental Psychology, 5, 55-68. Tversky, Α., 8c Kahneman, D. (1974), Judgment under uncertainty: Heuristics and biases. Science, 185, 1124-1131. Tversky, Α., 8c Kahneman, D. (1982a). Availability: A heuristic for judging frequency and probability. In D. Kahneman, P. Slovic, 8c A. Tversky (Eds.), Judgment under uncertainty: Heuristics and biases (pp. 163-178). Cambridge: Cambridge University Press. Tversky, Α., 8c Kahneman, D. (1982b). Evidential impact of base rates. In D. Kahneman, P. Slovic, 8c Tversky, A. (Eds.), Judgment under uncertainty: Heuristics and biases (pp. 153160). Cambridge: Cambridge University Press. Tversky, Α., 8c Kahneman, D. (1986). Rational choice and the framing of decisions. Journal of Business, 59, 5251-5278. van Ryn, M., 8c Heaney, C. A. (1992). What's the use of theory? Health Education Quarterly, 19,315-330. Vlek, C , 8c Keren, G. (1987). Behavioral decision theory and environmental risk management: Assessment and resolution of four "survival" dilemmas. Acta Psychologica, 80, 249-278. von Winterfeldt, D., 8c Edwards, W. (1986). Decision analysis and behavioral research. New York: Cambridge University Press. Watson, S. R., 8c Buede, D. M. (1987). Decision synthesis: The principles and practice of decision analysis. Cambridge: Cambridge University Press. Weinstein, Ν. D. (1988). The precaution adoption process. Health Psychology, 7, 355-386.

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Weinstein, Ν. D. (1993). Testing four competing theories of health-protective behavior. Health Psychology, 12, 324-333. Weinstein, Ν. D., & Sandman, P. M. (1992). A model of the precaution adoption process: Evidence from home radon testing. Health Psychology, 11, 170-180. Yates, J. F. (1990). Judgment and decision making. Englewood Cliffs, NJ: Prentice Hall. Yates, J. F. (1992). Risk-taking behavior. Chichester, England: John Wiley. Yates, J. F., 8c Stone, E. R. (1992). Risk appraisal. In J. F. Yates (Ed.), Risk-taking behavior (pp. 1 26). Chichester, England: John Wiley.

3

Moving People to Behavior Change A STAGED SOCIAL COGNITIVE APPROACH TO MESSAGE DESIGN

EDWARD W. MAIBACH DAVID COTTON

I

n C h a p t e r 2, Holtgräve, Tinsley, a n d Kay described stages of c h a n g e t h e o r y a n d illustrated h o w b e h a v i o r a l d e c i s i o n - m a k i n g p r i n c i p l e s i n f o r m m e s sages d e s i g n e d t o e n c o u r a g e p e o p l e t h r o u g h t h e initial steps of b e h a v i o r c h a n g e . W e , t o o , will b a s e o u r message design r e c o m m e n d a t i o n s o n a stages of c h a n g e a p p r o a c h , b u t r a t h e r t h a n d r a w o n t h e d e c i s i o n - m a k i n g l i t e r a t u r e , w e will e x a m i n e B a n d u r a ' s social cognitive t h e o r y a n d its i m p l i c a t i o n s for m o v i n g p e o p l e t o b e h a v i o r c h a n g e in a staged fashion. T o this e n d , w e briefly review b o t h t h e t r a n s t h e o r e t i c a l m o d e l a n d social c o g n i t i v e t h e o r y , a n d t h e n d e s c r i b e a n d illustrate social cognitive m e s s a g e d e s i g n strategies t o m o v e target a u d i e n c e m e m b e r s t h r o u g h t h e stages of c h a n g e . T h e m e s s a g e s w e u s e t o illustrate t h e r e c o m m e n d e d strategies are d r a w n from t w o multisite, c o m m u n i t y - l e v e l , H I V p r e v e n t i o n projects f u n d e d b y t h e C e n t e r s for D i s e a s e C o n t r o l a n d Prevention ( C D C ) : the AIDS C o m m u n i t y D e m o n s t r a t i o n Projects a n d t h e P r e v e n t i o n of H I V in W o m e n a n d Infants D e m o n s t r a t i o n P r o j e c t .

The Transtheoretical Model T h e t r a n s t h e o r e t i c a l m o d e l ( P r o c h a s k a 8c D i C l e m e n t e , 1 9 8 3 , 1 9 8 5 ; P r o c h a s k a , D i C l e m e n t e , 8c N o r c r o s s , 1992), also called stages of c h a n g e AUTHORS' NOTE: Portions of this chapter have been borrowed from E. Maibach & D. Murphy, Conceptualization and Measurement of Self-Efficacy in Health Promotion Research (in press), Health Education Research This chapter was supported in part by a Cooperative Agreement between the Association of Schools of Public Health/CDC and Emory School of Public Health (Edward Maibach, P.L)

41

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t h e o r y , describes b e h a v i o r c h a n g e as a p r o c e s s in w h i c h i n d i v i d u a l s p r o g r e s s t h r o u g h a series of discrete p h a s e s o r stages of c h a n g e . T h e s e stages of c h a n g e h a v e b e e n d o c u m e n t e d w i t h individuals u n d e r g o i n g b e h a v i o r c h a n g e in t h e areas of s m o k i n g cessation ( P r o c h a s k a 8c D i C l e m e n t e , 1983; P r o c h a s k a , D i C l e m e n t e , Velicer, Ginpil, 8c N o r c r o s s , 1985), s u b s t a n c e use ( D i C l e m e n t e 8c H u g h e s , 1990), w e i g h t c o n t r o l ( O ' C o n n e l l 8c Velicer, 1988; P r o c h a s k a , N o r c r o s s , Fowler, Follick, 8c A b r a m s , 1992), sun screen use (Rossi, 1989), a n d m o s t r e c e n t l y in t h e area of c o n d o m use (Galavotti, C a b r a l , G r i m l e y , Riley, 8c P r o c h a s k a , 1993; O'Reilly 8c Higgins, 1991; P r o c h a s k a , R e d d i n g , H a r l o w , Rossi, 8c Velicer, in p r e s s ) . T h e five stages have b e e n labeled P r e c o n t e m p l a t i o n , C o n t e m p l a t i o n , P r e p a r a t i o n , A c t i o n , a n d M a i n t e n a n c e . Precontemplation is t h e stage at w h i c h a n i n d i v i d u a l has n o i n t e n t i o n t o c h a n g e t h e relevant b e h a v i o r in t h e foreseeable future. P e o p l e at this stage are either u n a w a r e t h a t t h e i r b e h a v i o r places t h e m at risk, refuse t o a c k n o w l e d g e their risk, or h a v e d e c i d e d for s o m e o t h e r reason n o t to a d o p t the healthier behavior. Contemplation is t h e stage at w h i c h a n i n d i v i d u a l b e g i n s t o c o n s i d e r t h e n e e d t o c h a n g e t h e b e h a v i o r in q u e s t i o n at s o m e p o i n t in t h e future. P e o p l e often r e m a i n at this stage for a l o n g p e r i o d of t i m e b e c a u s e of t h e difficulty in e v a l u a t i n g t h e costs a n d benefits of c h a n g i n g their behavior (Prochaska, DiClemente, 8c Norcross, 1992). Preparation is t h e stage at w h i c h an i n d i v i d u a l m a k e s a decision t o c h a n g e t h e b e h a v i o r . A l t h o u g h s o m e p a r t i c u l a r l y r e s o l u t e i n d i v i d u a l s a r e able t o a d o p t n e w b e h a v i o r s i m m e d i a t e l y a n d consistently u p o n m a k i n g a d e c i s i o n t o c h a n g e , this is n o t t h e case for m o s t p e o p l e . T h e P r e p a r a t i o n stage is m o r e c o m m o n l y c h a r a c t e r i z e d as a t i m e of p l a n n i n g a b e h a v i o r c h a n g e strategy. E n g a g i n g in t h e n e w b e h a v i o r o n a trial basis c a n b e a n i m p o r t a n t p a r t of t h e P r e p a r a t i o n stage. Action is the stage at which individuals i m p l e m e n t t h e i r b e h a v i o r c h a n g e plan a n d begin p e r f o r m i n g t h e b e h a v i o r c o n s i s t e n t l y . T h e final stage, Maintenance, entails solidifying a n d r o u t i n i z i n g t h e b e h a v i o r a l p r a c t i c e a n d is c h a r a c t e r i z e d b y efforts t o p r e v e n t relapse i n t o t h e o l d f o r m of b e h a v i o r . Relapse m a y o c c u r at a n y p a r t of this s e q u e n c e a n d m a y o r m a y n o t b e followed b y a r e s u m p t i o n of p r o g r e s s t h r o u g h t h e stages of c h a n g e . T h e stages of c h a n g e p r o v i d e a d e s c r i p t i o n of w h e n p a r t i c u l a r shifts in a t t i t u d e s , i n t e n t i o n s , a n d b e h a v i o r s o c c u r . A s e c o n d c o m p o n e n t of t h e t r a n s t h e o r e t i c a l m o d e l , t h e processes of c h a n g e , describes h o w t h e s e shifts in stage o c c u r . C h a n g e processes are covert a n d o v e r t c o p i n g activities a n d e x p e r i e n c e s t h a t i n d i v i d u a l s engage in w h e n t h e y a t t e m p t to m o d i f y p r o b l e m b e h a v i o r s . Each p r o c e s s is a b r o a d category e n c o m p a s s i n g m u l t i p l e t e c h n i q u e s , m e t h o d s , a n d i n t e r v e n t i o n s t r a d i t i o n a l l y associated w i t h d i s p a rate theoretical orientations (Prochaska 8c D i C l e m e n t e , 1984, 1992). Detailed

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i n f o r m a t i o n a b o u t t h e processes of c h a n g e is b e y o n d t h e s c o p e of this c h a p t e r ; i n t e r e s t e d r e a d e r s a r e t h e r e f o r e e n c o u r a g e d t o refer t o P r o c h a s k a a n d D i C l e m e n t e ( 1 9 8 6 ) . T h e i m p o r t a n t p o i n t a b o u t processes o f c h a n g e for t h e p u r p o s e of this c h a p t e r is t h a t each p r o c e s s is m o r e influential at c e r t a i n stages t h a n at o t h e r stages ( P r o c h a s k a 8c D i C l e m e n t e , 1984; D i C l e m e n t e 8c P r o c h a s k a , 1982). P e o p l e m o v e m o r e efficiently t h r o u g h t h e stages w h e n s t a g e - a p p r o p r i a t e processes are u s e d ; similarly, if s o m e p r o c e s s e s a r e u s e d excessively at i n a p p r o p r i a t e stages, t h e y can actually o b s t r u c t c h a n g e o r p r e c i p i t a t e a relapse to a n earlier stage. T h e t r a n s t h e o r e t i c a l m o d e l ( T M ) has a n u m b e r of i m p o r t a n t i m p l i c a t i o n s for h e a l t h m e s s a g e design. First a n d m o s t obviously, it can serve as t h e basis for a n effective a u d i e n c e s e g m e n t a t i o n analysis. A n analysis of this t y p e is c o n d u c t e d b y assessing a r e p r e s e n t a t i v e s a m p l e of t h e target a u d i e n c e t o establish t h e i r c u r r e n t stage of c h a n g e a n d o t h e r relevant p s y c h o s o c i a l a n d b e h a v i o r a l variables (see C h a p t e r 10 in this v o l u m e for a full d i s c u s s i o n of a u d i e n c e s e g m e n t a t i o n strategies). W h e n m e m b e r s of t h e s a m p l e a r e s u b d i v i d e d i n t o five a u d i e n c e s e g m e n t s b a s e d o n t h e i r c u r r e n t stage of c h a n g e , p r o g r a m d e s i g n e r s will k n o w b o t h t h e size a n d t h e p s y c h o s o c i a l c o m p o s i t i o n of each p o t e n t i a l a u d i e n c e s e g m e n t . P r i m a r y d a t a collection a n d a n a l y sis of this t y p e can greatly e n h a n c e message design b y i n f o r m i n g d e c i s i o n s a b o u t w h i c h a u d i e n c e s e g m e n t ( s ) t o target ( a n d in w h a t o r d e r ) , w i t h w h a t objectives, a n d in w h a t m a n n e r . S e c o n d , t h e T M l i t e r a t u r e o n p r o c e s s e s of c h a n g e p r o v i d e s a rich s o u r c e of message design i n f o r m a t i o n o n strategies t o m o v e p e o p l e t h r o u g h t h e stages of c h a n g e . Message design d e c i s i o n s will benefit greatly b y taking advantage of information o n t h e staging d i s t r i b u t i o n of a target audience, as well as h o w to m o v e people t h r o u g h the various stages. C h a p t e r 2 in this v o l u m e e x a m i n e s t h e b e h a v i o r a l d e c i s i o n - m a k i n g lite r a t u r e for a d d i t i o n a l insights o n h o w t o m o v e p e o p l e t h r o u g h t h e early stages of c h a n g e . A n article b y B a r a n o w s k i ( 1 9 8 9 - 1 9 9 0 ) d r e w o n t h e t r a n s theoretical model to r e c o m m e n d both individual- and environmental-level strategies w i t h t h e p o t e n t i a l t o m o v e target a u d i e n c e s t h r o u g h e a c h of t h e stages of c h a n g e . As a c o m p l e m e n t t o these t w o w o r k s , t h e r e m a i n d e r of this c h a p t e r p r e s e n t s a m e s s a g e design view of h o w to m o v e p e o p l e t h r o u g h t h e stages of c h a n g e u s i n g a social cognitive a p p r o a c h .

Social Cognitive Theory Social cognitive t h e o r y (SCT) describes h u m a n b e h a v i o r as b e i n g r e c i p rocally d e t e r m i n e d b y internal personal factors a n d the e n v i r o n m e n t in w h i c h

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a p e r s o n lives ( B a n d u r a , 1986). Figure 3.1 p o r t r a y s a r e p r e s e n t a t i o n o f this reciprocal determination a m o n g behavior, person, and environment. SCT p r e s e n t s a b a l a n c e d a n d o p t i m i s t i c view of t h e h u m a n c o n d i t i o n : P e o p l e a n d t h e i r b e h a v i o r s are s h a p e d b y their e n v i r o n m e n t s , yet p e o p l e also s h a p e t h e i r e n v i r o n m e n t s t h r o u g h t h e i r b e h a v i o r a n d e x p e c t a t i o n s . T h e social c o g n i t i v e p e r s p e c t i v e o n h e a l t h b e h a v i o r c h a n g e is t h a t i n d i v i d u a l b e h a v i o r c h a n g e c a n b e facilitated b y m o d i f y i n g p e o p l e ' s p e r s o n a l factors a n d b y a l t e r i n g e n v i r o n m e n t a l factors t o e n c o u r a g e healthful b e h a v i o r . A l t h o u g h b o t h o p t i o n s a r e viable, health c o m m u n i c a t i o n c a m p a i g n s generally a t t e m p t t o i n f l u e n c e p e r s o n a l factors r a t h e r t h a n e n v i r o n m e n t a l factors (see M a i b a c h [1993] a n d W a l l a c k [ 1990] for d i s c u s s i o n s a b o u t t h e role of c o m m u n i c a t i o n c a m p a i g n s in p r o m o t i n g m a c r o - s o c i a l c h a n g e ) . S C T is a n i m p o r t a n t t h e o r y for h e a l t h message design for a n u m b e r of r e a s o n s . T h e r e is a large a n d r a p i d l y g r o w i n g l i t e r a t u r e t h a t s u b s t a n t i a t e s t h e p r e d i c t i v e a n d e x p l a n a t o r y value of social cognitive factors across a diverse g r o u p of h e a l t h b e h a v i o r s . T h e s e b e h a v i o r s i n c l u d e diet a n d n u t r i t i o n ; w e i g h t loss; exercise; c o n t r o l of addictive s u b s t a n c e use s u c h as t o b a c c o , alcohol, a n d opioid drugs; contraception and STD/HIV prevention; pain a n d disability r e d u c t i o n ; stress r e d u c t i o n ; a n d a d h e r e n c e t o p r e s c r i p t i v e a n d rehabilitative r e g i m e n s (see B a n d u r a [ 1991, in press] a n d Strecher, DeVellis, Becker, 8c R o s e n s t o c k [1988] for reviews). I n t e r v e n t i o n s t h a t e n h a n c e relev a n t social cognitive factors significantly i m p r o v e t h e r a t e at w h i c h t h e i r a s s o c i a t e d h e a l t h b e h a v i o r s are e n a c t e d (see B a n d u r a [1992, in press] for c o m p r e h e n s i v e reviews of this l i t e r a t u r e ) . M o r e o v e r , SCT e l u c i d a t e s m e c h a n i s m s for e n h a n c i n g social cognitive factors t o p r o m o t e a p p r o p r i a t e h e a l t h b e h a v i o r c h a n g e s . Strategies for e n h a n c i n g t h e p e r s o n a l factors specified in S C T a r e e x a m i n e d in t h e n e x t section. T h e s u b s e q u e n t section p r o p o s e s a m e t h o d t o o p t i m i z e social cognitive b e h a v i o r c h a n g e strategies b y t a i l o r i n g messages a c c o r d i n g t o t h e relevant stage of c h a n g e .

The Role of Personal Factors in Health Behavior Change KNOWLEDGE It takes little m o r e t h a n c o m m o n sense t o a p p r e c i a t e t h e fact t h a t k n o w l e d g e is a necessary p r e c o n d i t i o n for b e h a v i o r c h a n g e . Before b e h a v i o r c h a n g e is likely t o o c c u r , p e o p l e m u s t h a v e k n o w l e d g e b o t h a b o u t t h e i r risk factors ( t h e b e h a v i o r s o r c o n d i t i o n s t h a t place o n e at risk) a n d t h e ways in w h i c h t h e i r risk factors can b e r e d u c e d ( t h e alternative b e h a v i o r s ) . W i t h o u t

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Personal Factors

Environmental Factors

• knowledge • social • skills • institutional • self-efficacy • physical • outcome expectations • personal goals

• frequency • consistency • other relevant aspects

Behavior Figure 3.1. The Reciprocal Determination of Behavior, Person and Environment

s u c h k n o w l e d g e , p e o p l e are unlikely t o engage in t h e p r o c e s s t h a t can u l t i m a t e l y lead t o b e h a v i o r c h a n g e . Conversely, a l t h o u g h k n o w l e d g e is necessary, it is n o t sufficient t o m o t i v a t e o r activate b e h a v i o r c h a n g e . T h e transfer of k n o w l e d g e is an i n h e r e n t s t r e n g t h of t h e c o m m u n i c a t i o n p r o c e s s . H e a l t h c o m m u n i c a t i o n c a m p a i g n s c a n b e h i g h l y effective at g e n e r a t i n g a p p r o p r i a t e levels of k n o w l e d g e a m o n g m e m b e r s of t h e t a r g e t a u d i e n c e (e.g., M a c c o b y & A l e x a n d e r , 1980). H e a l t h m e s s a g e d e s i g n e r s s h o u l d , h o w e v e r , p a y close a t t e n t i o n t o t h e p r i n c i p l e s of effective m e s s a g e d e s i g n t o

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e n s u r e t h e effectiveness of t h e i r c o m m u n i c a t i o n efforts in e n h a n c i n g k n o w l e d g e (see C h a p t e r s 1, 2, 9, a n d 10 in this v o l u m e ) .

SKILLS O n e r e a s o n w h y k n o w l e d g e gains d o n o t lead inevitably t o b e h a v i o r c h a n g e is t h e lack of skills necessary t o p e r f o r m t h e b e h a v i o r . A d o p t i o n of a n e w h e a l t h - p r o m o t i n g b e h a v i o r often r e q u i r e s t h e e n a c t m e n t of a c o n s t e l l a t i o n of c o m p l e x cognitive, social, b e h a v i o r a l , a n d self-regulatory skills ( B a n d u r a , 1986, 1991, in press). E x a m p l e s of these respective skills as t h e y relate t o t h e p r o m o t i o n of safer sex i n c l u d e t h e ability t o r e c o g n i z e s i t u a t i o n s t h a t m a y lead t o sexual c o e r c i o n (a cognitive skill), t h e ability t o n e g o t i a t e safe b e h a v i o r w i t h a sexual p a r t n e r (a social skill), t h e ability t o use a c o n d o m p r o p e r l y (a b e h a v i o r a l skill), a n d t h e ability t o a d h e r e t o a p r e v i o u s l y m a d e d e c i s i o n t o e n g a g e o n l y in safe sex (a s e l f - r e g u l a t o r y skill). W i t h o u t t h e n e c e s s a r y skills t o s u p p o r t a n e w health b e h a v i o r , p e o p l e are unlikely to initiate a n d less likely t o sustain b e h a v i o r c h a n g e efforts. Skill d e v e l o p m e n t can b e a n o t h e r s t r e n g t h of t h e c o m m u n i c a t i o n p r o c e s s w h e n p r o p e r l y c o n d u c t e d . T h e steps t o s t r u c t u r i n g messages for skill develo p m e n t follow directly from t h e o b s e r v a t i o n a l l e a r n i n g p r o c e s s as d e s c r i b e d b y B a n d u r a ( 1 9 8 6 ) . Generally speaking, skill-building messages s y s t e m a t i cally d e c o n s t r u c t t h e b e h a v i o r of i n t e r e s t i n t o its c o m p o n e n t p a r t s a n d d e m o n s t r a t e h o w to reconstruct the behavior from those parts. Skill-building messages typically b e g i n b y conveying, t h r o u g h d e m o n s t r a t i o n a n d explan a t i o n (i.e., m o d e l i n g ) , a sense of w h a t successful b e h a v i o r a l p e r f o r m a n c e s l o o k like, preferably u s i n g a variety of different m o d e l s . If t h e b e h a v i o r is c o m p l e x o r c o m p o s e d of n u m e r o u s steps, t h e b e h a v i o r a l c o m p o n e n t s of t h e larger b e h a v i o r s h o u l d each b e explicitly d e m o n s t r a t e d . T h e cognitive, social, a n d b e h a v i o r a l ( a n d in s o m e i n s t a n c e s , t h e selfr e g u l a t o r y ) skills r e q u i r e d t o p e r f o r m t h e b e h a v i o r m u s t b e systematically identified a n d m o d e l e d . In t h e case of c o m p l e x b e h a v i o r s , this m o d e l i n g s h o u l d b e c o n d u c t e d for each of t h e b e h a v i o r a l c o m p o n e n t s . V e r b a l a n d b e h a v i o r a l m o d e l i n g s h o u l d also b e u s e d t o explain a n d d e m o n s t r a t e h o w t h e c o m p o n e n t skills a n d b e h a v i o r s s h o u l d b e i n t e g r a t e d i n t o a successful p e r f o r m a n c e of t h e larger b e h a v i o r . Ideally, message r e c i p i e n t s s h o u l d b e p r o v i d e d w i t h t h e o p p o r t u n i t y t o practice t h e m o d e l e d b e h a v i o r s (either behaviorally o r mentally) to m a x i m i z e their skill acquisition ( B a n d u r a , 1986) a n d c o n f i d e n c e t o a p p l y t h o s e skills ( M a i b a c h 8c Flora, 1993).

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SELF-EFFICACY Self-efficacy is a pivotal factor in SCT in t h a t it m e d i a t e s t h e a p p l i c a t i o n of k n o w l e d g e a n d skills in t h e p u r s u i t of b e h a v i o r a l a t t a i n m e n t s . Self-efficacy refers t o p e o p l e ' s belief in their capability t o o r g a n i z e a n d e x e c u t e t h e c o u r s e of a c t i o n r e q u i r e d t o p e r f o r m a given b e h a v i o r successfully ( B a n d u r a , 1986, in press). This includes people's confidence in their capability t o r e g u l a t e t h e i r m o t i v a t i o n , t h o u g h t processes, e m o t i o n a l states, a n d t h e i r physical a n d social e n v i r o n m e n t t o attain their b e h a v i o r a l goals. W h e n p e o p l e j u d g e t h e m s e l v e s t o b e efficacious, t h e y a r e c o n f i d e n t in t h e i r capability t o o v e r c o m e the difficulties i n h e r e n t in changing a n d m a i n t a i n i n g a specific b e h a v i o r . 1

Efficacy j u d g m e n t s affect t h e a d o p t i o n a n d m a i n t e n a n c e of h e a l t h b e h a v iors t h r o u g h four i m p o r t a n t m e c h a n i s m s : c h o i c e o f b e h a v i o r s , effort e x p e n diture a n d persistence, thought patterns, a n d emotional reactions. Choice of Behavior. Self-efficacy influences h e a l t h b e h a v i o r c h o i c e s in t h a t p e o p l e t e n d to avoid tasks they feel exceed their capabilities, while p u r s u i n g those they feel c o m p e t e n t to p e r f o r m ( B a n d u r a , 1986). For e x a m p l e , s m o k e r s w i t h l o w efficacy t o c o n t r o l t h e i r s m o k i n g b e h a v i o r a t t e m p t t o q u i t less often t h a n t h o s e w h o j u d g e t h e m s e l v e s m o r e efficacious ( D i C l e m e n t e , P r o c h a s k a , 8c G i l b e r t i n i , 1985). Effort Expenditure and Persistence. M a s t e r i n g n e w b e h a v i o r s r e q u i r e s b o t h effort a n d p e r s i s t e n c e . A s t r o n g sense of efficacy m o t i v a t e s p e o p l e t o e n g a g e t h e m s e l v e s fully in t h e tasks t h e y u n d e r t a k e . For e x a m p l e , h i g h l y efficacious c a r d i a c p a t i e n t s can get themselves t o exercise h a r d e r o n a treadmill t h a n patients with weaker efficacy (Ewart, Taylor, Reese, 8c D e B u s k , 1983). Self-efficacious i n d i v i d u a l s a r e also m o r e p e r s i s t e n t in t h e face of difficulties t h a n t h o s e p e r s o n s w i t h lower efficacy. For e x a m p l e , efficacy t o regulate eating behavior predicts decreased attrition from weight loss p r o g r a m s ( B e r n i e r 8c A v a r d , 1986). W h e n obstacles t o b e h a v i o r c h a n g e a t t e m p t s arise, p e o p l e of l o w efficacy t e n d t o give u p o r r e d u c e their effort, w h e r e a s t h o s e of h i g h efficacy generally intensify their efforts u n t i l t h e y s u c c e e d ( B a n d u r a 8c C e r v o n e , 1983; B r o w n 8c I n o u y e , 1978). Thought Patterns and Emotional Reactions. Efficacy beliefs affect t h o u g h t p a t t e r n s t h a t can e n h a n c e o r u n d e r m i n e b e h a v i o r c h a n g e . T h e s e p a t t e r n s i n c l u d e goals a n d a s p i r a t i o n s , visualization o f successful v e r s u s failed efforts, a n d t h e use of analytical t h o u g h t processes t o c o p e w i t h setbacks a n d

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difficulties ( W o o d 8c B a n d u r a , 1989). Perceived self-efficacy also influences t h e r e g u l a t i o n of affective states in t h a t p e o p l e w h o h a v e a l o w sense of efficacy a r e m o r e v u l n e r a b l e t o stress a n d d e p r e s s i o n w h e n c o p i n g w i t h t a x i n g s i t u a t i o n s ( B a n d u r a , 1986). Like k n o w l e d g e a n d skills, self-efficacy t o e n g a g e in v a r i o u s h e a l t h b e h a v iors is o p e n t o influence t h r o u g h t h e c o m m u n i c a t i o n p r o c e s s . P e r c e p t i o n s o f self-efficacy can b e altered b y four m a j o r m o d e s of influence: p e r f o r m a n c e m a s t e r y experiences, vicarious experiences (i.e., observational l e a r n i n g ) , v e r b a l p e r s u a s i o n r e g a r d i n g o n e ' s capabilities, a n d inferences f r o m physiological a n d affective states ( B a n d u r a , 1986). Performance Mastery Experiences. T h e m o s t d i r e c t w a y t o e n h a n c e selfefficacy is t o h a v e m e m b e r s of t h e target a u d i e n c e a t t e m p t a n d s u c c e e d in p e r f o r m i n g t h e b e h a v i o r in q u e s t i o n . Even success w i t h an a p p r o x i m a t i o n of t h e b e h a v i o r , u n d e r practice c o n d i t i o n s r a t h e r t h a n real-life c i r c u m s t a n ces, will h e l p t o bolster p e r c e p t i o n s of efficacy. R e p e a t e d successes in a safe s e t t i n g will further e n h a n c e p e r c e p t i o n s of efficacy a n d increase t h e l i k e l i h o o d of t r y i n g ( a n d s u c c e e d i n g ) in m o r e difficult s i t u a t i o n s . H e a l t h messages s h o u l d t h e r e f o r e e n c o u r a g e p e o p l e to t r y o u t t h e n e w b e h a v i o r in s o m e m a n a g e a b l e fashion a n d in an e n v i r o n m e n t in w h i c h t h e y a r e m o s t likely t o succeed. Vicarious Efficacy Information. Other people's behavioral performances, w h e t h e r live o r d e p i c t e d in p r i n t o r e l e c t r o n i c m e d i a , p r o v i d e a n a b u n d a n t s o u r c e of efficacy i n f o r m a t i o n . T h i s vicarious efficacy i n f o r m a t i o n c a n h a v e a p o w e r f u l i m p a c t o n an o b s e r v e r ' s efficacy beliefs, especially in t h e a b s e n c e o f m u c h d i r e c t p e r s o n a l e x p e r i e n c e w i t h t h e b e h a v i o r . H e a l t h messages can e n h a n c e p e r c e p t i o n s of efficacy b y m o d e l i n g successful d e m o n s t r a t i o n s of t h e b e h a v i o r . T h e i m p a c t of m o d e l e d b e h a v i o r , h o w e v e r , is m e d i a t e d b y characteristics of t h e m o d e l s a n d t h e m a n n e r in w h i c h t h e d e m o n s t r a t i o n is p e r f o r m e d . For e x a m p l e , the m o s t effective m o d e l s are t h o s e w h o a r e similar ( d e m o g r a p h i c a l l y a n d behaviorally) t o m e m b e r s of t h e target a u d i e n c e b u t s o m e w h a t m o r e c o m p e t e n t at t h e b e h a v i o r b e i n g m o d e l e d . T h e m o s t effective m o d e l i n g d e m o n s t r a t i o n s (of c o m p l e x b e h a v i o r s ) are t h o s e t h a t c o n f o r m t o t h e style d e s c r i b e d in t h e p r e c e d i n g section o n skill d e v e l o p m e n t . O t h e r i m p o r t a n t characteristics of effective m o d e l i n g d e m o n s t r a t i o n s inc l u d e c o n t r a s t i n g effective a n d ineffective p e r f o r m a n c e s of t h e b e h a v i o r , m a k i n g crucial b u t unobservable aspects of the p e r f o r m a n c e (such as t h o u g h t processes) o b s e r v a b l e t o t h e a u d i e n c e , a n d p r o v i d i n g t h e a u d i e n c e w i t h ins t r u c t i v e feedback a b o u t t h e s t r o n g ( a n d w e a k ) e l e m e n t s of t h e m o d e l e d

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p e r f o r m a n c e (see B a n d u r a [ 1986], H o s f o r d 8cMills [ 1 9 8 3 ] , M a i b a c h [ 1 9 9 2 ] , a n d P e r r y 8c F u r u k a w a [1986] for m o r e detailed d i s c u s s i o n s of effective modeling performances). Persuasory Efficacy Information. P e o p l e often a c c e p t t h e a p p r a i s a l s o f c r e d i b l e o t h e r s as valid a s s e s s m e n t s of t h e i r o w n ability. S u c h f e e d b a c k can influence p e r c e p t i o n s of efficacy (Chambliss 8c M u r r a y , 1979a, 1979b), e s p e cially for b e h a v i o r s w h e r e it is difficult t o j u d g e o n e ' s o w n capabilities objectively. H e a l t h messages can b e u s e d t o e n h a n c e a u d i e n c e m e m b e r s ' self-efficacy b y h i g h l i g h t i n g their existing skills a n d r e l e v a n t e x p e r i e n c e s . T h i s t y p e of i n f o r m a t i o n can h e l p recipients focus o n a n d utilize t h e i r existing s t r e n g t h s . Similarly, h e a l t h messages can b e u s e d t o b o l s t e r efficacy b y d i r e c t i n g a t t e n t i o n t o successful aspects of failed b e h a v i o r a l a t t e m p t s , r a t h e r t h a n focusing exclusively o n t h e o u t c o m e . A n d finally, h e a l t h m e s sages can e n h a n c e efficacy b y providing positive feedback regarding p r o g r e s s t o w a r d b e h a v i o r c h a n g e ( S c h u n k , 1982). Physiological and Affective Efficacy Information. P e o p l e m a k e inferences a b o u t t h e i r capabilities from e m o t i o n a l a r o u s a l a n d o t h e r p h y s i o l o g i c a l cues t h e y e x p e r i e n c e w h i l e e n a c t i n g o r a n t i c i p a t i n g a difficult b e h a v i o r . A r o u s a l t h a t is i n t e r p r e t e d negatively (e.g., fear o r anxiety) d i m i n i s h e s p e r c e p t i o n s of efficacy, w h e r e a s a r o u s a l t h a t is i n t e r p r e t e d positively (e.g., e x c i t e m e n t ) c a n raise efficacy beliefs. W i t h i n s t r u c t i o n o n a n t i c i p a t i o n a n d r e i n t e r p r e t ing physiological cues, people are able t o reduce or e l i m i n a t e this negat i v e a n t i c i p a t o r y a r o u s a l a n d t h e r e b y increase their p e r c e p t i o n s of efficacy ( B a n d u r a 8c A d a m s , 1977). H e a l t h m e s s a g e d e s i g n e r s c a n e n c o u r a g e r e i n t e r p r e t a t i o n b y a l e r t i n g t h e a u d i e n c e t h a t t h e a r o u s a l e x p e r i e n c e is n o r m a l a n d c o m m o n , even a m o n g t h e m o s t proficient m o d e l s , a n d b y n a m i n g t h e e x p e r i e n c e in a w a y t h a t e m p h a s i z e s its p e r f o r m a n c e e n h a n c i n g q u a l i t i e s .

O U T C O M E EXPECTANCIES S C T m a k e s a clear d i s t i n c t i o n b e t w e e n beliefs a b o u t ability t o e n a c t a b e h a v i o r (i.e., self-efficacy) a n d beliefs a b o u t t h e o u t c o m e s t h a t will r e s u l t f r o m t h e b e h a v i o r . B a n d u r a (1986) h a s t e r m e d t h e latter c o n c e p t o u t c o m e expectations. These anticipated o u t c o m e s can take the form of physical effects (e.g., i n c r e a s i n g o r d e c r e a s i n g h e a l t h o r t h e p l e a s u r e s of living), social effects ( i n c u r r i n g t h e a p p r o v a l o r d i s a p p r o v a l of o t h e r p e o p l e ) , o r self-evaluative effects ( i n c u r r i n g self-approval o r self-disapproval). P e o p l e are m o t i v a t e d t o p e r f o r m b e h a v i o r s t h a t t h e y believe will p r o d u c e o u t c o m e s t h e y desire.

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Self-efficacy m e d i a t e s this m o t i v a t i o n in t w o i m p o r t a n t ways, h o w e v e r . First, t h e s t r o n g e r a p e r s o n ' s j u d g m e n t s of efficacy for a p a r t i c u l a r b e h a v i o r , t h e m o r e likely h e o r she is t o have positive o u t c o m e e x p e c t a t i o n s associated w i t h p e r f o r m a n c e of t h a t b e h a v i o r . S e c o n d , p e o p l e can believe a b e h a v i o r will lead t o desirable o u t c o m e s , b u t if t h e y h a v e n o c o n f i d e n c e t h a t t h e y can p e r f o r m t h e r e q u i r e d b e h a v i o r t h e y a r e n o t likely t o b e m o t i v a t e d t o a t t e m p t it ( B a n d u r a , 1986). O u t c o m e e x p e c t a t i o n s a r e o p e n t o influence t h r o u g h t h e c o m m u n i c a t i o n p r o c e s s . Similar t o self-efficacy, p e o p l e d e v e l o p t h e i r o u t c o m e e x p e c t a t i o n s t h r o u g h s o m e c o m b i n a t i o n of d i r e c t e x p e r i e n c e , o b s e r v a t i o n a l l e a r n i n g , a n d p e r s u a s i v e c o m m u n i c a t i o n . H e a l t h messages t h a t m a n a g e t o establish n e w p o s i t i v e o u t c o m e e x p e c t a t i o n s o r t o reinforce existing p o s i t i v e e x p e c t a t i o n s , t h r o u g h d e m o n s t r a t i o n o r p e r s u a s i o n , are likely to increase p e o p l e ' s m o t i v a t i o n for e n g a g i n g in t h e relevant h e a l t h b e h a v i o r . H e a l t h messages t h a t r e d u c e o r e l i m i n a t e negative o u t c o m e e x p e c t a t i o n s associated w i t h t h e n e w b e h a v i o r are also likely to increase p e o p l e ' s m o t i v a t i o n t o e n a c t t h e b e h a v i o r . A l t h o u g h t h e ideal b a l a n c e b e t w e e n these t w o strategies ( p r o m o t i n g positive e x p e c t a t i o n s vs. m i n i m i z i n g negative e x p e c t a t i o n s ) is u n k n o w n , B a r a n o w s k i ' s (1992, p . 304) analysis of diverse r e s e a r c h l i t e r a t u r e s suggests e m p h a s i z i n g t h e benefits a n d establishing a p p r o p r i a t e e x p e c t a t i o n s of t h e costs. Regardless of t h e m i x , h e a l t h messages a t t e m p t i n g t o influence o u t c o m e e x p e c t a t i o n s p o r t r a y t h e o u t c o m e s r e s u l t i n g from t h e r e c o m m e n d e d b e h a v i o r s , in c o n t r a s t t o self-efficacy messages, w h i c h focus o n skills n e c e s sary t o p e r f o r m t h e b e h a v i o r .

P E R S O N A L GOALS S C T describes p e r s o n a l goals as o n e of t h e m a j o r s o u r c e s of m o t i v a t i o n for behavior change a n d m a i n t e n a n c e (Bandura, 1986, in press). T h e process o f s e t t i n g c h a l l e n g i n g p e r s o n a l goals h a s consistently b e e n s h o w n t o e n h a n c e m o t i v a t i o n across a variety of b e h a v i o r a l d o m a i n s , p o p u l a t i o n s , a n d t i m e s p a n s ( B a n d u r a , in press; Locke & L a t h a m , 1990). Goals p r o v i d e b o t h a d i r e c t i o n a n d a reference p o i n t against w h i c h p e o p l e can c o m p a r e t h e i r p r o g r e s s . W h e n p r o g r e s s is m a d e ( o r w h e n b e h a v i o r is m a i n t a i n e d at a level t h a t m e e t s t h e g o a l ) , p e o p l e t e n d t o b e satisfied a n d h a v e p o s i t i v e selfa p p r a i s a l s . Conversely, w h e n p e o p l e fail t o p r o g r e s s t o w a r d t h e i r goals, t h e y t e n d t o b e dissatisfied a n d h a v e negative self-appraisals. In either e v e n t , t h e c o n s e q u e n c e of h a v i n g a closely h e l d p e r s o n a l goal is e n h a n c e d m o t i v a t i o n a n d effort. W h e n goals are a t t a i n e d , p e o p l e often adjust t h e i r goal u p w a r d

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a n d i n c r e a s e t h e i r level of effort; w h e n p e o p l e fail t o p r o g r e s s , t h e y will generally r e n e w t h e i r effort t o w a r d a t t a i n m e n t of t h e o r i g i n a l goal. T h e h e a l t h m e s s a g e design i m p l i c a t i o n s of t h i s self-regulatory p r o c e s s a r e clear. Messages t h a t e n c o u r a g e p e o p l e t o set p e r s o n a l goals can h a v e a s t r o n g m o t i v a t i o n a l effect. P e o p l e m u s t b e able t o m o n i t o r t h e i r p r o g r e s s t o w a r d t h e i r goal, h o w e v e r , in o r d e r t o sustain t h e i r m o t i v a t i o n . T h e r e f o r e , s h o r t t e r m goals a r e m o r e effective t h a n l o n g - t e r m goals, b e c a u s e it is difficult t o m o n i t o r p r o g r e s s t o w a r d l o n g - t e r m goals. T h e a t t a i n m e n t of a s h o r t - t e r m goal is likely t o m o t i v a t e p e o p l e t o set a m o r e challenging, l o n g e r t e r m goal. T h e A m e r i c a n C a n c e r Society's G r e a t A m e r i c a n S m o k e o u t is a g o o d e x a m p l e o f a set of h e a l t h messages w h o s e objective is t o e n c o u r a g e s h o r t - t e r m goal setting. S m o k e r s a r e e n c o u r a g e d t o q u i t for o n e day, t h e d a y o f t h e G r e a t A m e r i c a n S m o k e o u t . T h e y a r e also e n c o u r a g e d t o feel p r o u d of t h e i r success w i t h t h e s h o r t - t e r m effort a n d t o use this as a s p r i n g b o a r d for f u t u r e q u i t attempts.

Influencing Social Cognitive Factors the Transtheoretical Way I n t h i s c h a p t e r , w e a r e r e c o m m e n d i n g t h e i n t e g r a t i o n o f social c o g n i t i v e t h e o r y w i t h t h e t r a n s t h e o r e t i c a l m o d e l for t h e p u r p o s e of h e a l t h m e s s a g e design. SCT offers a p a r s i m o n i o u s set of internal personal factors t h a t i n f l u e n c e t h e p r o d u c t i o n of b e h a v i o r (i.e., a c o m p e l l i n g e x p l a n a t i o n of w h y p e o p l e d o w h a t t h e y d o ) . T M offers a n e q u a l l y p a r s i m o n i o u s t e m p o r a l f r a m e w o r k a n d m o d e l o f b e h a v i o r c h a n g e d y n a m i c s (i.e., a c o m p e l l i n g e x p l a n a t i o n of h o w p e o p l e c h a n g e w h a t t h e y d o ) . As s u c h , T M offers a clear f r a m e w o r k for a d d r e s s i n g t h e i n t e r n a l p e r s o n a l factors s u g g e s t e d b y S C T as causal d e t e r m i n a n t s of b e h a v i o r . T h e t r a n s t h e o r e t i c a l m o d e l suggests several i m p o r t a n t m e s s a g e d e s i g n c o n s i d e r a t i o n s . First, messages m u s t b e t a i l o r e d t o t h e specific c o g n i t i v e a n d b e h a v i o r a l c o n d i t i o n s of p e o p l e at each given stage. For e x a m p l e , a m e s s a g e d e s i g n e d for p e o p l e in P r e c o n t e m p l a t i o n (to h e l p t h e m m o v e t o C o n t e m p l a t i o n ) will b e different t h a n a message d e s i g n e d for p e o p l e in t h e A c t i o n stage (to help t h e m m o v e t o M a i n t e n a n c e ) . This strategy is a distinct a d v a n c e m e n t over t h e a i l - t o o - c o m m o n a p p r o a c h in h e a l t h c a m p a i g n s w h e r e it is a s s u m e d t h a t all m e s s a g e r e c i p i e n t s a r e r e a d y a n d willing t o c h a n g e t h e i r behavior immediately u p o n being persuaded.

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52 Precontemplation to Contemplation

Contemplation to Preparation

Preparation to Action

APPROACHES Action to Maintenance

Knowledge About Risk Outcome Outcome Outcome Expectations: Expectations: Expectations: • risk behaviors • alternative behaviors • social reinforcement of the new - physical (-) -physical (+) behavior • alternative behaviors - social (+) - physical (+) - self-evaluation (+) - social (+) Self-Efficacy Self-Efficacy: • reduce risk behavior • adopt the alternaor tive behaviors • attempt an alternative behavior

Outcome Expectations: • self-evaluative reinforcement of the new behavior

Self-Efficacy: • overcome setbacks

Skills: • environmental restructuring • planning and problem solving

Skills: • relapse prevention

Personal Goals: • set proximal goals to adopt the alternative behaviors

Personal Goals: • monitor progress • extend goals

Figure 3.2. Internal Social Cognitive Factors That Encourage Change From One Stage to the Next

T h e s e c o n d i m p o r t a n t c o n s i d e r a t i o n suggested b y T M is t h a t t h e o r d e r in w h i c h i n t e r n a l p e r s o n a l factors are a d d r e s s e d has i m p o r t a n t i m p l i c a t i o n s for t h e l i k e l i h o o d of p r o m o t i n g s u s t a i n e d b e h a v i o r c h a n g e . F i g u r e 3.2 illustrates w h i c h i n t e r n a l p e r s o n a l factors are i m p o r t a n t at t h e v a r i o u s stages of c h a n g e ( b a s e d o n p r e v i o u s w o r k b y H e m o p h i l i a Behavioral I n t e r v e n t i o n E v a l u a t i o n Projects, 1993; P r o c h a s k a 8c D i C l e m e n t e , 1984). T h i s i n f o r m a t i o n can b e u s e d t o g u i d e message design a n d i n t e r v e n t i o n t a i l o r i n g . As n o t e d in t h e c h a p t e r ' s i n t r o d u c t i o n , t h e i n v e s t i g a t o r s in t h e A I D S C o m m u n i t y D e m o n s t r a t i o n Projects ( A C D P ) u s e d a stages of c h a n g e a p p r o a c h t o d e v e l o p p r e v e n t i o n m e s s a g e s for a u d i e n c e s at h i g h risk of H I V

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infection (O'Reilly 8c H i g g i n s , 1992; Pulley, McAlister, Kay, 8c O'Reilly, in p r e s s ) . T h e s e messages f e a t u r e d t h e stories a n d p i c t u r e s o f " r o l e m o d e l s " f r o m t h e c o m m u n i t i e s b e i n g targeted. T h e role m o d e l s a r e m e m b e r s o f t h e local c o m m u n i t y w h o s e t r u e stories of b e h a v i o r c h a n g e b e s t r e p r e s e n t e d t h e v a r i o u s stages of c h a n g e from C o n t e m p l a t i o n t o M a i n t e n a n c e . T h e i r stories w e r e p r i n t e d in a variety of f o r m a t s (e.g., flyers, n e w s l e t t e r s , " b a s e b a l l " t y p e c a r d s ) a n d d i s t r i b u t e d b y p e e r v o l u n t e e r s in t h a t c o m m u n i t y . R o l e m o d e l stories ( t h e n a m e given t o these p r i n t e d m a t e r i a l s ) for a n y given stage of c h a n g e w e r e i n t e n d e d t o influence t a r g e t a u d i e n c e m e m b e r s at t h e p r e v i o u s stage of c h a n g e . T h e c o m m u n i c a t i o n objectives of t h e s e r o l e m o d e l stories c o r r e s p o n d t o t h e factors d e p i c t e d in Figure 3.2. 2

T h e A D C P a p p r o a c h t o i n t e r v e n t i o n is c u r r e n t l y b e i n g refined b y a s e c o n d set of investigators in t h e P r e v e n t i o n of H I V in W o m e n a n d I n f a n t s D e m o n s t r a t i o n Projects ( W I D P ) (Centers for Disease C o n t r o l [ C D C ] , 1994; C o t t o n et a l , 1994; L i e b m a n et a l , 1994). W I D P e m p l o y s b o t h p a i d o u t r e a c h staff a n d v o l u n t e e r c o m m u n i t y m e m b e r s t o d i s t r i b u t e role m o d e l s t o r i e s , r e i n f o r c e p r o g r e s s t o w a r d b e h a v i o r c h a n g e , a n d e n c o u r a g e f u r t h e r risk r e d u c t i o n efforts. As w i t h t h e A C D P , t h e role m o d e l stories a r e staged; t h a t is, t h e y c o n t a i n i n f o r m a t i o n from t h e w o m a n t h a t clearly d e s c r i b e s h e r c u r r e n t r e a d i n e s s t o c h a n g e a n d t h e processes of c h a n g e she h a s u s e d t o m a k e t h e transition from t h e p r i o r stage t o her c u r r e n t o n e . T h e p a i d o u t r e a c h w o r k e r s a t t e m p t t o " s t a g e " (i.e., d e t e r m i n e t h e stage of c h a n g e of) e a c h p e r s o n t h e y interact with so that they can deliver a stage-appropriate o u t r e a c h encounter. T h e m i x of t h e s e role m o d e l stories is i n t e n d e d t o reflect t h e c u r r e n t n e e d s of w o m e n (i.e., t h e i r r e a d i n e s s t o c h a n g e ) a n d p r o v i d e m e s s a g e s t o h e l p t h e m m o v e t o w a r d c o n s i s t e n t safer sex. F o r i n s t a n c e , if m o s t w o m e n in t h e d e s i r e d a u d i e n c e are in C o n t e m p l a t i o n for c o n d o m use, t h e n a m a j o r i t y of t h e stories will b e a b o u t w o m e n in R e a d y - f o r - A c t i o n , telling h o w t h e y w e r e able t o m o v e f r o m C o n t e m p l a t i o n . T h e d i s t r i b u t i o n of w o m e n in t h e t a r g e t c o m m u n i t y across t h e stages w a s d e t e r m i n e d t h r o u g h p i l o t w o r k a n d b a s e line surveys ( a n d modified as successive waves of follow-up d a t a are collected). T h e d i s t r i b u t i o n of role m o d e l stories t h r o u g h peer n e t w o r k e r s is o n e e x a m p l e of h o w t o influence p e r s o n a l factors u s i n g a s t a g e - b a s e d a p p r o a c h . T h e n e x t s e c t i o n will p r e s e n t general r e c o m m e n d a t i o n s o n m o v i n g p e o p l e t o b e h a v i o r c h a n g e . E x a m p l e s of role m o d e l stories f r o m A C D P a n d W I D P a r e u s e d to illustrate o u r r e c o m m e n d a t i o n s .

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Influencing Personal Factors to Move People Through the Stages of Change MOVEMENT FROM PRECONTEMPLATION TO CONTEMPLATION T h e c o m m o n characteristic s h a r e d b y i n d i v i d u a l s in P r e c o n t e m p l a t i o n is t h e i r lack o f i n t e n t i o n t o m o d i f y t h e i r risk b e h a v i o r . T h e p r i m a r y goals for facilitating c h a n g e a m o n g P r e c o n t e m p l a t o r s are t o e n c o u r a g e r e e v a l u a t i o n of c u r r e n t b e h a v i o r , a n d t o engage t h e m in p r e l i m i n a r y c o n s i d e r a t i o n o f t h e a l t e r n a t i v e b e h a v i o r . Active c o n s i d e r a t i o n of, a n d d e l i b e r a t i o n a b o u t , b o t h c u r r e n t a n d a l t e r n a t i v e b e h a v i o r s will e n c o u r a g e m o v e m e n t t o t h e C o n t e m p l a t i o n stage. Because P r e c o n t e m p l a t o r s have s u c h low m o t i v a t i o n , t h e y will generally i g n o r e o r reject a c t i o n - o r i e n t e d suggestions. T h e y a r e m o r e likely t o r e s p o n d positively t o messages t h a t e n c o u r a g e s e l f - e x a m i n a t i o n r a t h e r t h a n b e h a v i o r c h a n g e . Messages of this type m i g h t i n c l u d e i n f o r m a t i o n a b o u t t h e risk b e h a v i o r itself; t h e likelihood of e x p e r i e n c i n g c o n s e q u e n c e s as a result of t h e risk b e h a v i o r ( p e r s o n a l risk); p e r s o n a l i z a t i o n of t h e risk m e s s a g e b y r e m i n d ing t h e p e r s o n of recent episodes of the risk behavior; potential c o n s e q u e n c e s of t h e p e r s o n ' s risk b e h a v i o r o n family, friends, o r v a l u e d o t h e r s ; a n d t h e l i k e l i h o o d of t h o s e c o n s e q u e n c e s t o o t h e r s (e.g., risk t o p a s s e n g e r s of d r u n k d r i v i n g o r risk of infecting a sex p a r t n e r w i t h a sexually t r a n s m i t t e d d i s e a s e ) . Thus, enhancing Precontemplators' knowledge of—and outcome expectancies about—the risk behavior, and personalizing the risk, are key strategies for encouraging movement to subsequent stages. A s e c o n d key strategy for m o v i n g P r e c o n t e m p l a t o r s is related to positive a n d n e g a t i v e o u t c o m e expectancies for t h e alternative (i.e., r i s k - r e d u c i n g ) b e h a v i o r . P r e c o n t e m p l a t o r s generally believe t h a t t h e d i s a d v a n t a g e s of a n d b a r r i e r s t o p r a c t i c i n g t h e alternative b e h a v i o r far o u t w e i g h t h e a d v a n t a g e s . T h e y m a y even h a v e difficulty listing positive aspects associated w i t h t h e a l t e r n a t i v e b e h a v i o r , a l t h o u g h t h e y often w e l c o m e n e w i n f o r m a t i o n a b o u t positive aspects. T h e r e f o r e , messages targeting Precontemplators should emphasize the positive attributes of the alternative behavior and encourage a reevaluation of outcome expectancies that includes the new positive information (see C h a p t e r 5 in this v o l u m e , for a d d i t i o n a l r a t i o n a l e r e g a r d i n g t h e use of positive m e s s a g e s ) . Such reevaluation of o u t c o m e e x p e c t a n c i e s is a critical e l e m e n t in h e l p i n g t o tip t h e b a l a n c e in favor of t h e alternative b e h a v i o r . T h e r a d i o c o m m e r c i a l Basketball Court #1 (see Figure 3.3), d r a w n from W I D P , is a n a d a p t a t i o n of t h e role m o d e l s t o r y a p p r o a c h . In this c o m m e r -

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Setting: Two young women (18-20) meet at a basketball court. Woman 1:

Hey girl. What's up?

Woman 2:

Hey, what's up?

Woman 1:

Did you check out that jump shot?

Woman 2:

Yeah, it was slammin'.

Woman 1:

Your man here too?

Woman 2:

Oh, I'm supposed to meet him here later. The reason I'm here is standing r i g h t . . . o v e r . . . there.

Woman 1:

You thinking about giving him some?

Woman 2:

Check him out girlfriend. His body is cut. I'm dying to get with him.

Woman 1:

Careful. You might get your wish.

Woman 2:

Where you comin' from with that? You checkin' him out too?

Woman 1:

Don't even try it. It's just that things are getting scary out here. That's why me and my man started using condoms. You know what I'm savin'?

Woman 2:

I don't know what you're talking about, but he's got it goin* on. Tell me you don't see it?

Woman 1:

Oh yeah, he's all that. I'll give him his props, but one at a time for me.

Woman 2:

What? Since when?

Woman 1:

Like I said, you gots to be careful out here now.

Woman 2:

Girl, you t r i p p i n . . . you talkin' about.

TAG: RAP . . . Real AIDS Prevention. Ladies, for more information about how you can protect yourself, call the Family Health Council at 361-RAPP. Find out how you can prevent the spread of AIDS. Call n o w . . . 361-RAPP. Figure 3.3. Script of a Radio Commercial Targeting W o m e n in Precontemplation for C o n d o m Use

cial, o n e y o u n g w o m a n ( w h o is in t h e A c t i o n stage for c o n d o m u s e ) p r o v i d e s p o s i t i v e m o d e l i n g for a s e c o n d y o u n g w o m a n ( w h o is clearly i n t h e P r e c o n t e m p l a t i o n stage). In h e r m o d e l i n g she includes a n explicit a c k n o w l e d g m e n t o f t h e r i s k s a s s o c i a t e d w i t h m u l t i p l e p a r t n e r s a n d u n p r o t e c t e d sex, a n d s h e e n d o r s e s several p o s i t i v e o u t c o m e s o f m o n o g a m y a n d c o n d o m u s e .

MOVEMENT FROM CONTEMPLATION TO PREPARATION P e o p l e in C o n t e m p l a t i o n a r e a w a r e of t h e n e e d t o p r a c t i c e a h e a l t h i e r b e h a v i o r b u t a r e n o t r e a d y y e t t o t a k e a c t i o n . C o n t e m p l a t o r s o f t e n like t o t a l k a b o u t t h e i r p r o b l e m a n d seek i n f o r m a t i o n f r o m a v a r i e t y o f s o u r c e s .

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C o n t e m p l a t o r s m a y b e in a state of distress as a result of a c k n o w l e d g i n g t h e i r p r o b l e m w h e n h a v i n g i n a d e q u a t e e m o t i o n a l , cognitive, o r b e h a v i o r a l ability t o m o u n t an effective behavior change effort. This distress m a y b e c o m p o u n d e d b y c o n c e r n a b o u t valued behaviors that m u s t b e given u p to a d o p t the a l t e r n a tive b e h a v i o r . In t h e a b s e n c e of a specific s t i m u l u s to c h a n g e , t h e C o n t e m plation stage can b e c o m e a chronic c o n d i t i o n for m a n y people. In order to help people move beyond this stage, Contemplators must be encouraged specifically to consider changing something about themselves. Moreover, they should be encouraged to gain behavioral experience with the change. T h i s c a n b e a c c o m p l i s h e d b y t r y i n g t h e n e w b e h a v i o r (at least o n c e ) , t r y i n g a n a p p r o x i m a t i o n of t h e b e h a v i o r , refraining from t h e risk b e h a v i o r o n a specific o c c a s i o n , o r partially s u b s t i t u t i n g t h e n e w b e h a v i o r for t h e risk b e h a v i o r . O u t c o m e e x p e c t a t i o n s r e m a i n a key issue in t h e C o n t e m p l a t i o n stage. It is useful for C o n t e m p l a t o r s to e x a m i n e their risk b e h a v i o r a n d w e i g h its costs v e r s u s its benefits. T h e s e costs a n d benefits m a y i n c l u d e physical (e.g., h e a l t h risks vs. e n j o y m e n t ) , social (e.g., t h e praise of friends vs. family) a n d self-evaluative (e.g., self-esteem a n d self-concept) c o n s e q u e n c e s . A l t h o u g h all b e h a v i o r c h a n g e s entail costs o r negative c o n s e q u e n c e s , p e o p l e are m o r e likely t o m o v e b e y o n d t h e C o n t e m p l a t i o n stage w h e n t h e positive o u t c o m e s a r e seen t o b e m o r e salient t h a n t h e costs (at least in t h e l o n g t e r m ) . M o r e o v e r , p e o p l e are less likely t o e x p e r i e n c e s u b s e q u e n t relapse if t h e y h a v e t h o r o u g h l y e x a m i n e d these e x p e c t e d costs a n d benefits a n d r e c o n c i l e d t h e i r values b e f o r e t a k i n g a c t i o n . Positive social a n d self-evaluative c o n s e q u e n c e s m a y b e p a r t i c u l a r l y i m p o r t a n t in m o v i n g p e o p l e b e y o n d this stage. For e x a m p l e , d a t a from t h e A C D P indicates t h a t p r o m o t i n g t r u s t in i n t i m a t e r e l a t i o n s h i p s a n d feeling p r i d e as a r e s u l t of d o i n g t h e " r i g h t t h i n g " w e r e i m p o r t a n t e x p e c t a t i o n s for p e o p l e w h o h a d m o v e d b e y o n d C o n t e m p l a t i o n . Intervention messages at the Contemplation stage should continue to promote new positive outcome expectations and reinforce existing positive expectations. Disputing commonly believed but untrue negative consequences and suggesting ways to minimize bona fide negative consequences may also be useful at this stage, a l t h o u g h it is generally easier t o p r o m o t e a d v a n t a g e s t h a n t o challenge p e r c e i v e d d i s a d v a n t a g e s . C o n t e m p l a t o r s m u s t begin to see themselves as capable of behavior c h a n g e . S u c h p e r c e p t i o n s of capability will, in t u r n , e n h a n c e positive o u t c o m e exp e c t a t i o n s a n d m o t i v a t i o n for c h a n g e . T h e r e f o r e , self-efficacy enhancement is another key strategy for moving people out of Contemplation and toward the Preparation stage. P e o p l e m a y b e g i n t o c o n s i d e r b a r r i e r s t o b e h a v i o r c h a n g e at this stage, w h i c h can have detrimental effect o n perceptions of self-efficacy.

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My Girlfriend Insists On It My name is Harold. I'm 28 years old. I started smoking marijuana when I was 14.1 experimented with cocaine back then, but I didn't like it. Lately I started shooting it up. I have heard about AIDS. My brother is infected. I have done a lot of reading and I've seen it on television. I've heard that AIDS is increasing at a rapid rate. My girlfriend is an IV drug user. She uses bleach to sterilize her equipment. Now she is insisting that I use it too. We already use condoms. We could really feel safe if I use the bleach too. I am planning to use bleach the next time I share needles. I enjoy life, I don't want to die. Figure 3.4. Harold's Story—A Role Model Story Targeting Bleach Use Contemplators

Messages should therefore identify how to effectively overcome perceived barriers to change. H a r o l d ' s story (see Figure 3.4), a role m o d e l story developed for t h e A C D P , is a g o o d e x a m p l e of a m e s s a g e d e s i g n e d t o m o v e injecting d r u g u s e r s c u r r e n t l y in t h e C o n t e m p l a t i o n stage for p r o p e r n e e d l e h y g i e n e t o t h e p r e p a r a t i o n stage (McAlister, Pulley, Kay, 8c O'Reilly, in p r e s s ) . T h e m e s s a g e is clear, s i m p l e , a n d c o m p e l l i n g . H a r o l d is a w a r e of his H I V risk; h e tells t h e r e a d e r o f his p e r s o n a l e x p e r i e n c e w i t h his b r o t h e r a n d a b o u t w h a t h e h a s seen a n d h e a r d o n television a n d t h r o u g h p r i n t m e d i a . H e also tells t h e r e a d e r a b o u t t h e social p r e s s u r e h e feels f r o m his girlfriend. H e p r o v i d e s i m p o r t a n t v i c a r i o u s efficacy i n f o r m a t i o n b y stating: " W e a l r e a d y u s e c o n d o m s . W e c o u l d feel really safe if I use t h e bleach t o o . " Finally, h e m a k e s a clear s t a t e m e n t a b o u t his s h o r t - t e r m b e h a v i o r a l goal: "I a m p l a n n i n g t o u s e bleach the next time I share needles."

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M O V E M E N T FROM PREPARATION TO ACTION P e o p l e w h o are p r e p a r i n g for A c t i o n often h a v e s o m e e x p e r i e n c e w i t h t h e n e w behavior and are n o w attempting to modify their behavior, experiences, a n d e n v i r o n m e n t in o r d e r to practice t h e n e w b e h a v i o r consistently. T h e i r b e h a v i o r at this stage is at best inconsistent, b u t they are f o r m i n g goals r e g a r d i n g c o m p l e t e a d o p t i o n of t h e n e w b e h a v i o r . T o m o v e b e y o n d this stage, p e o p l e m u s t m a i n t a i n their m o t i v a t i o n t o e l i m i n a t e t h e risk b e h a v i o r w h i l e s i m u l t a n e o u s l y b u i l d i n g t h e i r r e p e r t o i r e of safer alternative b e h a v i o r s . T h i s m a y r e q u i r e t h e a c q u i s i t i o n of skills a n d t h e c o n f i d e n c e t o use t h o s e skills in a v a r i e t y o f s i t u a t i o n s . It m a y also r e q u i r e t h a t p e o p l e r e s t r u c t u r e t h e i r e n v i r o n m e n t s t o r e m o v e cues a n d social s u p p o r t for p r a c t i c i n g t h e o l d b e h a v i o r a n d t o install cues a n d social influences t h a t s u p p o r t t h e n e w b e h a v i o r . T h i s m a y i n c l u d e enlisting t h e assistance of friends, p a r e n t s , p a r t n e r s , a n d o t h e r i m p o r t a n t social n e t w o r k m e m b e r s . Skills for b e h a v i o r c h a n g e are crucial at this stage. O n e i m p o r t a n t set of skills for p e o p l e a t t e m p t i n g to m o v e b e y o n d this stage is k n o w i n g h o w t o r e s t r u c t u r e t h e i r p e r s o n a l a n d social e n v i r o n m e n t t o e n s u r e t h e p r e s e n c e of cues a n d social r e l a t i o n s h i p s t h a t s u p p o r t t h e n e w b e h a v i o r . T h e lack of s u c h e n v i r o n m e n t a l cues a n d reinforcers can lead t o r e t u r n e d i n v o l v e m e n t in t h e u n h e a l t h y b e h a v i o r . Messages at the Action stage should instruct and encourage people to restructure their environments so that important cues for practicing the new behavior are obvious and supported socially. A n o t h e r i m p o r t a n t set of skills for m o v i n g b e y o n d this stage is t h e ability t o c o n s i d e r t h e obstacles t o b e h a v i o r c h a n g e a n d t o p l a n ways t o c i r c u m v e n t t h o s e obstacles. Successful m o v e m e n t f r o m P r e p a r a t i o n t o A c t i o n r e q u i r e s t h a t p e o p l e p l a n a h e a d for s i t u a t i o n s t h a t will j e o p a r d i z e their c h a n g e efforts a n d w o r k o u t specific strategies for d e a l i n g w i t h these c i r c u m s t a n c e s . T h i s t y p e of p l a n n i n g will also h e l p i n d i v i d u a l s identify p e o p l e in t h e i r social e n v i r o n m e n t s w h o can p r o v i d e social a n d o t h e r f o r m s of s u p p o r t . T h e r e fore, messages at the Action stage should encourage people to identify and plan solutions to the behavior change obstacles they are most likely to face. A t h i r d i m p o r t a n t set of skills for m o v i n g p e o p l e t o t h e A c t i o n stage is t h e ability t o set a p p r o p r i a t e b e h a v i o r a l goals. P e o p l e w h o set p e r s o n a l goals will b e b e t t e r able t o m a i n t a i n their m o t i v a t i o n for t h e b e h a v i o r c h a n g e . T h e m a n n e r in w h i c h t h e y set these goals, h o w e v e r , has an i m p o r t a n t m e d i a t i n g i n f l u e n c e . Establishing a n d a c c o m p l i s h i n g a series o f clear s h o r t - t e r m goals (to w o r k t o w a r d a l o n g - t e r m goal) is highly m o t i v a t i n g , w h e r e a s e s t a b l i s h i n g o n l y t h e l o n g - t e r m goal is fraught w i t h p r o b l e m s a n d is likely t o u n d e r m i n e

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m o t i v a t i o n . Messages at the Action stage should encourage people to set specific behavior change goals, and instruct them on appropriate ways to set incremental goals. A s t r o n g sense of self-efficacy is also crucial for m o v e m e n t b e y o n d t h i s stage. P e o p l e w h o are feeling highly efficacious are m o r e likely t o set b e h a v i o r c h a n g e goals a n d t o a p p l y t h e i r k n o w l e d g e a n d skills effectively i n p u r s u i t o f t h e s e goals. A d r o p in self-efficacy at this stage will d i s c o u r a g e goal s e t t i n g a n d m a y c a u s e p e o p l e t o r e e v a l u a t e their m o t i v a t i o n s . R e e v a l u a t i o n a t t h i s stage is dysfunctional, because excessive reevaluation n o w (as o p p o s e d t o tasko r i e n t e d c o p i n g o r p r o b l e m solving) is associated w i t h relapse. Messages at the Action stage should promote enhancement of self-efficacy. Wherever possible, these messages should bolster self-efficacy to cope with specific situations and other obstacles that people are likely to encounter in their change efforts. R e i n f o r c e m e n t for c h a n g e is also a n i m p o r t a n t c o n s i d e r a t i o n at this stage. S o u r c e s of s u c h r e i n f o r c e m e n t can b e i n t e r n a l o r e x t e r n a l t o t h e p e r s o n . E x t e r n a l reinforcers, s u c h as social a p p r o v a l , a r e p a r t i c u l a r l y influential in m o v i n g p e o p l e i n t o t h e A c t i o n stage, a n d care m u s t b e t a k e n t o s h a p e t h e s e influences in ways t h a t s u p p o r t h e a l t h y choices. Messages at the Action stage should model social reinforcement of appropriate behaviors. S h a v o n n e ' s story, d r a w n f r o m W I D P , is a g o o d e x a m p l e of a m e s s a g e t a r g e t i n g w o m e n in t h e P r e p a r a t i o n stage of c o n d o m use (see F i g u r e 3.5). I n t h e first p a r a g r a p h , she describes h e r r e e v a l u a t i o n of h e r m o t i v a t i o n s t o h a v e sex, a n d t h e u n i q u e s i t u a t i o n s t h a t led h e r t o p r a c t i c e risky b e h a v i o r s . She a c k n o w l e d g e s t h a t she h a s p u t herself at risk, a n d t h a t she h a s a l r e a d y suffered s o m e c o n s e q u e n c e s . She reveals t o t h e r e a d e r s o m e of h e r o u t c o m e e x p e c t a t i o n s b y stating, "I f o u n d o u t t h a t [ c o n d o m s ] w e r e n ' t as b a d as t h o s e m y t h s said." F u r t h e r , she lets t h e r e a d e r k n o w t h a t she h a s n o t b e e n perfect in h e r efforts, b u t t h a t she is t r y i n g h e r best t o b e m o r e c o n s i s t e n t . W o m e n in c i r c u m s t a n c e s similar t o S h a v o n n e ' s , b u t at t h e P r e p a r a t i o n stage for c o n d o m use, a r e likely t o find h e r story i n t e r e s t i n g a n d useful as a role m o d e l for b e h a v i o r c h a n g e . MOVEMENT FROM ACTION TO MAINTENANCE D u r i n g the m o v e m e n t from Action to Maintenance, people have been p r a c t i c i n g t h e n e w b e h a v i o r regularly for a p e r i o d of several m o n t h s . M a i n taining m o t i v a t i o n a n d building habit strength for the n e w b e h a v i o r are i m p o r t a n t t o e n s u r e t h a t it will r e m a i n a regular p a r t of t h e b e h a v i o r a l r e p e r t o i r e . Relapse is a v e r y real t h r e a t for p e o p l e in t h e A c t i o n stage. S e l f - m a n a g e m e n t

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4 11 18 25

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W h e n t was a teenager my self-esteem was low. I looked to men for validation; sex was love to me. I had many partners and was exposed to sexually transmitted diseases Being burned is a scary thing. I woke up. The reality was that I was at risk for having AIDS? Thank God I didn't get AIDS. I started trying out condoms with my partners out they weren't as bad as those myths said. I have to do what I have to do to protect myself I'm still b a t t l i n g — t r y i n g to separate sex f r o m love — but I'm taking one step at a time

I found

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KEMIOA 476-0802

Figure 3.5. Shavonne's Story—A Role Model Story Targeting W o m e n in the Preparation Stage for Condom Use

skills i n c l u d i n g t h e ability t o r e s t r u c t u r e cues a n d social s u p p o r t for t h e b e h a v i o r , t o a n t i c i p a t e a n d c i r c u m v e n t obstacles a n d s i t u a t i o n s t h a t m a y lead t o relapse, a n d t o m o d i f y b e h a v i o r a l goals in t h e face of set-backs o r s l i p - u p s , a r e crucial for t h e p r e v e n t i o n of relapse. Messages at the Maintenance stage should encourage refinement of skills, especially those skills that will help people avoid relapse and those that allow productive coping with set-backs to prevent full relapse. A related set of issues at this stage c o n c e r n s m a i n t a i n i n g p e o p l e ' s sense of self-efficacy t o c o p e w i t h n e w obstacles, set-backs, a n d s l i p - u p s . W h e n p e o p l e u n d e r s t a n d t h a t n e w obstacles a n d set-backs a r e c o m m o n d u r i n g t h e b e h a v i o r c h a n g e process, a n d w h e n t h e y feel c o n f i d e n t in t h e i r ability t o c o r r e c t t h e i r c o u r s e in the face of such difficulty, t h e y are m o r e likely t o c o p e p r o d u c t i v e l y w i t h these s i t u a t i o n s a n d avoid relapse. Therefore, messages at the Maintenance stage should bolster self-efficacy for dealing with new obstacles and set-backs in the behavior change process. R e i n f o r c e m e n t for c h a n g e r e m a i n s i m p o r t a n t a t t h i s stage. A l t h o u g h e x t e r n a l reinforcers a r e p a r t i c u l a r l y influential i n m o v i n g p e o p l e t o t h e A c t i o n stage, i n t e r n a l reinforcers b e c o m e increasingly i m p o r t a n t in m o v i n g

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p e o p l e i n t o t h e M a i n t e n a n c e stage. I n t e r n a l r e i n f o r c e r s take t h e f o r m of positive self-evaluations, as well as t h e t a n g i b l e r e w a r d s t h a t p e o p l e b e s t o w u p o n t h e m s e l v e s for t h e i r goal a c c o m p l i s h m e n t s . As a result, messages at the Maintenance stage should encourage people to feel good about themselves when they progress toward their goals, especially in the face of temptation. Feelings o f loss c o n c e r n i n g v a l u e d aspects of t h e risk b e h a v i o r m a y b e s t r o n g a t this stage. T h e r e f o r e , messages should also make explicit or reiterate the concrete and the self-evaluative long-term positive consequences of the behavior change. F u r t h e r m o r e , h e l p i n g p e o p l e t o identify p e e r s a n d o t h e r s w h o h a v e successfully e n g a g e d in t h e b e h a v i o r a n d are satisfied w i t h t h e i r c h a n g e s will h e l p t h e i n d i v i d u a l m a i n t a i n a s t r o n g sense of self-efficacy.

Conclusion As t h e p r e v i o u s d e s c r i p t i o n s a n d role m o d e l stories illustrate, social c o g n i t i v e t h e o r y a n d t h e t r a n s t h e o r e t i c a l m o d e l can b e effectively c o m b i n e d t o p r o d u c e t a i l o r e d messages d e s i g n e d t o facilitate b e h a v i o r c h a n g e . S C T d e l i n e a t e s t h e t r i a d i c n a t u r e of b e h a v i o r a l e x p r e s s i o n , t h a t is, t h e r e c i p r o c a l interaction a m o n g person, environment, and behavior. Furthermore, SCT identifies t h e i n t e r n a l p e r s o n a l factors, s u c h as self-efficacy a n d o u t c o m e e x p e c t a t i o n s , t h a t influence t h e d e v e l o p m e n t a n d m a i n t e n a n c e of h e a l t h b e h a v i o r s . T h e t r a n s t h e o r e t i c a l m o d e l p r o v i d e s a f r a m e w o r k for c o n c e p t u alizing t h e t e m p o r a l s e q u e n c e in w h i c h p e o p l e m o d i f y t h e i r i n t e n t i o n s a n d h e a l t h b e h a v i o r s . Efficient m o v e m e n t t h r o u g h t h e stages can b e p r o m o t e d b y a d d r e s s i n g specific i n t e r n a l p e r s o n a l factors w h e n t h e y a r e m o s t likely t o facilitate c h a n g e in t h e b e h a v i o r c h a n g e p r o g r e s s i o n . H e a l t h m e s s a g e d e signers can utilize this c o m b i n e d p e r s p e c t i v e t o d e v e l o p focused m e s s a g e s for a v a r i e t y of h e a l t h - r e l a t e d b e h a v i o r c h a n g e p r o g r a m s .

Notes 1. Self-efficacy judgments are tied to specific behaviors and the situations in which they occur. All people have varying levels of personal efficacy depending on the behavior and the situation. An individual cannot be thought of as having high or low self-efficacy in general, but rather as having high or low self-efficacy to engage in a specific behavior. 2. Their identities are typically altered to protect their privacy.

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References Bandura, A. (1986). Social foundations of thought and action: A social cognitive approach. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1991). Self-efficacy mechanism in physiological activation and health-promoting behavior. In J. Madden (Ed.), Neurobiology of learning, emotion and affect (pp. 229-269). New York: Raven. Bandura, A. (1992). A social cognitive approach to the exercise of control over AIDS infection. In R. DiClemente (Ed.), Adolescents and AIDS: A generation in jeopardy (pp. 89-116). Newbury Park, CA: Sage Bandura, A. (in press). Self-efficacy: The exercise of control. New York: Freeman. Bandura, Α., 8c Adams, N. (1977). Analysis of self-efficacy theory to behavioral change. Cognitive Therapy and Research, 1, 287-310. Bandura, Α., 8c Cervone, D. (1983). Self-evaluative and self-efficacy mechanisms governing motivational effects of goal systems. Journal of Personality and Social Psychology, 45, 1017-1028. Baranowski, T. (1989-1990). Reciprocal determinism at the stages of behavior change: An integration of community, personal, and behavioral perspectives. International Quarterly of Health Education, 10, 297-327. Baranowski, T. (1992). Beliefs as motivational influences at stages in behavior change. International Journal of Community Health Education, 13, 3-29. Bernier, M., & Avard, J. (1986). Self-efficacy, outcome, and attrition in a weight-reduction program. Cognitive Therapy and Research, 10, 319-338. Brown, I., 8c Inouye, D. K. (1978). Learned helplessness through modeling: The role of perceived similarity in competence. Journal of Personality and Social Psychology, 36, 900-908. Centers for Disease Control and Prevention. (1994). Prevention of HIV in Women and Infants Demonstration Project Protocol (Unpublished document). Atlanta: Centers for Disease Control and Prevention. Chambliss, C. Α., 8c Murray, E. J. (1979a). Cognitive procedures for smoking reduction: Symptom attribution versus efficacy attribution. Cognitive Therapy and Research, 3, 91-96. Chambliss, C. Α., 8c Murray, E. J. (1979b). Efficacy attribution, locus of control, and weight loss. Cognitive Therapy and Research, 3, 349-354. Cotton, D. C , Cabral, R., Gielen, Α., Semaan, S., Tunstall, C , Oliva, G., 8c Hembry, K. (1994). The transtheoretical foundation of the Prevention of HIV in Women and Infants Demonstration Projects. Unpublished manuscript. (Available from National Center for Prevention Services, Centers for Disease Control 8c Prevention, Atlanta, GA) DiClemente, C. C., 8c Hughes, S. O. (1990). Stages of change profiles in treatment. Journal of Substance Abuse, 2, 217-235. DiClemente, C. C , 8c Prochaska, J. O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142. DiClemente, C. C , Prochaska, J. O., 8c Gilbertini, Μ. (1985). Self-efficacy and the stages of self-change of smoking. Cognitive Therapy and Research, 9, 181-200. Ewart, C. K., Taylor, C. B., Reese, L. B., 8c DeBusk, R. F. (1983). Effects of early post myocardial infarction exercise testing on self-perception and subsequent physical activity. The American Journal of Cardiology, 51, 1076-1080.

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Galavotti, C , Cabral, R., Grimley, D., Riley, G. E., 8c Prochaska, J. O. (1993, June). Measurement of condom and other contraceptive behavior change among women at high risk of HIV infection and transmission (Abstract #PO-D38-4416). Paper presented at the Ninth International Conference on AIDS, Berlin. Hemophilia Behavioral Intervention Evaluation Projects. (1993). Hemophilia Behavioral Intervention Evaluation Projects adolescent and adult manuals. Atlanta: Centers for Disease Control and Prevention. Hosford, R., 8c Mills, M. (1983). Video in social skills training. In P. Dowrick 8c S. Biggs (Eds.), Using video: Psychological and social applications (pp. 125-150). New York: John Wiley. Liebman, J., Bond, L., Person, B., Terry, M , Stribling, M., 8c Dillard-Smith, C. (1994). Intervention design of the Prevention of HIV in Women and Infants Demonstration Project. Unpublished manuscript. (Available from National Center for Prevention Services, Centers for Disease Control & Prevention, Adanta, GA) Locke, Ε. Α., 8c Latham, G. P. (1990). A theory of goal setting and task performance. Englewood Cüffs, NJ: Prentice Hall. Maccoby, N., & Alexander, J. (1980). Use of media in lifestyle programs. In P. Davidson 8c S. Davidson (Eds.), Behavioral medicine: Changing health lifestyles (pp. 351-370). New York: Brunner/Mazel. Maibach, E. (1992). The use of behavioral theory in the development of AIDS information campaigns. In B. Thornton 8c G. Kreps (Eds.), Perspectives on health communication (pp. 207-217). Prospect Heights, IL: Waveland. Maibach, E. (1993). Social marketing for the environment: Using information campaigns to promote environmental awareness and behavior change. Health Promotion International 8, 209-224. Maibach, E., 8c Flora, J. (1993). Symbolic modeling and cognitive rehearsal: Using video to promote AIDS prevention self-efficacy. Communication Research, 20, 517-545. Maibach, E., 8c Murphy, D. (in press). Conceptualization and measurement of self-efficacy in health promotion research. Health Education Research. McAlister, Α., Pulley, L., Kay, L., 8c O'Reilly, K. R (in press). Community based prevention campaigns for hard to reach populations at high risk for HIV infection: Theory and implementation. American Journal of Health Promotion. O'Connell, D. O., 8c Velicer, W. F. (1988). A decisional balance measure of the stages of change model for weight loss. International Journal of the Addictions, 23, 729-740. O'Reilly, K. R , 8c Higgins, D. L. (1991). AIDS Community Demonstration Projects for HIV prevention among hard-to-reach groups. Public Health Reports, 106,714-720. Perry, M., 8c Furukawa, M. J. (1986). Modeling methods. In F. Kanfer 8c A. Goldstein (Eds.), Helping people change (3rd ed.) (pp. 66-110). Elmsford, NY: Pergamon. Prochaska, J. O., 8c DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395. Prochaska, J. O., 8c DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones/Irwin. Prochaska, J. O., 8c DiClemente, C. C. (1985). Common processes of change in smoking, weight control and psychological distress. In S. Shiffman 8c T. A. Willis (Eds.), Coping and substance abuse (pp. 345-363). New York: Academic Press. Prochaska. J. O., 8c DiClemente, C. C. (1986). The transtheoretical approach: Crossing the traditional boundaries of therapy (2nd ed.). Homewood, IL: Dow Jones/Irwin.

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Prochaska, J., DiClemente, C , 8c Norcross, J. (1992). In search of how people change: Application to addictive behaviors. American Psychobgist, 47,1102-1114. Prochaska, J. O., DiClemente, C. C , Velicer, W. F., Ginpil, S., & Norcross, J. C. (1985). Predicting change in smoking status for self-changers. Addictive Behaviors, 10, 395-406. Prochaska, J. O., Norcross, J. C , Fowler, J. L., Follick, M. J., 8c Abrams, D. B. (1992). Attendance and outcome in a work site weight control program: Processes and stages of change as process and predictor variables. Addictive Behaviors, 17, 35-45. Prochaska, J. O., Redding, C Α., Harlow, L. L., Rossi, J. S., 8c Velicer, W. F. (in press). The stages of change model and HIV prevention. Health Education Quarterly. Pulley, L., McAlister, Α., Kay, L., 8c O'Reilly, K. (in press). Prevention campaigns for hard-toreach populations at risk for HIV infection: Theory and implications. Health Education Quarterly. Rossi, J. S. (1989). Exploring behavioral approaches to UV risk reduction. In A. Moshell 8c L. W. Blankenbaker (Eds.), Sunlight, ultraviolet radiation, and the skin (pp. 91-93). Bethesda, MD: National Institutes of Health. Schunk, D. H. (1982). Effects of effort attributional feedback on children's perceived selfefficacy and achievement. Journal of Educational Psychology, 74, 548-556. Strecher, V., DeVellis, B., Becker, M , 8c Rosenstock, I. M. (1986). The role of self-efficacy in achieving health behavior change. Health Education Quarterly, 13, 73-91. Wallack, L. (1990). Mass media and health promotion: Promise, problem and challenge. In C. Atkin 8c L. Wallack (Eds.), Mass communication and public health (pp. 41-51). Newbury Park, CA: Sage. Wood, R., 8c Bandura, A. (1989). Social cognitive theory of organizational management. Academy of Management Review, 14, 361-384.

4

Fear Appeals in Health Promotion Campaigns T O O M U C H , T O O LITTLE, OR JUST RIGHT?

JEROLD L. HALE JAMES PRICE DILLARD

w

h e n d e s i g n i n g h e a l t h p r o m o t i o n c a m p a i g n s , t h e r e a r e a n y n u m b e r of

V V p e r s u a s i v e m e s s a g e strategies t h a t can b e used. O n e of t h e s e strategies involves t h e use of fear appeals t o p r o m o t e b e t t e r h e a l t h . Fear a p p e a l s a r e p e r s u a s i v e messages t h a t e m p h a s i z e t h e h a r m f u l physical o r social c o n s e q u e n c e s of failing t o c o m p l y w i t h m e s s a g e r e c o m m e n d a t i o n s . T h e use of fear a p p e a l s in t h e m e d i a t o p r o m o t e h e a l t h is w i d e s p r e a d . O n e w e l l - k n o w n fear a p p e a l d e p i c t s a h a r m f u l physical c o n s e q u e n c e of d r u g u s e . T h e c o m m e r c i a l s h o w s a n egg, a frying p a n , a n d t h e n t h e egg frying. T h e voice-over says: "This is y o u r brain. This is y o u r b r a i n o n d r u g s . A n y q u e s t i o n s ? " T h e i n t e n t of t h e message is t o d e m o n s t r a t e t h a t d r u g u s e kills b r a i n cells. H e a l t h p r o m o t i o n messages also use fear appeals t h a t stress h a r m f u l social c o n s e q u e n c e s for failing t o c o m p l y w i t h m e s s a g e r e c o m m e n d a t i o n s . A r e c e n t m e s s a g e for an alcohol t r e a t m e n t c e n t e r serves as a g o o d e x a m p l e . T h e c o m m e r c i a l shows a h u s b a n d being arrested for driving u n d e r t h e influe n c e of a l c o h o l . At t h e s a m e t i m e , a w o r r i e d wife is o n t h e t e l e p h o n e p l e a d i n g w i t h t h e m a n ' s e m p l o y e r n o t t o fire h i m . M o r e s y s t e m a t i c e v i d e n c e of t h e use of fear a p p e a l s t o p r o m o t e b e t t e r health comes from a study by Freimuth, H a m m o n d , Edgar, a n d M o n a h a n ( 1 9 9 0 ) . T h e y e x a m i n e d t h e c o n t e n t of p u b l i c service a n n o u n c e m e n t s (PSAs) related t o A I D S . Fear a p p e a l s w e r e u s e d in r o u g h l y 2 6 % of t h e PSAs. T h i s c o m b i n a t i o n of a n e c d o t a l a n d c o n t e n t - a n a l y t i c e v i d e n c e a p p e a r s t o i n d i c a t e t h a t p r o d u c e r s of health p r o m o t i o n messages believe that fear appeals are a n

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effective h e a l t h p r o m o t i o n strategy. I n t e r v i e w s w i t h h e a l t h c o m m u n i c a t i o n p r o d u c e r s , h o w e v e r , s h o w t h a t h e a l t h c a m p a i g n professionals are split in t h e i r o p i n i o n s o n t h e usefulness of fear appeals. Backer, R o g e r s , a n d S o p o r y (1992) i n t e r v i e w e d 30 individuals w h o c o n s t r u c t e d h e a l t h c o m m u n i c a t i o n c a m p a i g n s a n d asked t h e m w h e t h e r fear appeals w e r e effective strategies t o p r o m o t e h e a l t h . T h e interview results s h o w e d t h a t 6 of t h e c a m p a i g n p r o ducers believed that fear appeals were effective strategies for p r o m o t i n g b e t t e r h e a l t h , a n o t h e r 13 believed fear appeals w e r e ineffective, 10 w e r e u n s u r e , a n d 1 failed to r e s p o n d . A m o n g social scientists t h e r e is n o m o r e a g r e e m e n t t h a n a m o n g h e a l t h p r o m o t i o n p r a c t i t i o n e r s . T h e r e a r e n e a r l y as m a n y e x p l a n a t i o n s for t h e effects of fear appeals as there are folk remedies for t h e c o m m o n cold. A brief review a n d c r i t i q u e of t h o s e e x p l a n a t i o n s will follow.

Fear Appeal Explanations A l t h o u g h t h e r e are several e x p l a n a t i o n s for t h e effects of fear a p p e a l s , Dillard (in press) a n d W i t t e (1992a) p o s i t e d t h a t t h e e x p l a n a t i o n s fall w i t h i n t h r e e categories: drive e x p l a n a t i o n s , parallel r e s p o n s e e x p l a n a t i o n s , a n d subjective e x p e c t e d utilities e x p l a n a t i o n s .

DRIVE EXPLANATIONS D r i v e e x p l a n a t i o n s for t h e effects of fear a p p e a l s all a s s u m e t h a t feara r o u s i n g c o n t e n t p r o d u c e s a drive. Drives are bodily states, in this case activat i o n , a r o u s a l , o r anxiety, t h a t result in s o m e general r e s p o n s e ( N e w c o m b e , T u r n e r , & C o n v e r s e , 1965). A l t h o u g h t h e several d r i v e e x p l a n a t i o n s agree t h a t f e a r - a r o u s i n g c o n t e n t p r o d u c e s drive, t h e y d i s a g r e e o n t h e g e n e r a l r e s p o n s e t h a t drive p r o d u c e s . For e x a m p l e , t h e o r i g i n a l d r i v e e x p l a n a t i o n suggested that fear-arousing c o n t e n t p r o d u c e d fear o r anxiety a b o u t t h e n e g a tive c o n s e q u e n c e s d e p i c t e d in t h e m e s s a g e ( H o v l a n d , Janis, &Kelley, 1953). T h a t a n x i e t y p r o m p t e d c o m p l i a n c e w i t h t h e message r e c o m m e n d a t i o n s . P u t a n o t h e r w a y , t h e m o r e f e a r - a r o u s i n g c o n t e n t c o n t a i n e d in t h e m e s s a g e , t h e m o r e effective t h e a p p e a l was p r e d i c t e d t o b e . A p e r s u a s i v e m e s s a g e d e s i g n e d t o r e d u c e h i g h - r i s k b e h a v i o r s related t o A I D S s h o u l d , a c c o r d i n g t o this e x p l a n a t i o n , rely o n heavy doses of f e a r - a r o u s i n g c o n t e n t . Research b y Janis a n d Feshbach (1953) p r o d u c e d a " r e s i s t a n c e " e x p l a n a t i o n w i t h i n t h e category of drive e x p l a n a t i o n s . Janis a n d F e s h b a c h gave h i g h

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s c h o o l s t u d e n t s o n e of t h r e e messages d e s i g n e d t o p r o m o t e b e t t e r d e n t a l h y g i e n e : a low, m o d e r a t e , o r h i g h fear a p p e a l . T h e y f o u n d t h a t t h e l o w fear m e s s a g e led t o b e t t e r d e n t a l h y g i e n e a n d a r g u e d t h a t t h e d r i v e o r a n x i e t y p r o d u c e d b y t h e m o d e r a t e a n d h i g h fear messages t r i g g e r e d defensive avoidance. Defensive a v o i d a n c e w a s t h e t e n d e n c y t o i g n o r e o r d e n y t h e n e g a t i v e c o n s e q u e n c e s d e p i c t e d in t h e m e s s a g e . T h e y suggested t h a t s o m e s t u d e n t s r e a s o n e d s o m e t h i n g like: " m y t e e t h d o n ' t l o o k like t h o s e , so m y h y g i e n e m u s t b e fine." C o n t r a r y t o t h e p r e v i o u s a p p r o a c h , t h e r e s i s t a n c e v e r s i o n of t h e d r i v e e x p l a n a t i o n posits t h a t as f e a r - a r o u s i n g m e s s a g e c o n t e n t i n c r e a s e s , c o m p l i a n c e w i t h t h e m e s s a g e r e c o m m e n d a t i o n s will d e c r e a s e . A c c o r d i n g t o t h i s d r i v e e x p l a n a t i o n a m e s s a g e d e s i g n e d t o r e d u c e risk b e h a v i o r s r e l a t e d t o A I D S s h o u l d m i n i m i z e t h e u s e of fear a p p e a l s . A final d r i v e e x p l a n a t i o n posits a curvilinear r e l a t i o n s h i p b e t w e e n fear a n d p e r s u a s i v e o u t c o m e s (e.g., Miller, 1963). As w i t h t h e o t h e r d r i v e e x p l a n a t i o n s , t h e c u r v i l i n e a r h y p o t h e s i s suggested t h a t l o w fear m e s s a g e s w o u l d b e ineffective b e c a u s e t h e messages d i d n o t p r o d u c e e n o u g h d r i v e t o m o t i v a t e c o m p l i a n c e , a n d t h a t h i g h fear messages w o u l d b e ineffective b e c a u s e t h e y p r o d u c e d defensive a v o i d a n c e . A c c o r d i n g t o this d r i v e e x p l a n a t i o n , t h e m o s t effective fear a p p e a l w o u l d b e a m o d e r a t e fear m e s s a g e . A n A I D S r e l a t e d m e s s a g e s h o u l d seek m i d d l e g r o u n d in t e r m s of f e a r - a r o u s i n g c o n tent, according to this explanation. Q u a n t i t a t i v e reviews b y Boster a n d M o n g e a u (1984) a n d M o n g e a u (in p r e s s ) o f t h e fear a p p e a l l i t e r a t u r e d i s c o u n t t h e validity of t h e v a r i o u s d r i v e a p p r o a c h e s . B o t h o f t h o s e reviews f o u n d t h a t t h e r e l a t i o n s h i p b e t w e e n feara r o u s i n g c o n t e n t a n d p e r c e i v e d fear (drive) w a s positive, as p r e d i c t e d . T h e r e l a t i o n s h i p b e t w e e n f e a r - a r o u s i n g c o n t e n t a n d p e r s u a s i v e n e s s w a s also p o s i t i v e , h o w e v e r . T h a t o u t c o m e is i n c o n s i s t e n t w i t h t h e r e s i s t a n c e v e r s i o n of d r i v e , w h i c h h y p o t h e s i z e s a negative r e l a t i o n s h i p . It is also at o d d s w i t h the curvilinear variation, which predicts an inverted U - s h a p e d relationship b e t w e e n f e a r - a r o u s i n g c o n t e n t a n d p e r s u a s i v e n e s s . T h e o r i g i n a l d r i v e form u l a t i o n — t h a t is, m o r e fear p r o d u c e s m o r e p e r s u a s i v e n e s s — w a s f o u n d w a n t i n g b e c a u s e each of t h e m e t a - a n a l y s e s identified several m o d e r a t o r variables t h a t w e r e n o t specified b y t h e e x p l a n a t i o n a n d t h a t d i s c o u n t t h e n o t i o n o f a g e n e r a l r e s p o n s e t o t h e t e n s i o n p r o d u c e d b y t h e fear a p p e a l .

PARALLEL R E S P O N S E M O D E L S L e v e n t h a l (1971) believed t h a t fear appeals t r i g g e r e d t w o p r o c e s s e s in t h e targets of t h e a p p e a l s . H e a r g u e d t h a t f e a r - a r o u s i n g c o n t e n t p r o d u c e d t h e

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e m o t i o n of fear a n d the need to m a n a g e the fear. At t h e same time, fear a p p e a l s t r i g g e r e d a desire t o e l i m i n a t e t h e d a n g e r p o s e d b y t h e m e s s a g e . L e v e n t h a l a r g u e d t h a t targets of fear appeals h a d t o e n g a g e in b o t h fear c o n t r o l a n d / o r d a n g e r c o n t r o l . Fear control referred t o a n e e d t o r e d u c e t h e e m o t i o n of fear. D i l l a r d (in press) p o i n t e d o u t t h a t fear c o n t r o l c o u l d b e a c c o m p l i s h e d b y several m e a n s , s u c h as denial, a v o i d a n c e , d i s t r a c t i o n , o r d u l l i n g t h e i m p a c t of t h e e m o t i o n via t h e c o n s u m p t i o n of d r u g s a n d / o r alcohol. Danger control, o n t h e o t h e r h a n d , referred t o a n e e d to r e d u c e t h e negative c o n s e q u e n c e d e p i c t e d in t h e message. D a n g e r c o n t r o l w o u l d result in c o m p l i a n c e w i t h t h e m e s s a g e r e c o m m e n d a t i o n s . T h e target of an A I D S - r e l a t e d fear a p p e a l w o u l d e x p e r i e n c e t h e e m o t i o n of fear, w h i c h w o u l d trigger a desire t o r e d u c e t h e fear, a desire t o r e d u c e t h e d a n g e r , o r b o t h . L e v e n t h a P s a p p r o a c h , a l t h o u g h t h o u g h t p r o v o k i n g , was n o t a very useful e x p l a n a t i o n for t h e effects of fear appeals. Dillard (in press) n o t e d t h a t t h r e a t c o n t r o l a n d d a n g e r c o n t r o l c o u l d serve c o n t r a d i c t o r y p u r p o s e s . It is possible for t h e t a r g e t to m a n a g e t h e t h r e a t in ways t h a t i n h i b i t d a n g e r c o n t r o l , t h a t is, c o n s u m p t i o n of alcohol t o r e d u c e fear m i g h t p r e v e n t t h e t a r g e t from p e r f o r m i n g t h e b e h a v i o r s n e e d e d for effective d a n g e r c o n t r o l . Several scientists h a v e also n o t e d t h a t Leventhal's m o d e l d o e s n o t spell o u t t h e c o n d i t i o n s u n d e r w h i c h a target m i g h t o p t for t h r e a t c o n t r o l , d a n g e r c o n t r o l , or s o m e c o m b i n a t i o n of the t w o (e.g., Boster & M o n g e a u , 1984). W i t t e (1992a) c o n s t r u c t e d an e x t e n d e d parallel p r o c e s s m o d e l in w h i c h she d i d p r e d i c t w h e n t h r e a t c o n t r o l a n d / o r d a n g e r c o n t r o l w o u l d b e trigg e r e d . She a r g u e d t h a t n e i t h e r p r o c e s s w o u l d b e activated w i t h a l o w fear m e s s a g e , b e c a u s e t h e message w o u l d n o t p r o d u c e t h e e m o t i o n of fear (a n e c e s s a r y c o n d i t i o n for b o t h t h r e a t c o n t r o l a n d d a n g e r c o n t r o l ) . W i t h a h i g h fear m e s s a g e , h o w e v e r , t h e e m o t i o n of fear w o u l d b e p r o d u c e d . A c c o r d i n g to Witte, the extent to which danger control would operate d e p e n d e d on t h e efficacy of the message r e c o m m e n d a t i o n s . If the r e c o m m e n d a t i o n s offered a n effective m e t h o d t o e l i m i n a t e t h e negative o u t c o m e , t h e n t h e target w o u l d c o m p l y w i t h t h o s e r e c o m m e n d a t i o n s . If t h e r e c o m m e n d a t i o n s w e r e a n ineffective m e a n s t o e l i m i n a t e t h e negative o u t c o m e , t h e n t h r e a t c o n t r o l in a n y of its m a n i f e s t a t i o n s w o u l d o c c u r . W i t t e ' s a p p r o a c h a p p e a r s t o b e a p r o m i s i n g o n e . She h a s tested t h e effects of efficacy o n t h e effectiveness of A I D S - r e l a t e d fear appeals, a n d f o u n d t h a t efficacy d o e s influence t h e p e r suasiveness of t h e message ( W i t t e , 1992b). Nevertheless, t h e j u r y is still o u t o n this e x p l a n a t i o n u n t i l m o r e d a t a are available a n d u n t i l tests of t h e e n t i r e e x p l a n a t i o n are r e p o r t e d .

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SUBJECTIVE EXPECTED UTILITY MODELS Subjective e x p e c t e d utility m o d e l s generally p r e d i c t t h a t o u t c o m e s a r e s o m e f u n c t i o n of several variables. O n e p o p u l a r e x p l a n a t i o n for t h e effect o f fear appeals will illustrate this p o i n t . R o g e r s (1975) p r o p o s e d a p r o t e c t i o n motivation explanation. The protection motivation explanation hypothesized t h a t p e r s u a s i v e o u t c o m e s w o u l d b e a m u l t i p l i c a t i v e f u n c t i o n o f (a) t h e severity o f t h e t h r e a t , (b) t h e target's v u l n e r a b i l i t y t o t h e t h r e a t , a n d (c) r e s p o n s e efficacy. Because t h e variables c o m b i n e d multiplicatively, if a n y of t h e variables t o o k o n a z e r o value, t h e n t h e fear a p p e a l w o u l d b e ineffective. F o r e x a m p l e , if an A I D S - r e l a t e d m e s s a g e failed t o d e p i c t a n e g a t i v e o u t c o m e , it w o u l d n o t b e p e r s u a s i v e . If t h e message p r e d i c t e d a n e g a t i v e o u t c o m e f r o m A I D S (certain d e a t h ) b u t t h e t a r g e t d i d n o t feel v u l n e r a b l e o r at risk for t h e n e g a t i v e o u t c o m e , t h e n t h e fear a p p e a l w o u l d n o t b e p e r s u a s i v e . If a m e s s a g e d e p i c t e d a negative o u t c o m e a n d t h e target felt v u l n e r a b l e t o t h e o u t c o m e * b u t t h e r e c o m m e n d e d m e a n s t o a v o i d t h e o u t c o m e w a s ineffective, t h e fear a p p e a l s w o u l d n o t p r o d u c e c o m p l i a n c e w i t h t h e r e c o m m e n d a t i o n . I m p o r t a n t l y , R o g e r s (1975) largely i g n o r e d t h e e m o t i o n of fear a n d f o c u s e d i n s t e a d o n t h e n o t i o n of t h r e a t s . T h a t is, h e a r g u e d t h a t a sufficient t h r e a t ( n o x i o u s n e s s ) c o m b i n e d w i t h c o m b i n a t i o n s of v u l n e r a b i l i t y a n d r e s p o n s e efficacy w o u l d b e p e r s u a s i v e w h e t h e r o r n o t fear w a s p r o d u c e d . Beck a n d F r a n k e l (1981) a r g u e d t h a t a subjective e x p e c t e d utility m o d e l s h o u l d differentiate b e t w e e n personal efficacy o n t h e o n e h a n d a n d response efficacy o n t h e o t h e r . P e r s o n a l efficacy refers t o t h e ability of t h e t a r g e t t o perform the r e c o m m e n d e d response—for example, to wear a c o n d o m , r e m a i n m o n o g a m o u s , o r a v o i d s h a r i n g n e e d l e s . R e s p o n s e efficacy is r e l a t e d t o t h e i m p a c t of r e c o m m e n d e d b e h a v i o r ( s ) o n t h e n e g a t i v e o u t c o m e . S u b s e q u e n t subjective e x p e c t e d utility m o d e l s h a v e t e n d e d t o differentiate p e r s o n a l efficacy a n d r e s p o n s e efficacy. T h e r e h a s b e e n c o n s i d e r a b l e d i s a g r e e m e n t a b o u t h o w t h e four variables relevant t o t h e s e m o d e l s w o u l d c o m b i n e t o g e t h e r t o influence p e r s u a s i v e o u t c o m e s (e.g., S u t t o n & Eiser, 1984; S u t t o n 8c H a l l e « , 1989). Even R o g e r s ( 1 9 8 3 ) , in t h e face o f e v i d e n c e i n v a l i d a t i n g his o r i g i n a l m o d e l (e.g., Boster 8c M o n g e a u , 1984), p r o p o s e d a n a l t e r n a t i v e m o d e l . In it h e h y p o t h e s i z e d t h a t n o x i o u s n e s s , v u l n e r a b i l i t y , p e r s o n a l efficacy, a n d r e s p o n s e efficacy w o u l d exert largely a d d i t i v e influences o n c o m p l i a n c e w i t h message r e c o m m e n d a t i o n s . T h a t is, t h e m o r e e a c h q u a l i t y was p r e s e n t , t h e m o r e persuasive t h e m e s s a g e w o u l d b e . H e also h y p o t h e s i z e d s o m e i n t e r a c t i o n effects. M o n g e a u ' s (in p r e s s ) m e t a - a n a l y s i s r e p o r t s s o m e s u p p o r t for t h e a d d i t i v e effects of t h e p r o p o s e d c o m p o n e n t s

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b u t fails t o find c o n s i s t e n t s u p p o r t for t h e n o n a d d i t i v e c o m b i n a t i o n s of variables.

SUMMARIZING FEAR A P P E A L R E S E A R C H F r o m t h e available e v i d e n c e o n t h e effects of fear a p p e a l s , t h r e e c o n c l u s i o n s s e e m a p p r o p r i a t e . First, t h e available d a t a are i n c o n s i s t e n t w i t h explan a t i o n s for t h e effects of fear appeals. T h i s m i g h t lead s o m e h e a l t h p r o m o t i o n p r a c t i t i o n e r s t o a b a n d o n t h e use of f e a r - a r o u s i n g c o n t e n t . S u c h a d r a s t i c step w o u l d certainly b e p r e m a t u r e . S e c o n d , d e s p i t e d i s a p p o i n t i n g results related t o t h e v a r i o u s fear a p p e a l e x p l a n a t i o n s , a c o m p e l l i n g case can b e m a d e for t h e p e r s u a s i v e i m p a c t of fear. T h r e e q u a n t i t a t i v e reviews (Boster 8c M o n g e a u , 1984; M o n g e a u , in press; S u t t o n , 1982) all s h o w reliable a n d c o m p e l l i n g e v i d e n c e t h a t fear is persuasive. T h e m o s t r e c e n t of t h e m e t a analyses, a n d b y v i r t u e of i n c l u d i n g several n e w e r studies p e r h a p s t h e best of t h e lot, c o n c l u d e d t h a t p e r c e i v e d fear a n d t h e a t t i t u d e o f t h e target w e r e positively c o r r e l a t e d , as w e r e p e r c e i v e d fear a n d b e h a v i o r . It is clear from t h e s e findings t h a t f e a r - a r o u s i n g m e s s a g e c o n t e n t is p e r s u a s i v e a n d t h a t a b a n d o n i n g t h e use of fear w o u l d b e t o a b a n d o n an effective p e r s u a s i v e strategy. T h i r d , t h e q u a n t i t a t i v e reviews also d e m o n s t r a t e t h a t t h e r e l a t i o n s h i p b e t w e e n fear a n d p e r s u a s i o n is a c o m p l e x o n e . Several variables t h a t i n f l u e n c e fear-persuasiveness c o r r e l a t i o n s h a v e b e e n identified a n d will b e d i s c u s s e d later. A l t h o u g h w e h a v e identified c o n c l u s i o n s w a r r a n t e d b y available d a t a , t h e r e a r e also s o m e l i m i t a t i o n s t o w h a t w e k n o w a b o u t fear a p p e a l s . F o r e x a m p l e , we k n o w very little a b o u t t h e effects of messages c o n t a i n i n g e x t r e m e l y h i g h a m o u n t s of f e a r - a r o u s i n g c o n t e n t . Boster a n d M o n g e a u (1984) a r g u e d t h a t t h e s t r e n g t h of t h e fear m a n i p u l a t i o n s in fear a p p e a l s t u d i e s i n f l u e n c e d the a m o u n t of fear perceived b y t h e targets of t h e appeals. T h e y also s u g g e s t e d t h a t v e r y few of t h e s t u d i e s i n c l u d e d s t i m u l i t h a t p r o d u c e d e x t r e m e a m o u n t s of fear. Largely for ethical r e a s o n s , w e k n o w very little a b o u t t h e effects of fear a p p e a l s o n very y o u n g c h i l d r e n . Even before t h e o n s e t of i n s t i t u t i o n a l review b o a r d s , t h e y o u n g e s t p a r t i c i p a n t s in fear a p p e a l s t u d i e s w e r e typically h i g h s c h o o l s t u d e n t s . So even t h o u g h t h e r e are reliable effects for f e a r - a r o u s i n g c o n t e n t , t h e r e are also i m p o r t a n t limits t o t h e k n o w l e d g e a c c u m u l a t e d t o d a t e a b o u t fear a p p e a l s . For n o w , t h e m o s t a p p r o p r i a t e q u e s t i o n is: "If fear a p p e a l s are effective, h o w s h o u l d t h e y b e d e s i g n e d ? "

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Designing Fear Appeals In t h i s p o r t i o n of t h e c h a p t e r w e will c o n s i d e r t h e b a s i c s t r u c t u r e of effective fear a p p e a l s , h o w t h o s e appeals s h o u l d b e o r g a n i z e d , a n d r e l e v a n t m o d e r a t o r variables t h a t influence t h e i r effectiveness. Let u s first c o n s i d e r t h e b a s i c s t r u c t u r e of effective fear a p p e a l s .

THE STRUCTURE O F FEAR APPEALS Based o n t h e p r e c e d i n g d i s c u s s i o n , it is clear t h a t effective fear a p p e a l s i n c l u d e t w o g e n e r a l categories of c o m p o n e n t s : t h r e a t c o m p o n e n t s a n d a c t i o n c o m p o n e n t s . W e will c o n s i d e r each c a t e g o r y in t u r n . Threat Components. Effective fear appeals a r o u s e t h e e m o t i o n of fear. T o a c c o m p l i s h this affective a r o u s a l , t h e fear a p p e a l s m u s t i n c l u d e t w o b a s i c t h r e a t c o m p o n e n t s . First, an effective fear a p p e a l m u s t i n c l u d e a t h r e a t of severe physical o r social h a r m if t h e target d o e s n o t c o m p l y w i t h t h e a p p e a l ' s r e c o m m e n d a t i o n s . As Boster a n d M o n g e a u (1984; M o n g e a u , in press) c o n v i n c i n g l y r e m i n d us, m o r e f e a r - a r o u s i n g m e s s a g e c o n t e n t (i.e., a severe t h r e a t ) p r o d u c e s m o r e p e r c e i v e d fear. T h e t h r e a t c o n t a i n e d in t h e m e s s a g e m u s t entail a t r u l y negative c o n s e q u e n c e . M o s t A I D S - r e l a t e d fear a p p e a l s i n c l u d e t h e t h r e a t o f d e a t h . O n e A I D S p u b l i c service a n n o u n c e m e n t c o n t e n t analyzed b y F r e i m u t h et al. (1990) showed a picture of a m o r g u e . T h e m e s s a g e said, "If y o u h a v e sex w i t h o u t a c o n d o m o r s h a r e a n e e d l e w i t h a d r u g a d d i c t y o u c o u l d e n d u p h e r e . " T h e negative c o n s e q u e n c e is clear. I n a n o t h e r A I D S a p p e a l , G r e e n e , R u b i n , a n d H a l e (1993) t o l d a d o l e s c e n t s , " A I D S is fatal—it kills p e o p l e . T h e r e is n o c u r e for A I D S . " I n a n o t h e r r e c e n t s t u d y H a l e , M o n g e a u , a n d L e m i e u x ( 1 9 9 3 ) u s e d fear a p p e a l s in a n a t t e m p t t o l i m i t e x p o s u r e t o t h e s u n a n d o t h e r s o u r c e s of u l t r a violet r a d i a t i o n . T h e h i g h fear m e s s a g e e m p h a s i z e d t h a t e x p o s u r e t o u l t r a violet r a d i a t i o n i n c r e a s e d t h e target's c h a n c e s o f d e v e l o p i n g n o n - m e l a n o m a cancers a n d / o r malignant melanoma, disfigurement from removing canc e r o u s g r o w t h s f r o m t h e face a n d n e c k , a n d t h e l i k e l i h o o d o f p e r m a n e n t l y d a m a g i n g o n e ' s skin. I n s h o r t , t h e c r e a t o r o f t h e m e s s a g e m u s t explicitly i n d i c a t e t h e negative effects of failing t o c o m p l y w i t h t h e m e s s a g e recommendations. S e c o n d , a n effective fear a p p e a l m u s t p e r s o n a l i z e t h e risk t o t h e t a r g e t of t h e m e s s a g e . T h e target m u s t b e m a d e t o feel v u l n e r a b l e o r s u s c e p t i b l e t o t h e n e g a t i v e c o n s e q u e n c e d e p i c t e d in t h e m e s s a g e . Several s t u d i e s h a v e

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f o u n d t h a t a l t h o u g h t h e y are c o n c e r n e d a b o u t A I D S generally, m e m b e r s of h i g h - r i s k g r o u p s d e n y p e r s o n a l risk of c o n t r a c t i n g t h e H I V virus (e.g., G r a y & S a r a c i n o , 1989; Q u i n l e y , 1988). Edgar, F r e i m u t h , a n d H a m m o n d (1988) f o u n d t h a t A I D S p r e v e n t i o n messages t h a t p e r s o n a l i z e d t h e d a n g e r c o u l d lead t o t h e p e r f o r m a n c e of fewer risk b e h a v i o r s . G r e e n e a n d colleagues (1993) a t t e m p t e d to p e r s o n a l i z e t h e A I D S risk b y i n c l u d i n g t h e following passage in o n e of t h e messages u s e d in t h e study: Young people between the ages of 12 and 22 have been identified as a group at risk for contracting AIDS. You are a member of this group. The number of AIDS cases among young people is doubling each year, and young people may be more likely to get AIDS than other groups. In their study of exposure to ultraviolet radiation, Hale a n d colleagues ( 1 9 9 3 ) a t t e m p t e d t o p e r s o n a l i z e t h e risk of skin c a n c e r b y d e m o n s t r a t i n g t h a t college-aged s t u d e n t s w e r e a m o n g t h e m o s t r a p i d l y g r o w i n g g r o u p of skin c a n c e r v i c t i m s . T h e targets of t h e a p p e a l w e r e also t o l d t h a t , a c c o r d i n g t o o n e r e c e n t s t u d y , "If y o u are s u n b u r n e d t o t h e p o i n t of blistering, o n e t i m e d u r i n g t h e first 25 years of y o u r life, y o u r c h a n c e s of c o n t r a c t i n g n o n m e l a n o m a a n d m e l a n o m a skin c a n c e r s will d o u b l e . "

ACTION COMPONENTS T h e a c t i o n c o m p o n e n t s of a n effective fear a p p e a l a r e related t o t h e b e h a v i o r a l r e c o m m e n d a t i o n s m a d e in t h e a p p e a l . T h e r e are t w o a c t i o n c o m p o n e n t s : p e r s o n a l efficacy a n d r e s p o n s e efficacy. Personal Efficacy. P e r s o n a l efficacy c o n c e r n s t h e target's p e r c e p t i o n t h a t h e o r she h a s t h e ability to follow t h e m e s s a g e r e c o m m e n d a t i o n s . W i t t e ( 1 9 9 2 b ) , for e x a m p l e , e m p h a s i z e d t h e ease of p u t t i n g o n a c o n d o m . A r e c e n t PSA, albeit n o t a fear a p p e a l , d i d likewise b y c o m p a r i n g p u t t i n g o n a c o n d o m w i t h p u t t i n g o n y o u r socks. Related t o different issues, H a l e et al. (1993) e m p h a s i z e d t h e simplicity of s u c h a c t i o n s as a p p l y i n g a s u n b l o c k o r a v o i d ing s u n e x p o s u r e d u r i n g p e a k h o u r s t o decrease e x p o s u r e t o ultraviolet r a d i a t i o n . M e y e r o w i t z a n d C h a i k e n (1987) e m p h a s i z e d t h e simplicity of b r e a s t s e l f - e x a m i n a t i o n s for early b r e a s t c a n c e r d e t e c t i o n b y w o m e n . Before t h e t a r g e t of a p e r s u a s i v e a p p e a l will c o m p l y w i t h t h e m e s s a g e r e c o m m e n d a t i o n s , h e o r she m u s t possess t h e skills n e e d e d t o d o so. In c o n s t r u c t i n g fear a p p e a l s , t h e p r o d u c e r of t h e a p p e a l w o u l d b e wise t o c o n s i d e r t h e skills

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n e e d e d t o avert t h e t h r e a t a n d t h e skills likely t o b e p o s s e s s e d b y m e m b e r s of t h e t a r g e t a u d i e n c e . Response Efficacy. R e s p o n s e efficacy is t h e ability of t h e m e s s a g e r e c o m m e n d a t i o n t o eliminate o r reduce the threat depicted in t h e message. A r e c e n t s t u d y b y B r o u w e r s a n d S o r r e n t i n o (1993) e x a m i n e d t h e i m p a c t of r e s p o n s e efficacy o n i n d i v i d u a l s ' willingness t o u n d e r g o a d i a g n o s t i c h e a l t h e x a m . W h e n r e s p o n s e efficacy was h i g h , in o t h e r w o r d s , w h e n t h e test was d e p i c t e d as a n effective diagnostic tool, willingness to have t h e test p e r f o r m e d i n c r e a s e d . I n h e r s t u d y of A I D S - r e l a t e d risks, W i t t e ( 1 9 9 2 b ) e m p h a s i z e d t h e reliability o f c o n d o m s in p r e v e n t i n g t h e s p r e a d of A I D S . R o g e r s a n d M e w b o r n ( 1 9 7 6 ) s h o w e d t h a t i n c r e a s e d r e s p o n s e efficacy h e i g h t e n e d t h e p e r s u a s i v e i m p a c t of a fear d e s i g n e d t o p r o m o t e cessation of s m o k i n g . F r u i n , P r a t t , a n d O w e n (1992) r e p o r t e d t h a t t h e r e s p o n s e efficacy of a r e c o m m e n d e d p r o g r a m of exercise t o r e d u c e risks of c a r d i o v a s c u l a r disease i n f l u e n c e d t h e w i l l i n g n e s s of i n d i v i d u a l s t o b e g i n t h e p r o g r a m . In his review of t h e fear a p p e a l literat u r e , S u t t o n (1982) c o n c l u d e d : " W e can t h e r e f o r e state w i t h s o m e c o n fidence t h a t i n c r e a s e d ( r e s p o n s e ) efficacy p r o d u c e s s t r o n g e r i n t e n t i o n s t o a d o p t t h e r e c o m m e n d e d r e s p o n s e s " ( p . 8 1 6 ) . T h e c r e a t o r of a f e a r - a r o u s i n g m e s s a g e w o u l d d o well t o i n s u r e t h a t t h e effectiveness o f r e c o m m e n d e d r e s p o n s e s is clearly d e m o n s t r a t e d w i t h i n t h e message.

O R G A N I Z I N G T H E MESSAGE A n effective fear a p p e a l m u s t i n c l u d e a severe t h r e a t , v u l n e r a b i l i t y o f t h e t a r g e t t o t h e t h r e a t , p e r s o n a l efficacy, a n d r e s p o n s e efficacy. T h e r e a r e a n y n u m b e r of ways t h o s e c o m p o n e n t s can b e o r g a n i z e d w i t h i n a p e r s u a s i v e m e s s a g e . I n d e e d , even a casual glance t h r o u g h t h e s p a t e of available p u b l i c s p e a k i n g texts will identify a q u a n t i t y of o r g a n i z a t i o n a l strategies (e.g., t o p i c a l o r g a n i z a t i o n , cause-effect, p r o b l e m - s o l u t i o n ) . U n f o r t u n a t e l y t h e r e is v e r y little e m p i r i c a l e v i d e n c e r e g a r d i n g t h e effectiveness of t h e v a r i o u s organizational patterns. W h a t w e will offer as a guide is a personal preference, a l t h o u g h s o u n d a r g u m e n t s c a n b e a d v a n c e d in favor of t h a t p r e f e r e n c e . W e r e c o m m e n d o r g a n i z i n g t h e fear a p p e a l u s i n g a p r o b l e m - s o l u t i o n p a t t e r n . T h e p r o b l e m - s o l u t i o n p a t t e r n is easy for a u d i e n c e m e m b e r s t o follow. It is also well s u i t e d t o t h e fear a p p e a l c o m p o n e n t s d i s c u s s e d a b o v e . T h e p r o b l e m p o r t i o n of t h e m e s s a g e s h o u l d i n c l u d e b o t h t h e t h r e a t a n d a r g u m e n t s d e s i g n e d t o h e i g h t e n p e r c e p t i o n s of v u l n e r a b i l i t y t o t h e t h r e a t . T h e severity of t h e t h r e a t c o u l d b e d o c u m e n t e d w i t h statistics r e g a r d i n g t h e

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n u m b e r of A I D S - r e l a t e d fatalities a n d s t a t e m e n t s i n d i c a t i n g t h a t t h e r e is n o c u r e for A I D S . T h e solution p o r t i o n of the message should r e c o m m e n d solutions to a v o i d t h e t h r e a t d e p i c t e d earlier in t h e message. In a n A I D S - r e l a t e d m e s s a g e o n e m i g h t r e c o m m e n d use of c o n d o m s d u r i n g sex o r a v o i d i n g s h a r i n g n e e d l e s d u r i n g i n t r a v e n o u s d r u g use. In a d d i t i o n t o m a k i n g t h e r e c o m m e n d a t i o n s , t h e solution p o r t i o n of the speech m u s t also d e m o n s t r a t e b o t h response efficacy p e r s o n a l efficacy.

V I V I D N E S S O F T H E APPEAL Vivid i n f o r m a t i o n is e m o t i o n a l l y i n t e r e s t i n g . It p r o v o k e s clear i m a g e s a n d m a k e s c o n t e n t seem physically, psychologically, a n d t e m p o r a l l y close t o t h e p e r s o n w h o experiences t h e i n f o r m a t i o n . Several r e s e a r c h e r s h a v e c o n t e n d e d t h a t vivid i n f o r m a t i o n is m o r e likely to k e e p a p e r s o n ' s a t t e n t i o n , t o b e recalled at a later time, a n d to b e persuasive. Taylor a n d T h o m p s o n (1982) r e v i e w e d m o r e t h a n 50 studies of t h e effects of vividness, h o w e v e r , a n d c o n c l u d e d t h a t s u p p o r t for vividness effects w a s e q u i v o c a l at best. Eagly a n d Chaiken (1993) suggest, despite research findings that are g e n e r ally d i s a p p o i n t i n g , t h a t t h e r e a r e several c o n t e x t s in w h i c h vividness d o e s a p p e a r t o i m p r o v e persuasiveness. T h o s e c o n t e x t s i n c l u d e t h e p e r s u a s i v e n e s s of p i c t o r i a l i n f o r m a t i o n , health appeals, a n d fear a p p e a l s . Because fear a p p e a l s f r e q u e n t l y a d d r e s s health issues a n d rely o n pictorial i n f o r m a t i o n , v i v i d n e s s m i g h t b e especially i m p o r t a n t for s u c h messages. A n d i n d e e d , v i v i d n e s s h a s b e e n a staple of s t r o n g fear appeals for q u i t e s o m e t i m e . A n early e x a m p l e of vivid i n f o r m a t i o n w o u l d b e p i c t u r e s of diseased t e e t h a n d g u m s in Janis a n d F e s h b a c h ' s (1953) s t u d y of d e n t a l h y g i e n e . A r e c e n t e x a m p l e of a vivid h i g h fear message c o m e s f r o m W i t t e ' s s t u d y of A I D S p r e v e n t i o n b e h a v i o r s , w h e r e t h e h i g h fear message i n c l u d e d c o l o r p h o t o s of a n e m a c i a t e d v i c t i m , t u m o r s o n a p e n i s , a n d lesions o n a foot. V i v i d visual images o n a n y n u m b e r of health related topics should b e available t o p r o d u c e r s of h e a l t h p r o m o t i o n messages, for e x a m p l e , m a s t e c t o m y p a t i e n t s , skin c a n c e r v i c t i m s , o r l u n g s of s m o k e r s . C a r e s h o u l d b e t a k e n in t h e use of vivid i n f o r m a t i o n . Eagly a n d C h a i k e n ( 1 9 9 3 ) p o i n t o u t t h a t vividness d o e s n o t s i m p l y e n h a n c e m e s s a g e c o n t e n t . It m a y e n h a n c e s o u r c e characteristics. T h e y use v i d e o t a p e d versus w r i t t e n m e s s a g e s as a n e x a m p l e , a n d p o i n t o u t t h a t v i d e o t a p e m a k e s characteristics o f t h e m e s s a g e s o u r c e (e.g., a p p e a r a n c e , vocal qualities) m o r e salient. T h e

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p e r s u a s i v e n e s s of e n h a n c e d s o u r c e characteristics d e p e n d s o n w h e t h e r t h o s e characteristics are p e r c e i v e d positively o r negatively. O u r p o i n t is t h a t vivid i n f o r m a t i o n s h o u l d d r a w a t t e n t i o n p r i m a r i l y t o t h e m e s s a g e c o n t e n t a n d , if a t t e n t i o n is d r a w n t o t h e s o u r c e of t h e m e s s a g e , care m u s t b e t a k e n in selecting a s o u r c e t h a t will b e positively p e r c e i v e d .

FRAMING T H E APPEAL T h e t h r e a t in a fear appeal can b e p h r a s e d in either a "loss frame" o r a " g a i n f r a m e " (see C h a p t e r 2 in this v o l u m e ) . T h e loss f r a m e p r e s e n t s t h e failure t o p e r f o r m t h e r e c o m m e n d e d r e s p o n s e in t e r m s of lost o p p o r t u n i t i e s o r i n c r e a s e d n e g a t i v e c o n s e q u e n c e s . A gain f r a m e w o u l d p r e s e n t p e r f o r m i n g t h e r e c o m m e n d e d r e s p o n s e in t e r m s of g a i n e d o p p o r t u n i t i e s o r d e c r e a s e d n e g a t i v e c o n s e q u e n c e s . T h e difference b e t w e e n t h e t w o frames of r e f e r e n c e is t h e p e r s u a s i v e e q u i v a l e n t t o asking w h e t h e r t h e c u p is half e m p t y o r half full. S o m e e x a m p l e s will h e l p clarify t h e difference b e t w e e n loss a n d g a i n frames. T w o g o o d e x a m p l e s o f loss v e r s u s gain frames c o m e f r o m M e y e r o w i t z a n d C h a i k e n ' s (1987) research o n breast cancer detection. T h e r e c o m m e n d e d response in their messages was that w o m e n engage in breast self-examination. E a c h of t h e following e x a m p l e s , f r o m t h e messages u s e d in t h e i r s t u d y , is p h r a s e d in a gain f r a m e . T h e l a n g u a g e u s e d in t h e loss f r a m e d m e s s a g e s is i n c l u d e d in p a r e n t h e s e s n e x t t o t h e w o r d o r p h r a s e for w h i c h it w a s s u b s t i t u t e d . " B y ( n o t ) d o i n g Breast Self E x a m i n a t i o n n o w y o u (will n o t ) c a n l e a r n w h a t y o u r n o r m a l , h e a l t h y b r e a s t feels like so t h a t y o u will b e (ill) b e t t e r p r e p a r e d t o n o t i c e a n y small a b n o r m a l c h a n g e s t h a t m i g h t o c c u r as y o u get o l d e r " ( p . 5 0 4 ) . A n o t h e r e x a m p l e was: " R e s e a r c h s h o w s t h a t w o m e n w h o ( d o n o t d o ) d o Breast Self E x a m i n a t i o n h a v e (a d e c r e a s e d ) a n i n c r e a s e d chance of finding a t u m o r " (p. 504). T h e results of t h e i n q u i r y b y M e y e r o w i t z a n d C h a i k e n ( 1 9 8 7 ) s h o w t h a t loss frames are m o r e effective t h a n gain frames. This was true b o t h for p a r t i c i p a n t s ' i m m e d i a t e r e s p o n s e s t o t h e messages a n d for t h e i r r e s p o n s e s m e a s u r e d 4 m o n t h s later. F r o m this research, it a p p e a r s t h a t fear a p p e a l s s h o u l d e m p h a s i z e n e g a t i v e c o n s e q u e n c e s for n o t following m e s s a g e r e c o m m e n d a t i o n s as o p p o s e d t o e m p h a s i z i n g positive c o n s e q u e n c e s for c o m p l y i n g w i t h t h e r e c o m m e n d e d r e s p o n s e , for e x a m p l e , "if y o u d o n o t s t o p s m o k i n g y o u will significantly increase y o u r risk of h e a r t d i s e a s e " i n s t e a d of "if y o u s t o p s m o k i n g y o u will significantly decrease y o u r risk of h e a r t d i s e a s e . "

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Ineffective Use of Fear Appeals In t h e p r e v i o u s section of this c h a p t e r w e o u t l i n e d t h e c o n d i t i o n s n e c e s sary for a fear a p p e a l t o b e p e r s u a s i v e . Even w h e n a fear a p p e a l c o n t a i n s a severe t h r e a t t h a t is p e r s o n a l i z e d b y t h e target of t h e m e s s a g e a n d m e s s a g e r e c o m m e n d a t i o n s t h a t are effective a n d can b e easily p e r f o r m e d , t h e m e s sage m a y b e ineffective. T h i s is b e c a u s e fear appeals a r e s i m p l y ineffective for s o m e a u d i e n c e s (Boster 8c M o n g e a u , 1984; M o n g e a u , in p r e s s ) . W h a t follows is a discussion of issues e x t r a n e o u s t o t h e c o n t e n t or f o r m of t h e m e s s a g e t h a t c a n i n h i b i t t h e effectiveness of fear a p p e a l s .

V O L U N T E E R S OR NONVOLUNTEERS? T h e t a r g e t of a persuasive message m a y a t t e n d t o a p e r s u a s i v e m e s s a g e e i t h e r v o l u n t a r i l y o r n o n v o l u n t a r y . T h e r e is c o n v i n c i n g e v i d e n c e t o i n d i cate v o l u n t e e r s a n d n o n v o l u n t e e r s r e s p o n d differently t o fear a p p e a l s . H o r o w i t z ( 1 9 6 9 , 1972) e x a m i n e d t h e effects of v o l u n t a r i s m o n t h e p e r s u a siveness of fear appeals d e s i g n e d to p r e v e n t d r u g a b u s e . H e f o u n d t h a t h i g h fear m e s s a g e s w e r e m o r e p e r s u a s i v e for v o l u n t e e r s t h a n w e r e l o w fear m e s s a g e s . For n o n v o l u n t e e r s , p e o p l e w h o h a v e n o c h o i c e a b o u t b e i n g e x p o s e d t o t h e message, high fear messages w e r e ineffective. H e r e a s o n e d t h a t n o n v o l u n t e e r s e n g a g e d in reactance. R e a c t a n c e is a p s y c h o l o g i c a l p r o cess t h a t o c c u r s w h e n a p e r s o n feels t h a t his o r h e r f r e e d o m t o act is b e i n g r e s t r i c t e d . T h e result of t h e r e a c t a n c e is t h a t t h e i n d i v i d u a l refuses t o follow t h e m e s s a g e r e c o m m e n d a t i o n s , in an effort t o r e c o u p t h e lost f r e e d o m . T h e s e results clearly s h o w t h a t fear appeals are a p o o r l y c o n c e i v e d strategy for a n a u d i e n c e of n o n v o l u n t e e r s . F o r e x a m p l e , h i g h s c h o o l s t u d e n t s w h o a t t e n d a d r u g a b u s e p r e v e n t i o n p r o g r a m b e c a u s e their p r e s e n c e is c o m p e l l e d b y a p r i n c i p a l o r t e a c h e r w o u l d n o t r e s p o n d favorably t o a fear a p p e a l . A p a t i e n t w h o s e d o c t o r uses a s t r o n g fear a p p e a l m a y n o t r e s p o n d positively t o it d e p e n d i n g o n w h o initiated t h e c o n v e r s a t i o n a n d t h e p a t i e n t ' s p e r ceived d e g r e e of v o l u n t a r i s m . Fear appeals w o u l d b e best for p u b l i c p r e s e n t a t i o n s w h e r e a t t e n d a n c e w a s n o t c o m p e l l e d o r for c o n v e r s a t i o n s explicitly i n i t i a t e d b y t h e t a r g e t of t h e a p p e a l . S o m e h e a l t h c o m m u n i c a t i o n c a m p a i g n s t h a t involve fear appeals a n d u s e television d o n o t succeed ( K o h n , G o o d s t a d t , C o o k , S h e p p a r d , 8c C h a n , 1982). O n e reason m a y b e that television viewers, a l t h o u g h voluntarily c h o o s ing to w a t c h e n t e r t a i n m e n t p r o g r a m m i n g , involuntarily watch c o m m e r c i a l s . If viewers believe t h e y are c o m p e l l e d to w a t c h c o m m e r c i a l s or t h a t t h e

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r e s p o n s e costs (see b e l o w ) for a v o i d i n g t h e c o m m e r c i a l s a r e t o o h i g h , t h e y will e n g a g e in r e a c t a n c e a n d t h e fear a p p e a l will fail. P r o d u c e r s o f h e a l t h p r o m o t i o n c a m p a i g n s m u s t c o n s i d e r w h e t h e r t h e target a u d i e n c e for t h e c a m p a i g n will b e e x p o s e d t o p e r s u a s i v e messages of their o w n v o l i t i o n .

H O W O L D IS T H E T A R G E T A U D I E N C E ? A n o t h e r variable t h a t m a y i n h i b i t t h e effectiveness of fear a p p e a l s is t h e age of t h e t a r g e t a u d i e n c e . Boster a n d M o n g e a u (1984; M o n g e a u , i n p r e s s ) r e p o r t e d t h a t fear a p p e a l s a r e m o r e effective for o l d e r a u d i e n c e s . T h e age of t h e t a r g e t a u d i e n c e influences t h e a u d i e n c e ' s p e r c e i v e d v u l n e r a b i l i t y t o t h e t h r e a t . Y o u n g e r p e r s o n s feel as t h o u g h d e a t h a n d disease h a p p e n t o elders o r p e r h a p s t o o t h e r y o u n g p e o p l e , b u t n o t t o t h e m s e l v e s ( I r w i n 8c Millstein, 1986). O l d e r p e r s o n s , o n t h e o t h e r h a n d , perceive a g r e a t e r t h r e a t t o t h e i r health a n d well-being. T h e i m p a c t o f age o n t h e p e r s u a s i v e n e s s of fear a p p e a l s also h e l p s t o e x p l a i n w h y so m a n y fear a p p e a l s t o p r o m o t e b e t t e r h e a l t h a r e ineffective. Televised p u b l i c service messages t o decrease d r i v i n g u n d e r t h e i n f l u e n c e of a l c o h o l o r d r u g a b u s e are frequently t a r g e t e d at a d o l e s c e n t s . T h o s e m e s s a g e s f r e q u e n t l y e m p l o y fear a p p e a l s , b u t fear a p p e a l s are unlikely t o i n f l u e n c e t h e y o u n g p e o p l e at w h o m t h e y are a i m e d . W e c a n i m a g i n e living r o o m s a c r o s s A m e r i c a w h e r e p a r e n t s of a d o l e s c e n t s find a p u b l i c service a n n o u n c e m e n t compelling, b u t w h e r e the target of t h e appeal (the child) is unaffected b y it.

H O W A N X I O U S ARE T A R G E T S A N D W H A T ARE T H E I R R E S P O N S E COSTS? Trait Anxiety. Social science l i t e r a t u r e differentiates b e t w e e n " s t a t e " a n d "trait" anxiety. State anxiety is tension that results from a specific a n d localized set of c i r c u m s t a n c e s . It is fleeting a n d c h a n g e s f r o m o n e c o n t e x t t o t h e n e x t . Trait anxiety, o n t h e o t h e r h a n d , is a p e r s o n a l i t y t r a i t — a relatively e n d u r i n g p e r s o n a l quality. T h e r e a r e s o m e p e o p l e w h o a r e " a n x i o u s b y n a t u r e " ; t h o s e p e o p l e suffer f r o m trait anxiety. T h e r e is e v i d e n c e t o suggest t h a t a n x i o u s p e r s o n s , also called "avoiders," r e s p o n d differently t o fear appeals t h a n d o t h e i r less a n x i o u s c o u n t e r p a r t s , also called c o p e r s . Specifically, for c o p e r s h i g h fear messages are m o r e effective t h a n low fear messages. For avoiders, high fear m e s s a g e s a r e n o m o r e o r less p e r s u a s i v e t h a n l o w fear m e s s a g e s (e.g., Boster 8c M o n g e a u , 1984). U n f o r t u n a t e l y , h e a l t h c a m p a i g n d i r e c t o r s r a r e l y h a v e specific e n o u g h i n f o r m a t i o n a b o u t a t a r g e t p e r s o n o r a u d i e n c e t o tailor a

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message based o n trait anxiety. It is also the case t h a t e x t r e m e a m o u n t s of trait a n x i e t y are u n c o m m o n , so fear a p p e a l s w o u l d b e an effective strategy for a m a s s audience. T h e trait anxiety finding, however, helps to explain w h y s o m e p e r s o n s d o n o t r e s p o n d favorably t o h i g h fear messages. Response Costs. Response costs refer to negative o u t c o m e s that result from c o m p l y i n g w i t h a m e s s a g e r e c o m m e n d a t i o n . In F r u i n et al.'s ( 1 9 9 2 ) s t u d y of exercise t o r e d u c e risks of c a r d i o v a s c u l a r disease, r e s p o n s e costs i n c l u d e d lost t i m e a n d physical d i s c o m f o r t associated w i t h exercising. I n W i t t e ' s (1992b) study of risk behaviors a n d AIDS, response costs of w e a r i n g c o n d o m s m i g h t h a v e i n c l u d e d lost s p o n t a n e i t y . In H a l e et al.'s ( 1 9 9 3 ) s t u d y of risks f r o m u l t r a v i o l e t r a d i a t i o n , several p a r t i c i p a n t s w o u l d n o t use a s u n b l o c k every d a y b e c a u s e its a p p l i c a t i o n w a s i n c o n v e n i e n t . T h e r e is little d o u b t t h a t p e r c e i v e d r e s p o n s e costs i n h i b i t t h e effectiveness of fear appeals. Response costs can, however, frequently b e r e d u c e d b y careful p l a n n i n g a n d c o m m u n i c a t i o n . W i t t e ' s ( 1 9 9 2 b ) messages, for e x a m p l e , s p e cifically refuted t h e n o t i o n t h a t c o n d o m use interfered w i t h s p o n t a n e i t y . T h e i n c o n v e n i e n c e of a p p l y i n g a s u n b l o c k every m o r n i n g c a n b e directly r e f u t e d b y suggesting t h a t t h e a p p l i c a t i o n takes very little t i m e . T h e m e s s a g e p r o d u c e r m u s t either a n t i c i p a t e t h e r e s p o n s e costs o r carefully p r e t e s t t h e messages (a strategy w e w h o l e h e a r t e d l y r e c o m m e n d ) . If r e s p o n s e costs a r e n o t a n t i c i p a t e d o r d i s c o v e r e d a n d refuted, t h e n a c e r t a i n p o r t i o n of fear a p p e a l s will n o t r e a c h t h e i r persuasive p o t e n t i a l .

Summing Up Fear a p p e a l s h a v e e n o r m o u s p e r s u a s i v e p o t e n t i a l a n d can p r o m o t e b e t t e r health. T h e i r effectiveness d e p e n d s in large p a r t o n the structure of t h e m e s sages. At t h e least, a n effective fear appeal m u s t include a severe threat, e v i d e n c e s u g g e s t i n g t h e target is especially v u l n e r a b l e t o t h e t h r e a t , a n d s o l u t i o n s t h a t a r e b o t h easy t o p e r f o r m a n d effective. A d d i t i o n a l features t h a t s h o u l d b e c o n s i d e r e d a r e t h e u s e of a p r o b l e m - s o l u t i o n f o r m a t for t h e m e s s a g e a n d vivid c o n t e n t t h a t is negatively f r a m e d . Finally, fear a p p e a l s d o n o t w o r k in every circumstance, so o n e should b e mindful of t h e age of t h e target a u d i e n c e a n d t h e l i k e l i h o o d of v o l u n t a r y message p r o c e s s i n g w h e n d e c i d i n g w h e t h e r t o c o n s t r u c t a fear a p p e a l . M a n y fear a p p e a l s fail t o m o d i f y u n h e a l t h y b e h a v i o r s b e c a u s e t h e y d o n o t follow t h e m a x i m s listed above. Recall t h e d r u g abuse p r e v e n t i o n PSA d e p i c t i n g t h e egg, t h e frying p a n , a n d t h e fried egg t h a t w e u s e d as a n i l l u s t r a t i o n in

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t h e o p e n i n g o f t h i s c h a p t e r . T h e v e r b a l c o n t e n t o f t h e a p p e a l s a i d " T h i s is y o u r b r a i n . T h i s is y o u r b r a i n o n d r u g s . A n y q u e s t i o n s ? " T h e m e s s a g e is a g o o d e x a m p l e of a b a d fear a p p e a l . T h e threat, vulnerability, p e r s o n a l efficacy, a n d r e s p o n s e efficacy of t h e m e s s a g e a r e n o n e x i s t e n t o r s o c o n f u s i n g t h a t t h e y a r e useless. R e s p o n s e s t o t h a t p a r t i c u l a r message h a v e even b e e n d e r i s i v e . W h e n o n e c o n s i d e r s t h e p o o r u s e of fear a p p e a l c o m p o n e n t s i n t h e m e s s a g e , it is n o w o n d e r t h a t p o s t e r s a n d T - s h i r t s h a v e b e e n p r i n t e d s h o w i n g a fried egg a n d t w o s t r i p s o f b a c o n , w i t h t h e p h r a s e , " T h i s is y o u r b r a i n w i t h a s i d e of b a c o n . "

References Backer, Τ. E., Rogers, Ε. M., 8c Sopory, P. (1992). Designing health care campaigns: What works. Newbury Park, CA: Sage. Beck, Κ. H., & Frankel, A. (1981). A conceptualization of threat communication and protective health behavior. Social Psychology Quarterly, 44, 204-217. Boster, F. J., 8c Mongeau, P. A. (1984). Fear-arousing persuasive messages. In R. Bostrom (Ed.), Communication yearbook (Vol. 8, pp. 330-375). Newbury Park, CA: Sage. Brouwers, M. C , 8c Sorrentino, R M. (1993). Uncertainty orientation and protection motivation theory The role of individuals differences in health compliance. Journal of Personality and Social Psychology, 65, 102-112. Dillard, J. P. (in press). Rethinking the study of fear appeals. Communication Theory. Eagly, Α., 8c Chaiken, S. (1993). The psychology of attitudes. Orlando, FL: Harcourt Brace Jovanovich. Edgar, T., Freimuth, V. S., 8c Hammond, S. L. (1988). Communicating the AIDS risk to college students: The problem of motivating change. Health Education and Research: Theory and Practice, 3, 59-65. Freimuth, V. S., Hammond, S. L., Edgar, T., 8c Monahan, J. L. (1990). Reaching those at risk: A content analytic study of AIDS PSA's. Communication Research, 17, 775-791. Fruin, D . J., Pratt, C , 8c Owen, N. (1992). Protection motivation theory and adolescents' perceptions of exercise. Journal of Abnormal Social Psychology, 22, 55-69. Gray, L. Α., 8c Saracino, M. (1989). AIDS on campus: A preliminary study of college students' knowledge and behaviors. Journal of Counseling and Development, 68,199-202. Greene, K. L., Rubin, D., 8c Hale, J. L. (1993, November). Egocentrism, message explicitness and AIDS messages directed toward adolescents: A test of the theory of reasoned action. Paper presented at the annual meeting of the Speech Communication Association, Miami Beach, FL. Hale, J. L., Mongeau, P. Α., & Lemieux, R. (1993, November). Trait anxiety and fear arousing messages regarding sun exposure. Paper presented at the annual meeting of the Speech Communication Association, Miami Beach, FL. Horowitz, I. A. (1969). Effects of volunteering, fear arousal, and number of communications on attitude change. Journal of Personality and Social Psychology, 11, 34-77. Horowitz, I. A. (1972). Attitude change as a function of perceived arousal. Journal of Social Psychology, 87, 117-126.

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Hovland, C. I., Janis, I. L., 8c Keiley, Η. H. (1953). Communication and persuasion. New Haven, CT: Yale University Press. Irwin, C. E., 8c Millstein, S. G. (1986). Biopsychosocial correlates of risk taking behaviors during adolescence: Can the physician intervene? Journal of Adolescent Health Care, 7, 82-96. Janis, I. L., 8c Feshbach, S. (1953). Effects of fear-arousing communications. Journal of Abnormal and Social Psychology, 48, 78-92. Kohn, P. M., Goodstadt, M. S., Cook, G. M., Sheppard, M., 8c Chan, G. (1982). Ineffectiveness of threat appeals about drinking and driving. Accident Analysis and Prevention, 14,457-464. Leventhal, Η. (1971). Fear appeals and persuasion: The differentiation of a motivational construct. American Journal of Public Health, 61, 1205-1224. Meyerowitz, Β. E., 8c Chaiken, S. (1987). The effect of message framing on breast self-examination attitudes, intentions, and behaviors. Journal of Personality and Social Psychology, 52, 500-510. Miller, G. R. (1963). Studies on the use of fear appeals: A summary and analysis. Central States Speech Journal, 24, 117-125. Mongeau, P. A. (in press). Fear-arousing persuasive messages: A meta-analysis revisited. In M. Allen 8c R. Preiss (Eds.), Persuasion: Advances through meta-analysis. Thousand Oaks, CA: Sage. Newcombe, Τ. M., Turner, R. H., 8c Converse, P. E. (1965). Social psychology. New York: Holt, Rinehart 8c Winston. Quinley, H. (1988). The new facts of life: Heterosexuals and AIDS. Public Opinion, 11, 53-55. Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change. Journal of Psychology, 91, 93-114. Rogers, R. W. (1983). Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In J. Cacioppo 8c R. Petty (Eds.), Social psychophysiology (pp. 153-176). New York: Guilford. Rogers, R. W., 8c Mewborn, C. R. (1976). Fear appeals and attitude change: Effects of a threat's noxiousness, probability of occurrence, and the efficacy of coping responses. Journal of Personality and Social Psychology, 34, 54-61. Sutton, S. R. (1982). Fear-arousing communication: A critical examination of theory and research. In J. R. Eiser (Ed.), Social psychology and behavioral medicine (pp. 303-337). London: John Wiley. Sutton, S. R., 8c Eiser, J. R. (1984). The effect of fear-arousing communications on cigarette smoking: An expectancy-value approach. Journal of Behavioral Medicine, 7, 13-33. Sutton, S. R., 8c Halle«, R. (1989). The contribution of fear and cognitive factors in mediating the effects of fear-arousing communications. Social Behaviour, 4, 83-98. Taylor, S. E., 8c Thompson, S. C, (1982). Stalking the elusive "vividness" effect. Psychological Review, 89, 155-181. Witte, Κ. (1992a). Putting fear back into fear appeals: The extended parallel process model. Communication Monographs, 59, 329-349. Witte, Κ. (1992b). The role of threat and efficacy in AIDS prevention. International Quarterly of Community Health Education, 12, 225-249.

5

Thinking Positively USING POSITIVE AFFECT W H E N DESIGNING HEALTH MESSAGES

JENNIFER L. M O N A H A N

C

o m m u n i c a t i o n c a m p a i g n s play an i m p o r t a n t role in disease p r e v e n t i o n a n d h e a l t h p r o m o t i o n . D e s i g n i n g effective c a m p a i g n s a b o u t h e a l t h is a difficult task, h o w e v e r . As A r k i n (1989) n o t e s , " H e a l t h i n f o r m a t i o n is often c o m p l e x a n d technical. In a d d i t i o n , t h e i n f o r m a t i o n m a y b e i n c o n c l u s i v e , c o n t r o v e r s i a l , c o n t r a d i c t o r y a n d subject t o c h a n g e as n e w r e s e a r c h findings are r e l e a s e d " ( p . 3). M o r e o v e r , c o m m u n i c a t i o n specialists are often p u t in t h e u n e n v i a b l e p o s i t i o n of c o n d u c t i n g c a m p a i g n s a s k i n g p e o p l e t o give t h i n g s u p , t o c h a n g e c o m f o r t a b l e h a b i t s , a n d t o refrain f r o m p l e a s u r a b l e e x p e r i e n c e s . C o n s i d e r messages in w h i c h t h e a u d i e n c e is asked t o s t o p e a t i n g fatty foods, q u i t s m o k i n g , "Just Say N o , " a n d "Be S m a r t — D o n ' t S t a r t . " In t r y i n g t o r e a c h a b r o a d p o p u l a t i o n w i t h messages a b o u t u n h e a l t h f u l p r a c t i c e s , c a m p a i g n s h a v e often relied o n t w o strategies: fear a p p e a l s a n d straightforward presentations of fact. A recent c o n t e n t analysis of A I D S p u b l i c service a n n o u n c e m e n t s (PSAs) f o u n d t h a t a p p r o x i m a t e l y o n e f o u r t h o f t h e PSAs u s e d fear a p p e a l s t o p e r s u a d e i n d i v i d u a l s t o c h a n g e risky b e h a v i o r s , a n d half of the PSAs were affectively neutral, utilizing straightforward p r e s e n t a t i o n s o f facts ( F r e i m u t h , H a m m o n d , Edgar, 8c M o n a h a n , 1990). A l t h o u g h fear a p p e a l s a n d affectively n e u t r a l r a t i o n a l a p p e a l s h a v e l o n g b e e n t h e m a i n s t a y s of p u b l i c c o m m u n i c a t i o n c a m p a i g n s , t h e o p p o s i t e is t r u e for c o m m e r c i a l advertising. C o m m e r c i a l advertisers t e n d to avoid n e g a t i v e affect a n d r a t i o n a l claims a n d instead focus t h e i r messages o n t h e p o s i t i v e side of life. C o n s u m e r advertisers ask t h e i r a u d i e n c e s t o "Be All T h a t Y o u C a n Be," "Reach O u t a n d T o u c h S o m e o n e , " or "Be H e a r t Smart." T h e a p p e a l of positive affect for c o m m e r c i a l advertisers is s i m p l e : R e s e a r c h c o n s i s t e n t l y s h o w s a d v e r t i s e m e n t s t h a t a r o u s e positive e m o t i o n s result in m o r e p o s i t i v e 81

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feelings t o w a r d t h e p r o d u c t a n d greater i n t e n t t o c o m p l y w i t h t h e m e s s a g e (see, e.g., B a t r a 8c Ray, 1986; T h o r s o n 8c Friestad, 1989). T h i s c h a p t e r explores t h e p o t e n t i a l of s i m p l e positive affective a p p e a l s in reaching audiences i m p o r t a n t to t h e health c o m m u n i c a t o r . M o r e o v e r , it d o e s so f r o m a t h e o r e t i c a l f r a m e w o r k t h a t allows m e s s a g e d e s i g n e r s t o i n t e r p r e t h o w a n d w h e n positive messages will be m o s t a p p r o p r i a t e . Literature is r e viewed that suggests positive feelings can substantially influence social b e h a v i o r a n d c o g n i t i v e processes.

Positive Affect Affect is a generic t e r m for a whole range of feelings a n d e m o t i o n s . T h e o r i s t s often u s e t h e t e r m affect to refer t o messages a n d r e s p o n s e s t o messages t h a t i n c l u d e a subjective feeling c o m p o n e n t . M o r e specific t e r m s s u c h as feelings o r emotions a r e defined b y t h e i n t e n s i t y a n d pervasiveness o f t h e affect. Positive feelings are relatively m i l d subjective r e a c t i o n s — t h o s e t h a t a r e essentially pleasant, s u c h as a t t r a c t i o n a n d liking. T h e s e feelings a r e called m o o d s w h e n t h e y refer t o global, generalized affective states t h a t i n f l u e n c e n o n s p e c i f i c affective events. E m o t i o n s refer t o a m o r e c o m p l e x a s s o r t m e n t of affects s u c h as joy, serenity, o r elation. E m o t i o n s a r e t h o u g h t of as m o r e i n t e n s e a n d s h o r t - l i v e d t h a n are m o o d s . I n a d d i t i o n , e m o t i o n s u s u a l l y h a v e physical as well as m e n t a l m a n i f e s t a t i o n s .

Types of Affective Appeals Affect c a n b e c o n c e p t u a l i z e d as r e s i d i n g w i t h i n a p e r s o n (i.e., s o m e t h i n g t h a t h a p p e n s t o t h e viewer in r e s p o n s e t o a c a m p a i g n ) , o r it can b e c o n c e i v e d of as t h e e m o t i o n a l valence of a message. T h e p r i m a r y focus of this c h a p t e r is h o w best t o e m p l o y affect w h e n d e s i g n i n g messages in o r d e r t o trigger an a p p r o p r i a t e r e s p o n s e in t h e a u d i e n c e . T w o f o r m s of m e s s a g e s , e m o t i o n a l benefit a p p e a l s a n d h e u r i s t i c appeals, will b e e x a m i n e d . T h e chief d i s t i n c t i o n b e t w e e n these t w o forms of messages is that e m o t i o n a l benefit appeals i n c o r p o r a t e b o t h affective a n d r a t i o n a l e l e m e n t s w h e r e a s h e u r i s t i c a p p e a l s rely p r i m a r i l y o n affect. T r a d i t i o n a l l y , it w a s a s s u m e d t h a t messages w e r e e i t h e r r a t i o n a l o r affective. F o r e x a m p l e , s t r a i g h t f o r w a r d p r e s e n t a t i o n s of facts w e r e e n v i s i o n e d as r a t i o n a l a p p e a l s , w h e r e a s fear appeals w e r e s u p p o s e d t o solicit a n e m o t i o n a l

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r e s p o n s e . M o r e recently, analyses find m o s t messages utilize, o r at least a r e perceivedby audiences as utilizing, b o t h rational a n d affective appeals ( S t e w a r t 8c F u r s e , 1986). Messages t h a t h a v e b o t h affective a n d r a t i o n a l c o m p o n e n t s a r e called emotional benefit appeals a n d i n c l u d e slice-of-life a d s s u c h as t h o s e e m p h a s i z i n g p e o p l e getting over a n illness ( p e r s u a s i o n t h r o u g h p e e r influe n c e ) , celebrity a d s ( p e r s u a s i o n t h r o u g h credibility), a n d certain t y p e s of fear a p p e a l s ( p e r s u a s i o n t h r o u g h fear of i n j u r y o r h a r m ) . E m o t i o n a l benefit appeals elicit affective r e s p o n s e s t o a m e s s a g e b y c r e a t i n g e m o t i o n a l states t h a t exemplify t h e e m o t i o n a l , psychological, o r e x p e riential benefits of c o m p l y i n g w i t h a c a m p a i g n ( P e c h m a n 8c Stewart, 1989). S u c h a p p e a l s a r e g r o u n d e d p r i m a r i l y in o b s e r v a t i o n a l l e a r n i n g p r i n c i p l e s : It is e x p e c t e d t h a t m e s s a g e recipients will c o m p l y w i t h t h e m e s s a g e in o r d e r t o o b t a i n t h e benefits t h a t t h e m e s s a g e p r o m i s e s . A c a m p a i g n t h a t s h o w s healthy p e o p l e engaging in "fun" activities with a message that tells t h e viewer t o "live l o n g e r a n d live h e a l t h i e r b y e a t i n g m o r e fruits a n d v e g e t a b l e s " is a n e x a m p l e of a n e m o t i o n a l benefit a p p e a l . U n l i k e e m o t i o n a l benefit a p p e a l s , w h i c h rely o n b o t h r a t i o n a l a n d affective c u e s , heuristic appeals utilize a m o r e i n d i r e c t a p p r o a c h t o t a r g e t i n d i viduals w h o d o n o t have t h e time, skill, o r m o t i v a t i o n t o evaluate t h e a t t r i b u t e s a n d benefits of a p a r t i c u l a r c a m p a i g n ( P e c h m a n 8c Stewart, 1989). F o r e x a m p l e , ATcVTs " R e a c h O u t a n d T o u c h S o m e o n e " c a m p a i g n u s e d p o s i t i v e affect i n d i r e c t l y t o influence t h e viewer. I n s t e a d of t r y i n g t o p e r s u a d e t h e viewer t h a t t h e features of AT8cTs service are good, heuristic appeals a t t e m p t t o m a k e t h e m e s s a g e r e c i p i e n t feel g o o d a b o u t t h e p r o d u c t . C a m p a i g n s u s e m u s i c , a r t w o r k , o r b a c k g r o u n d t o evoke positive i m a g e r y o r a favorable m o o d , a n d it is t h e m o o d o r feeling t h a t is e x p e c t e d t o sell t h e i d e a r a t h e r t h a n t h e benefits o n e c o u l d derive from c o m p l y i n g w i t h t h e m e s s a g e .

The Primacy of Affect Positive affect i n d u c e d via h e u r i s t i c a p p e a l s r e p r e s e n t s a d i s t i n c t c a m p a i g n style t h a t can b e c o n t r a s t e d w i t h s t r a i g h t f o r w a r d p r e s e n t a t i o n o f facts a n d e m o t i o n a l benefit a p p e a l s . H o w d o s u c h h e u r i s t i c a p p e a l s w o r k ? W h y s h o u l d m o o d , feelings, o r i m a g e m a t t e r ? Z a j o n c (1980) a r g u e d t h a t feelings m a t t e r b e c a u s e o u r r e s p o n s e s t o social s t i m u l i a r e s e l d o m e m o t i o n a l l y n e u t r a l , a n d t h a t t h e r e a r e few social p e r c e p t i o n s o r t h o u g h t s t h a t d o n o t i m p l i c a t e affect in s o m e significant w a y . Further, he n o t e d that:

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it is entirely possible that the very first stage of the organism's reaction to stimuli and the very first elements in retrieval are affective. It is further possible that we can like something or be afraid of it before we know precisely what it is and perhaps even without knowing what it is. (p. 154) Research has s h o w n that affective responses are u n m e d i a t e d a n d fast initial r e a c t i o n s t o p e o p l e , events, a n d o t h e r s t i m u l i (see M u r p h y 8c Z a j o n c [1993] for a r e v i e w ) . After this i m m e d i a t e feeling r e s p o n s e , cognitive a n d affective reactions interact resulting in a specific response to a message ( M u r p h y , 1990). Affective r e a c t i o n s t o s t i m u l i are a s s u m e d to b e p r i m a r y , o c c u r r i n g b e f o r e a n d i n f l u e n c i n g s u b s e q u e n t cognitive p r o c e s s i n g . F r o m this p e r s p e c t i v e , r e s e a r c h e r s believe t h a t first we feel, a n d t h e n w e t h i n k . T h i s c h a p t e r explores h o w t o use e m o t i o n a l benefit a n d h e u r i s t i c appeals to trigger positive initial feelings t o w a r d a campaign. Further, it illustrates h o w t h e s e initial positive r e a c t i o n s can b e u s e d t o effect s u b s e q u e n t c o g n i t i v e a n d b e h a v i o r a l r e s p o n s e s s u c h as selective a t t e n t i o n , d e g r e e of p r o c e s s i n g , m e m ory, a t t i t u d e , a n d c o m p l i a n c e .

SELECTIVE A T T E N T I O N V i e w e r s h a v e an a r r a y of defense m e c h a n i s m s t o filter o u t i n f o r m a t i o n t h a t is n o t salient t o t h e m o r t o c h a n g e messages t h a t m a y b e t r o u b l i n g . Affective a p p e a l s can b e q u i t e p o w e r f u l in o v e r c o m i n g these defense m e c h a n i s m s b e c a u s e p e o p l e p a y greater a t t e n t i o n to affective messages t h a n t o o t h e r m e s s a g e types (Ray, 1977). M o r e o v e r , research indicates t h a t positive affect is an especially effective t o o l in o v e r c o m i n g filtering devices. A p e r s o n ' s feelings often act like a selective filter, t u n e d to i n c o m i n g m a t e r i a l t h a t s u p p o r t s o r justifies these feelings. F r o m a n affect p r i m a c y p e r s p e c t i v e , initial p o s i t i v e r e s p o n s e s to a n y s t i m u l i (e.g., a p u b l i c service a d v e r t i s e m e n t ) s h o u l d result in approach b e h a v i o r s . A p p r o a c h b e h a v i o r s allow i n d i v i d u a l s t o o p e n u p a n d b e receptive to t h e e x t e r n a l s t i m u l i , t o relax t h e i r g u a r d . Like affect theorists, advertising practitioners a n d public health r e s e a r c h e r s also find positive affect is a useful ploy to gain attention. O n e survey of a d v e r t i s i n g p r a c t i t i o n e r s f o u n d t h a t m o s t advertising specialists believe h u m o r is v e r y effective in d r a w i n g a t t e n t i o n t o a n issue ( M a d d e n & W e i n b e r g e r , 1984). In a d d i t i o n , several studies have d e m o n s t r a t e d t h a t positive affect leads t o greater receptiveness of messages (see Janis, Kay, 8c K i r s c h n e r , 1965; Reeves, N e w h a g e n , M a i b a c h , Basil, 8c K u r z , 1991). Overall, p u b l i c service messages t h a t are e n t e r t a i n i n g , e n g a g i n g , h u m o r o u s , or d r a m a t i c a r e m o r e likely t o

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s u c c e e d in o v e r c o m i n g s u c h b a r r i e r s as selective p e r c e p t i o n a n d selective r e t e n t i o n t h a n a r e m o r e strictly r a t i o n a l m e s s a g e s . Heuristic appeals such as a g o o d - l o o k i n g spokesperson, beautiful a r t w o r k , o r a p o p u l a r s o n g can b e especially g o o d a t t e n t i o n - g a i n i n g devices. For e x a m p l e , t h e California Raisin A d v i s o r y B o a r d u s e d a positive h e u r i s t i c c u e in t h e f o r m of a p o p u l a r s o n g , "I H e a r d It T h r o u g h t h e G r a p e v i n e , " t o g a r n e r i m m e d i a t e a t t e n t i o n a n d positive feelings t o w a r d t h e i r m e s s a g e . H e u r i s t i c cues a r e v e r y effective at g a r n e r i n g positive a t t e n t i o n b e c a u s e t h e a u d i e n c e d o e s n o t h a v e t o think a b o u t t h e c u e , t h e positive i m p a c t is i m m e d i a t e . Positive affect c a n b e a p a r t i c u l a r l y useful a t t e n t i o n - g e t t i n g device w h e n a t t e m p t i n g t o r e a c h i n d i v i d u a l s w h o c o n s i d e r t h e m s e l v e s t o b e overly familiar w i t h a c a m p a i g n . I n t h e s e cases, i n d i v i d u a l s m a y n o t p a y a t t e n t i o n t o n e w i n f o r m a t i o n b e c a u s e t h e y feel t h a t t h e y k n o w all t h e y n e e d t o k n o w . T h e u s e o f h u m o r o r w a r m a n d t o u c h i n g s i t u a t i o n s is p a r t i c u l a r l y effective in g e t t i n g individuals t o process messages a b o u t topics that are already familiar (Ogilvy 8c R a p h a e l s o n , 1982). A l t h o u g h positive affect w i t h i n messages usually leads t o greater r e c e p tiveness, t h e r e a r e c i r c u m s t a n c e s in w h i c h this m a y n o t h o l d t r u e . In p a r t i c u l a r , w h e n i n d i v i d u a l s a r e t h r e a t e n e d b y a n issue, u s i n g p o s i t i v e affect in a m e s s a g e m a y n o t p r o m o t e receptiveness (Forest, C l a r k , Mills, 8c Isen, 1979). T h e s e findings are c o n s i s t e n t w i t h a p r i m a c y of affect p e r s p e c t i v e , b e c a u s e s u c h a p e r s p e c t i v e a s s u m e s negative feelings e v o k e avoidance b e h a v i o r s . A v o i d a n c e b e h a v i o r s result in i n d i v i d u a l s b l o c k i n g s u b s e q u e n t m e s s a g e s , t u r n i n g away from t h e negative s o u r c e , o r p r o c e s s i n g t h e m e s s a g e t h r o u g h a defensive filter. I n this s i t u a t i o n , even if a positive m e s s a g e a t t r a c t s a t t e n t i o n , m e s s a g e recipients are likely t o slow d o w n t h e i r p r o c e s s i n g a n d e x a m i n e s u b s e q u e n t i n f o r m a t i o n critically r a t h e r t h a n acceptingly. I n s u m m a r y , positive affect is a g o o d a t t e n t i o n - g e t t i n g device. T h e u s e of positive e m o t i o n s s u c h as h u m o r a n d j o y can catch t h e a u d i e n c e ' s eye a n d convince individuals to watch something they might otherwise avoid. H e u ristic cues s u c h as t h e use of visual i m a g e r y o r a p o p u l a r s o n g a r e t h e m o s t effective a t t e n t i o n - g e t t e r s , p r i m a r i l y b e c a u s e s u c h cues can b e p r o c e s s e d w i t h m i n i m u m t h o u g h t . A n affect p r i m a c y t h e o r e t i c a l p e r s p e c t i v e suggests t h a t positive affect is a useful a t t e n t i o n - g e t t i n g device b e c a u s e p o s i t i v e affect invokes approach behaviors, enhancing the probability that the audience will b e receptive t o t h e f o r t h c o m i n g m e s s a g e . A n e x c e p t i o n is w h e n t h e a u d i e n c e feels t h r e a t e n e d b y a n issue. U n d e r t h e s e c i r c u m s t a n c e s , p o s i t i v e affect m a y n o t p r o m o t e receptiveness.

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D E P T H OF PROCESSING A s e c o n d cognitive p r o c e s s t h a t is i n f l u e n c e d b y affective a p p e a l s is d e p t h o f p r o c e s s i n g . O n c e t h e a u d i e n c e is p a y i n g a t t e n t i o n , h o w m u c h effort will t h e y e x p e n d t o p r o c e s s t h e i n f o r m a t i o n p r e s e n t e d ? T h e a m o u n t of effort i n d i v i d u a l s e x p e n d t o p r o c e s s a message is i m p o r t a n t b e c a u s e it can affect w h a t t h e y r e m e m b e r , t h e i r a t t i t u d e s , a n d their i n t e n t t o c o m p l y w i t h t h e m e s s a g e . T h e valence of affective appeals (positive vs. n e g a t i v e ) a p p e a r s t o b e r e l a t e d t o h o w m u c h effort an a u d i e n c e will e x p e n d t o p r o c e s s a m e s s a g e . N e g a t i v e messages foster t h e use o f m o r e e l a b o r a t e , d e t a i l - o r i e n t e d , a n d analytical p r o c e s s i n g strategies. Negative messages result in m o r e t h o u g h t f u l p r o c e s s i n g b e c a u s e negative affect i n f o r m s t h e a u d i e n c e t h a t t h e c u r r e n t s i t u a t i o n is p r o b l e m a t i c . I n d i v i d u a l s are t h e r e f o r e m o r e likely t o focus t h e i r a t t e n t i o n o n aspects of t h e s i t u a t i o n t h a t elicited b a d feelings a n d a r e less likely t o p a y a t t e n t i o n t o i n c o n s e q u e n t i a l i n f o r m a t i o n or get d i s t r a c t e d . Positive messages, o n t h e o t h e r h a n d , foster g o o d feelings a n d t h e use of less e l a b o r a t e o r m o r e h e u r i s t i c strategies. Positive affect d o e s n o t activate feelings of self-protection b u t r a t h e r e n g e n d e r s feelings of ease o r c o m f o r t . A m e s s a g e t h a t uses positive affect i n f o r m s the a u d i e n c e t h a t t h e c u r r e n t s i t u a t i o n is n o n t h r e a t e n i n g a n d t h a t a h i g h d e g r e e of a t t e n t i o n o r p r o c e s s i n g is n o t necessary. Positive messages t h u s trigger w h a t is k n o w n as peripheral processing ( P e t t y 8c C a c i o p p o , 1986). P e r i p h e r a l p r o c e s s i n g o c c u r s w h e n i n d i v i d u a l s s p e n d very little t i m e t h i n k i n g a b o u t a message a n d is a relatively m i n d l e s s e n d e a v o r . This type of p r o c e s s i n g m o s t likely o c c u r s as t h e r e s u l t o f s o m e s i m p l e cue in t h e m e s s a g e t h a t i n d u c e s a r e a c t i o n w i t h o u t necessit a t i n g a n y s c r u t i n y of t h e message. C h a n g e s t h a t o c c u r via p e r i p h e r a l p r o c essing a r e often short-lived effects, a l t h o u g h systematic c h a n g e s in a t t i t u d e s d o occur in response to such processing ( M u r p h y , M o n a h a n , 8c Zajonc, 1992). Overall, t h e e v i d e n c e suggests t h a t a s t r e n g t h of positive affect is t h a t it d r a w s a t t e n t i o n to a message; its w e a k n e s s is t h a t it e n c o u r a g e s p e r i p h e r a l processing rather than m o r e thoughtful information processing. Although positive affect is a s s u m e d t o p r o v o k e m i n i m a l p r o c e s s i n g a n d , t h u s , relatively s h o r t - l i v e d effects, t h e r e are f o r m s of positive a p p e a l s t h a t result in l o n g - t e r m effects. Recall t h a t e m o t i o n a l benefit appeals c o m b i n e r a t i o n a l a n d affective c o m p o n e n t s t o p r e s e n t t h e e m o t i o n a l , psychological, or e x p e riential benefits of c o m p l y i n g w i t h a c a m p a i g n . T h e s e messages can p r o d u c e relatively p e r m a n e n t c h a n g e s in a t t i t u d e s a n d / o r b e h a v i o r s w i t h o u t n e c e s sarily r e q u i r i n g the message recipient to engage in effortful systematic p r o c e s s ing. E m o t i o n a l benefit appeals can b e persuasive, regardless of t h e t y p e of c o g n i t i v e p r o c e s s i n g t h e y evoke.

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Positive h e u r i s t i c a p p e a l s , o n t h e o t h e r h a n d , a r e t a r g e t e d at i n d i v i d u a l s w h o a r e n o t m o t i v a t e d t o evaluate t h e benefits of a c a m p a i g n . T h e s e a p p e a l s e v o k e a n affective r e s p o n s e t h a t is n o t directly related t o t h e c a m p a i g n a n d a r e likely t o result in less stable effects t h a n a r e e m o t i o n a l benefit a p p e a l s . A l t h o u g h h e u r i s t i c a p p e a l s usually result in s h o r t - l i v e d a t t i t u d e shifts, t h e y c a n b e q u i t e useful in a c a m p a i g n . For e x a m p l e , C a c i o p p o a n d P e t t y ( 1 9 8 9 ) suggest t h a t m e s s a g e designers m i g h t use h e u r i s t i c a p p e a l s as a first step in e n h a n c i n g t h e l i k e l i h o o d t h a t individuals will e n g a g e in t h o u g h t f u l p r o c e s s ing. If t h e t a r g e t e d a u d i e n c e d o e s n o t h a v e t h e m o t i v a t i o n t o t h i n k carefully a b o u t t h e m e r i t s of a c a m p a i g n , t h e n r e p e a t e d p r e s e n t a t i o n s o f a p o s i t i v e c u e w i t h t h e c a m p a i g n m a y b e o n e of t h e few ways t o i n d u c e a n a u d i e n c e t o e n g a g e in p r o c e s s i n g i n f o r m a t i o n . M u l t i p l e e x p o s u r e s of a positive h e u r i s t i c c u e is a n effective strategy, b e c a u s e r e p e a t e d e x p o s u r e t o a h e u r i s t i c a p p e a l ( s u c h as t h e use of a p o p u l a r s o n g o r visual i m a g e r y ) generally leads t o an i n c r e a s e d positive feeling t o w a r d t h e specific m e s s a g e associated w i t h t h e c u e . T h i s a s s o c i a t i o n m a y result in a p p r o a c h b e h a v i o r s , facilitating a m o r e o p e n - m i n d e d a n d t h o u g h t f u l c o n s i d e r a t i o n of an issue. Positive affect c a n also b e a useful strategy w h e n it is i m p o r t a n t t o h e l p i n d i v i d u a l s r e f r a m e issues t h a t t h e y feel are n o t salient o r r e l e v a n t t o t h e i r lives. M o n a h a n a n d Collins-Jarvis (1992) e v a l u a t e d t h e effectiveness of several A I D S PSAs f r o m t h e p e r s p e c t i v e of y o u n g a d u l t s . T h e college s t u d e n t s in this s a m p l e w e r e q u i t e familiar w i t h t h e A I D S crisis, felt t h a t t h e i r c h a n c e o f b e c o m i n g H I V positive was q u i t e r e m o t e , a n d t h a t H I V / A I D S h a d little t o d o w i t h their lives. M o s t of t h e PSAs t h e y v i e w e d d i d little t o c h a n g e t h e s e i m p r e s s i o n s ; h o w e v e r , t h o s e t h a t c u e d e m p a t h y w e r e effective in g e t t i n g s t u d e n t s t o p r o c e s s t h e m e a n i n g in t h e ad. For e x a m p l e , o n e s p o t entitled " H o m e M o v i e s " f e a t u r e d t h r e e v i c t i m s of A I D S : a t e e n a g e r , a y o u n g w o m a n , a n d a t o d d l e r . E a c h v i c t i m w a s s h o w n in a h o m e m o v i e - s t y l e clip enjoying s o m e f o r m of family c e l e b r a t i o n . E a c h clip e n d e d w i t h a free-frame c l o s e - u p o n t h e v i c t i m a n d t h e s u p e r i m p o s i t i o n of t h e i r b i r t h a n d d e a t h dates. T h i s s p o t is a n e x a m p l e of t h e t y p e o f PSA t h a t i n c r e a s e d subjects' s e l f - r e p o r t e d feelings of e m p a t h y a n d c o m p a s s i o n for t h e v i c t i m s o f t h e disease. PSAs t h a t elicited feelings of e m p a t h y also r e s u l t e d in significant c h a n g e s in t h e s t u d e n t s ' subjective p r o b a b i l i t y r a t i n g s t h a t t h e y o r s o m e o n e t h e y k n o w m i g h t c o n t r a c t H I V . T h e s e PSAs w e r e also m o r e likely t o s t i m u l a t e t h e s t u d e n t s t o discuss t h e m e s s a g e afterwards a n d t o feel t h o u g h t f u l a b o u t it. T h e s e results suggest t h a t e v o k i n g positive e m o t i o n s s u c h as e m p a t h y a n d c o m p a s s i o n m a y result in t h e a u d i e n c e r e f r a m i n g a n issue t o c o n s i d e r t h e i m p l i c a t i o n s in a n e w light.

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In s u m m a r y , positive message a p p e a l s t e n d t o p r o v o k e less t h o u g h t f u l p r o c e s s i n g t h a n d o o t h e r f o r m s of a p p e a l s . Positive affect c a n b e usefully e m p l o y e d in message design w h e n t h e target a u d i e n c e is overfamiliar w i t h a n issue o r w h e n an issue needs t o b e refrained for a u d i e n c e m e m b e r s . E m o t i o n a l benefit appeals are likely t o p r o d u c e s t r o n g e r , m o r e d u r a b l e effects t h a n h e u r i s t i c appeals. H e u r i s t i c appeals, h o w e v e r , are effective in g a i n i n g a t t e n t i o n a n d in associating t h e c a m p a i g n w i t h g o o d feelings.

RECALL Evaluations of campaigns often include a c o m p o n e n t to assess h o w m e m o rable t h e c a m p a i g n was for t h e i n t e n d e d a u d i e n c e . D o a u d i e n c e m e m b e r s recall seeing a n y c a m p a i g n materials? W h a t d i d t h e messages say? It is p r e s u m e d t h a t in o r d e r for a message t o b e effective, t h e a u d i e n c e m u s t first b e able t o recall t h e message. Studies r e p e a t e d l y find t h a t affective messages a r e b e t t e r r e m e m b e r e d t h a n a r e nonaffective messages. F u r t h e r , a l t h o u g h affective m a t e r i a l , r e g a r d less of valence, s e e m s t o b e r e m e m b e r e d better, t h e influence o f p o s i t i v e m e s s a g e a p p e a l s o n cognitive processes is p r o n o u n c e d a n d relatively d i r e c t , w h e r e a s t h e influence of negative affect is m o r e c o m p l e x a n d h a r d e r t o p r e d i c t ( C r o c k e t t , 1988; Isen, 1987). Results f r o m m e m o r y studies indicate t h a t issues already associated w i t h g o o d feelings m a y b e t h e best issues t o use in c o n j u n c t i o n w i t h positive affect in a c a m p a i g n . Positive m o o d selectively p r o m o t e s retrieval of p o s i t i v e i n f o r m a t i o n f r o m m e m o r y a n d inhibits retrieval of negative m a t e r i a l (see C l a r k & Isen, 1982; Isen, 1989). T h i s finding implies t h a t messages t h a t e v o k e positive feelings cue m a t e r i a l t h a t is o r g a n i z e d in t h e m i n d as r e l e v a n t t o p o s i t i v e affect. C o n s i d e r a c a m p a i g n t o c o n v i n c e y o u n g m o t h e r s t o b r e a s t - f e e d t h e i r infants. Y o u n g m o t h e r s m o s t likely feel positive t o w a r d i n f a n t s , a n d this feeling can b e capitalized o n in c a m p a i g n s b y p r e s e n t i n g i n f o r m a t i o n a b o u t b r e a s t - f e e d i n g in a positive light r a t h e r t h a n b y a c c e n t u a t i n g t h e negatives associated w i t h n o t b r e a s t - f e e d i n g . I n c a m p a i g n s w h e r e t h e a u d i e n c e a l r e a d y feels q u i t e negatively t o w a r d an issue (e.g., b r e a s t c a n c e r ) t h e r e is little e v i d e n c e t o c o n c l u d e t h a t p a i r i n g t h e issue w i t h p o s i t i v e affect will e n h a n c e m e m o r y o r recall for t h e issue. Breast c a n c e r p r e v e n t i o n , o n t h e o t h e r h a n d , m a y b e facilitated b y use of positive affect a p p e a l s . T h e relationship between affect a n d m e m o r y is also c o n f o u n d e d b y i n v o l v e m e n t . Affective m e s s a g e s a p p e a r t o b e m o r e m e m o r a b l e for i n d i v i d u a l s w h o d o n o t feel m u c h i n v o l v e m e n t w i t h an issue, w h e r e a s highly i n v o l v e d i n d i v i d u a l s are n o m o r e likely to recall affective messages t h a n r a t i o n a l o n e s

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(Flora & M a i b a c h , 1990). T h e s e results suggest t h a t positive affect m a y b e a n especially useful p l o y t o r e a c h t h e " l o w - i n v o l v e m e n t " a u d i e n c e . A g a i n , it r e i n f o r c e s t h e p o i n t t h a t w h e n p e o p l e d o n o t c a r e a b o u t a m e s s a g e / c a m p a i g n , positive m e s s a g e appeals m a y b e a t o o l t o gain a t t e n t i o n . For i n d i v i d u a l s w h o a l r e a d y feel s t r o n g l y c o m m i t t e d , t h e affective c o m p o n e n t o f a m e s s a g e d o e s n o t s e e m as i m p o r t a n t . I n g e n e r a l , t h e r e l a t i o n s h i p b e t w e e n m e m o r y a n d positive affect is q u i t e r o b u s t . Positive messages in t h e f o r m of e m o t i o n a l benefit o r h e u r i s t i c a p p e a l s c a n e v o k e a positive m o o d that, in t u r n , facilitates recall. Positive affect is m o s t likely t o e n h a n c e m e m o r y w h e n u s e d in c o n j u n c t i o n w i t h issues t h a t are associated w i t h g o o d feelings a n d w h e n i n d i v i d u a l s a r e n o t h i g h l y i n v o l v e d w i t h a n issue.

ATTITUDES A l t h o u g h t h e u l t i m a t e goal of c a m p a i g n s m i g h t b e b e h a v i o r a l c h a n g e , messages also focus o n c h a n g i n g a t t i t u d e s . F o r e x a m p l e , a c a m p a i g n t o p r e v e n t d r u n k d r i v i n g m i g h t use messages d e s i g n e d t o facilitate p o s i t i v e feelings t o w a r d d e s i g n a t e d d r i v e r s o r m a y p r o m o t e feelings of d i s g u s t t o w a r d d r u n k d r i v e r s . C a m p a i g n s are also u s e d t o c h a n g e a t t i t u d e s t o w a r d t h e v i c t i m s of a disease (e.g., p e o p l e w i t h A I D S are n o t i m m o r a l ) o r t o elicit feelings of s y m p a t h y (e.g., Jerry Lewis's M u s c u l a r D y s t r o p h y C a m p a i g n ) . T h e r e is v e r y s t r o n g e v i d e n c e t o suggest t h a t positive affect w i t h i n m e s sages c a n lead t o positive feelings w i t h i n t h e p e r s o n t h a t , in t u r n , m a k e t h e p e r s o n easier t o p e r s u a d e . O n e review o n p e r s u a s i o n a n d p o s i t i v e affect c o n c l u d e d t h a t p e r s u a s i v e i m p a c t is s t r o n g e r w h e n messages i n d u c e a n i n d i v i d u a l t o b e h a p p y o r t o smile, o r w h e n messages a r e c o m b i n e d w i t h w a t c h i n g a g o o d p r o g r a m ( M c G u i r e , 1985). Heuristic appeals (e.g., using pleasant m u s i c , a r t w o r k , o r b a c k g r o u n d t o e v o k e positive i m a g e r y o r a favorable m o o d ) c a n b e especially useful w h e n a t t e m p t i n g t o get t h e a u d i e n c e " i n t h e m o o d " t o be persuaded. T h e r e a r e at least t h r e e i m p o r t a n t factors t o c o n s i d e r w h e n u s i n g p o s i t i v e affect in a m e s s a g e t o i n d u c e a t t i t u d e c h a n g e : (a) h o w familiar is t h e m e s s a g e / t o p i c t o t h e a u d i e n c e ; (b) h o w s t r o n g a r e t h e a r g u m e n t s t h a t a r e b e i n g m a d e ; a n d (c) h o w involved is t h e a u d i e n c e w i t h t h e m e s s a g e . T o b e g i n w i t h , t h e a t t i t u d e s of i n d i v i d u a l s w i t h little k n o w l e d g e a b o u t a t o p i c a r e often significantly i n f l u e n c e d b y positive appeals, w h e r e a s t h o s e w h o a r e v e r y familiar w i t h t h e t o p i c are less influenced b y t h e u s e of positive a p p e a l s . In o n e s t u d y of affective messages, P a r k a n d T h o r s o n (1990) h a d p a r t i c i p a n t s e v a l u a t e 74 c o m m e r c i a l s . Based o n t h e i r findings, t h e y s u g g e s t e d t h a t w h e n

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familiarity w i t h a c a m p a i g n is low, c a m p a i g n s s h o u l d focus o n p o s i t i v e affect in t h e form of c o m p a r i s o n s , d e m o n s t r a t i o n s , a n d testimonials (i.e., e m o t i o n a l benefit a p p e a l s ) . O n c e message recipients are familiar w i t h a c a m p a i g n o r t h e issues r e l a t e d t o a c a m p a i g n , h e u r i s t i c appeals p r o v e useful in r e c a p t u r ing the audience's attention. T h e influence of positive affect o n a t t i t u d e s is f u r t h e r m e d i a t e d b y t h e q u a l i t y of a r g u m e n t s in t h e message. Messages t h a t create a positive m o o d (as c o m p a r e d t o a n e u t r a l state) t e n d t o increase p e r s u a s i o n w h e n a r g u m e n t s a r e w e a k , b u t t e n d t o decrease it w h e n a r g u m e n t s are s t r o n g ( B a t r a 8c S t a y m a n , 1990; Bless, B o h n e r , Schwarz, 8c Strack, 1990). T h u s , if f o r m a t i v e r e s e a r c h i n d i c a t e s t h a t t h e t a r g e t e d a u d i e n c e m a y b e skeptical t o w a r d a n a r g u m e n t o r m a y b e difficult to p e r s u a d e a b o u t t h e m e r i t s of an a r g u m e n t , p o s i t i v e affect s h o u l d b e p a i r e d w i t h t h e a r g u m e n t in an e m o t i o n a l benefit a p p e a l . If f o r m a t i v e research indicates t h a t t h e r a t i o n a l a p p e a l is s t r o n g or a c c e p t a b l e t o t h e a u d i e n c e , h o w e v e r , t h e use of positive affect m a y d o little t o e n h a n c e t h e l i k e l i h o o d of p e r s u a s i o n . Finally, t h e a m o u n t of c o m m i t m e n t a n d / o r i n v o l v e m e n t t h e a u d i e n c e feels t o w a r d an issue also has i m p l i c a t i o n s for u s i n g positive m e s s a g e s t o i n d u c e a t t i t u d e c h a n g e . R e c e n t research finds t h a t messages t h a t p r o d u c e a p o s i t i v e m o o d lead t o m o r e positive a t t i t u d e s regardless of h o w i n v o l v e d t h e a u d i e n c e feels t o w a r d the message (Petty, S c h u m a n n , R i c h m a n , 8c S t r a t h m a n , 1993). H o w e v e r , positive affect influenced the positivity of subjects' t h o u g h t s o n l y u n d e r h i g h - i n v o l v e m e n t c o n d i t i o n s . This s e c o n d finding is i m p o r t a n t b e c a u s e p r e v i o u s research i n d i c a t e s a t t i t u d e c h a n g e is m o r e stable a n d l o n g - l a s t i n g w h e n i n d i v i d u a l s r e p o r t positive t h o u g h t s a b o u t a t o p i c . T h a t h i g h l y i n v o l v e d individuals m a y exhibit m o r e stable a t t i t u d e c h a n g e in r e s p o n s e t o a positive message t h a n i n d i v i d u a l s w h o feel relatively u n i n v o l v e d is n o t p a r t i c u l a r l y s u r p r i s i n g . After all, it is t h e highly i n v o l v e d i n d i v i d u a l w h o feels m o t i v a t e d to p r o c e s s b o t h t h e affective a n d r a t i o n a l c o m p o n e n t s of t h e message. T h e less involved i n d i v i d u a l is likely t o p r o c e s s a n d retain o n l y t h e positive affect, i g n o r i n g o r forgetting t h e content of t h e m e s s a g e . H e n c e t h e highly involved p e r s o n feels m o r e positively t o w a r d a m e s s a g e a n d h a s g o o d r e a s o n s t o b a c k u p his o r h e r feelings, w h e r e a s t h e less i n v o l v e d i n d i v i d u a l feels positive t o w a r d t h e m e s s a g e b u t m a y h a v e n o g o o d r e a s o n s for his o r h e r feelings. A l t h o u g h t h e r e l a t i o n s h i p b e t w e e n positive affect a n d a t t i t u d e c h a n g e is s t r o n g , t h e r e a r e issues t h a t are n o t g o o d c a n d i d a t e s for positive messages. F o r e x a m p l e , w h e n an issue is viewed b y t h e i n t e n d e d a u d i e n c e as negative, campaign designers m a y be t e m p t e d to change that negative image t h r o u g h association w i t h positive affect. T h e research l i t e r a t u r e , h o w e v e r , suggests

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t h a t it m a y b e v e r y difficult t o d o so. First, positive affect d o e s n o t a p p e a r t o e x t e n d its influence t o negative m a t e r i a l s . Positive feelings a r e generally f o u n d t o influence t h e r a t i n g s of n e u t r a l o r a m b i g u o u s m a t e r i a l r a t h e r t h a n t o influence t h e r a t i n g s o f m o r e clearly negatively v a l e n c e d m a t e r i a l s (Schiffenbauer, 1974). S e c o n d , positive affect is m o s t effective w h e n subjects a r e relatively u n c e r t a i n as t o their a t t i t u d e s o r w h e n t h e y a l r e a d y h a v e s o m e p o s i t i v e feelings t o w a r d t h e c a m p a i g n . T h e s e results are c o n s i s t e n t w i t h a p r i m a c y of affect p e r s p e c t i v e b e c a u s e it is very difficult t o c h a n g e initial p o s i t i v e / n e g a t i v e biases t o w a r d a s t i m u l u s . W h e n d e a l i n g w i t h a n issue t h a t has negative affect associated w i t h it, r e s e a r c h e r s m i g h t c o n s i d e r u s i n g positive affect in a m o r e i n d i r e c t fashion. I n o t h e r w o r d s , m e s s a g e designers w o u l d p r o b a b l y n o t c h a n g e a s t r o n g l y held negative feeling to a positive o n e , b u t it m a y b e possible to shift e m p h a s i s in a c a m p a i g n . T h e N a t i o n a l C a n c e r P r e v e n t i o n A w a r e n e s s P r o g r a m is a n e x e m p l a r of a c a m p a i g n d e s i g n e d t o use positive affect t o c h a n g e p e o p l e ' s feelings a b o u t a negative issue. F o r m a t i v e r e s e a r c h s u g g e s t e d t h a t t h e p u b l i c was "confused a n d skeptical a b o u t cancer, its risks, a n d p r e v e n t i o n " ( R o m a n o , 1986, p . 9 4 ) . Results of a 1983 survey i n d i c a t e d t h a t t h e p u b l i c ' s p e r c e p t i o n s o f risk a n d p o t e n t i a l for p e r s o n a l c o n t r o l o v e r c a n c e r w e r e overly p e s s i m i s t i c ( N C I C a n c e r P r e v e n t i o n A w a r e n e s s Survey; see R o m a n o , 1986). F o r e x a m ple, m o s t p e o p l e e x p e c t e d t h a t o n l y o n e in five p e r s o n s w i t h c a n c e r w o u l d survive for 5 years, w h e r e a s t h e actual rate w a s n e a r l y 5 0 % ( R o m a n o , 1986). T h e r e is little a c a m p a i g n can d o t o change the negative attitudes associated w i t h c a n c e r . If t h e s e feelings b e c o m e o v e r w h e l m i n g , h o w e v e r , i n d i v i d u a l s m a y s t o p c o n t r i b u t i n g t o c a n c e r research a n d m a y a v o i d messages d e s i g n e d t o r e d u c e their l i k e l i h o o d of c o n t r a c t i n g cancer. T h e N a t i o n a l C a n c e r P r e v e n t i o n A w a r e n e s s P r o g r a m w a s d e s i g n e d t o p r o m o t e a m o r e p o s i t i v e view o f issues r e l a t e d t o c a n c e r p r e v e n t i o n . F o r e x a m p l e , t h e c a m p a i g n r e i n f o r c e d a p o s i t i v e , g o o d - n e w s t h e m e ( C a n c e r P r e v e n t i o n : T h e N e w s Is G e t t i n g Better All t h e T i m e ) , d e s c r i b e d risk factors t h a t i n d i v i d u a l s c o u l d c o n t r o l , a n d r e c o m m e n d e d positive steps o r a c t i o n s t o t a k e t o p r e v e n t c a n c e r . T h e press kits a n d p r o m o t i o n a l packets sent to d o c t o r s c h a m p i o n e d this p o s i t i v i t y effect b y u s i n g survivors of c a n c e r a n d b y s h o w i n g p r o g r e s s . For e x a m p l e , c o n s i d e r t h r e e messages u s e d in this c a m p a i g n : GOOD NEWS: Everyone does not get cancer. 2 out of 3 Americans will never get it. BETTER NEWS: Every day more and more people with cancer are cured. BEST NEWS: Every day you can do something to help protect yourself from cancer.

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A l t h o u g h this c a m p a i g n will p r o b a b l y n o t c h a n g e t h e n e g a t i v e affect a s s o ciated w i t h cancer, it m a y e n h a n c e attitudes t o w a r d p r e v e n t i o n (I can c o n t r o l m y l i k e l i h o o d of getting c a n c e r ) a n d m a y e n h a n c e positive a t t i t u d e s t o w a r d c a n c e r research. In s u m m a r y , a r a t h e r s u b s t a n t i a l l i t e r a t u r e indicates t h a t p o s i t i v e m e s sages often i n v o k e positive affect t h a t , in t u r n , fosters a t t i t u d e c h a n g e . T h e s e effects are especially p r o n o u n c e d w h e n t h e issue is u n f a m i l i a r o r t h e i n t e n d e d a u d i e n c e a l r e a d y feels positive a b o u t it. Messages t h a t u s e p o s i t i v e affect p r o d u c e shifts in a t t i t u d e regardless of h o w i n v o l v e d i n d i v i d u a l s feel t o w a r d a n issue o r topic. Finally, even t h o u g h there is little evidence t o suggest t h a t positive affect can c h a n g e s t r o n g l y h e l d negative a t t i t u d e s , p o s i t i v e i n f o r m a t i o n c a n b e u s e d indirectly t o c h a n g e related a t t i t u d e s .

COMPLIANCE M o s t c a m p a i g n e v a l u a t o r s are i n t e r e s t e d in t h e i m p a c t of positive affective appeals o n selective perception, d e p t h of processing, m e m o r y , a n d a t t i t u d e s b e c a u s e these m e n t a l processes can b e p r e d i c t i v e of b e h a v i o r a l o u t c o m e s . H o w can affect e n h a n c e b e h a v i o r a l m o d i f i c a t i o n o r c o m p l i a n c e w i t h t h e goals of t h e campaign? T h o u g h research e x a m i n i n g the role of affective m e s sages o n c o m p l i a n c e is scarce, it is suggestive. W i t h o u t d i s c r i m i n a t i n g a m o n g positive a n d negative a p p e a l s , a few s t u d ies suggest t h a t affect can b e i n s t r u m e n t a l in s t i r r i n g i n d i v i d u a l s t o w a r d a c t i o n . F o r e x a m p l e , o n e s t u d y f o u n d affective a p p e a l s w o r k e d b e t t e r t h a n logical o r r a t i o n a l appeals at m o t i v a t i n g t h o s e w h o are indifferent ( A t k i n , 1979). Flora a n d M a i b a c h (1990) also f o u n d affective messages w e r e signific a n t l y m o r e effective in s t i m u l a t i n g a desire t o learn m o r e a b o u t A I D S t h a n were primarily rational appeals. In a n i n t e r e s t i n g c o m p a r i s o n of positive a n d negative a p p e a l s , M c N e i l a n d colleagues (1982) d e m o n s t r a t e d greater c o m p l i a n c e with a d o c t o r ' s r e c o m m e n d a t i o n for a surgical p r o c e d u r e w h e n t h e o u t c o m e f r o m s u r g e r y w a s p r e s e n t e d as t h e p r o b a b i l i t y of survival (a positive g a i n ) relative t o w h e n t h e o u t c o m e w a s p r e s e n t e d as t h e p r o b a b i l i t y of m o r t a l i t y (fear). O n e s t u d y of a d e n t a l h y g i e n e p r o g r a m f o u n d t h a t a l t h o u g h n e g a t i v e a p p e a l s elicited m o r e verbal p r o m i s e s t o c o m p l y , as well as r e p o r t s of h a v i n g c o m p l i e d , t h e y w e r e actually less effective t h a n positive appeals in i n c r e a s i n g message r e t e n t i o n a n d compliance (Evans et al., 1970). T h u s negative a p p e a l s m a y p r o v o k e a social desirability bias: I n d i v i d u a l s m a y feel t h e n e e d t o say t h e y u n d e r s t o o d t h e message a n d are " c h a n g i n g " t h e i r ways, b u t feel n o m o t i v a t i o n t o actually c h a n g e t h e i r b e h a v i o r s . T h o u g h n e g a t i v e affect m a y

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p r o v o k e a social desirability bias, positive affect c a n b e u s e d t o m a k e p e o p l e feel g o o d a b o u t t h e m s e l v e s . P e o p l e h a v e a p o w e r f u l n e e d t o t h i n k p o s i t i v e l y o f t h e m s e l v e s , especially a l o n g d i m e n s i o n s t h a t a r e i m p o r t a n t t o t h e m . M e s s a g e s t h a t p r o m o t e g o o d feelings a b o u t t h e self can b e especially p e r s u a sive. Positive messages m a k e p e o p l e feel b e t t e r a b o u t t h e m s e l v e s a n d t h u s lead t o i n c r e a s e d b e n e v o l e n c e t o w a r d o t h e r s (Isen, 1987). A r e c e n t e x a m p l e of a c a m p a i g n t h a t u s e d positive h e u r i s t i c a n d e m o t i o n a l b e n e f i t a p p e a l s t o increase c o m p l i a n c e was t h e 1993 c a m p a i g n of t h e California T r a n s p o r t a t i o n D e p a r t m e n t a n d t h e S o u t h c o a s t Air Q u a l i t y M a n a g e m e n t District's " T e a m R i d e s h a r e . " T h e p u r p o s e of t h i s c a m p a i g n w a s t o e n c o u r a g e c o m m u t e r s t o c a r p o o l o n e d a y a week. F o r m a t i v e r e s e a r c h i n d i c a t e d t h a t m o s t c o m m u t e r s believed in r i d e s h a r i n g , w e r e a w a r e o f t h e i r o p t i o n s r e g a r d i n g r i d e s h a r i n g , a n d felt r i d e s h a r i n g was a great i d e a . . . for s o m e o n e else. T o e v o k e i n t e r e s t in a n e w c a m p a i g n o n a n o l d issue for C a l i f o r n i a n s , a h e u r i s t i c affective c u e in t h e f o r m of a t h e m e s o n g " S h a r i n a R i d e , " b a s e d o n an u p b e a t s o n g " H i t c h i n a R i d e , " was e m p l o y e d . T h e u s e of t h i s s o n g was successful in gaining the attention of c o m m u t e r s . O n c e t h e c o m m u t e r a u d i e n c e ' s a t t e n t i o n was c a p t u r e d a n d a positive feeling t o w a r d t h e c a m p a i g n w a s e s t a b l i s h e d via this h e u r i s t i c a p p e a l , e m o t i o n a l benefit a p p e a l s w e r e t h e n used to present compelling reasons to change behaviors. T h e emotional benefit a p p e a l s focused o n t h e benefit of r i d e s h a r i n g for t h e e n v i r o n m e n t ( h e a l t h i e r air a n d a cleaner e n v i r o n m e n t ) a n d t h e benefits t o t h e c o m m u t e r ( m o r e t i m e a n d m o n e y t o enjoy, less stress, a n d i n c r e a s e d s p e e d s o n t h e freeway system). In addition, parties were set u p at major employers t h r o u g h o u t t h e a r e a as a p l e a s a n t w a y for p r o s p e c t i v e r i d e s h a r e p a r t n e r s t o m e e t a n d b e c o m e a c q u a i n t e d . As p a r t of t h e c a m p a i g n ' s e v a l u a t i o n , traffic e n g i n e e r s m o n i t o r e d c a r p o o l a n d v a n p o o l lanes d u r i n g t h e c a m p a i g n a n d r e p o r t e d an a p p r o x i m a t e l y 2 5 % increase in c a r p o o l activity for " R i d e s h a r e T h u r s d a y . " 1

Finally, t h e r e are c i r c u m s t a n c e s in w h i c h positive affect m a y h i n d e r t h e l i k e l i h o o d o f c o m p l i a n c e . O n e s t u d y , for e x a m p l e , f o u n d p e o p l e in w h o m positive affect h a d b e e n i n d u c e d w e r e less helpful t o a disliked c a u s e t h a n w e r e c o n t r o l subjects (Forest et al., 1979): A t t e m p t s t o i m p r o v e t h e i m a g e of a disliked t o p i c / c a m p a i g n b y m e a n s of a t t a c h i n g p o s i t i v e affect t o it m a y backfire. P e o p l e in w h o m positive feelings h a v e b e e n i n d u c e d m a y d e m o n s t r a t e m o r e f r e e d o m t o express their t h o u g h t s a n d d o as t h e y please. If p e o p l e a r e generally negatively d i s p o s e d t o an idea (say, w e a r i n g a c o n d o m ) , i n d u c i n g positive affect b y m e a n s of a h u m o r o u s PSA c a m p a i g n m a y c a u s e r e c i p i e n t s of t h e m e s s a g e t o d e n i g r a t e t h e idea even further. I m p o r t a n t l y , t h e s e findings reinforce t h o s e b a s e d o n d e p t h - o f - p r o c e s s i n g , m e m o r y , a n d

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a t t i t u d e c h a n g e studies: Positive affect m a y n o t b e a useful p l o y t o gain c o m p l i a n c e w h e n s t r o n g l y h e l d negative a t t i t u d e s a l r e a d y exist. E v a l u a t i o n s of c a m p a i g n s u s i n g positive affect t o i n d u c e b e h a v i o r a l c h a n g e are few a n d far between. T h e few results that exist suggest t h a t p o s i t i v e affect m i g h t b e m o r e effective t h a n negative affect in getting i n d i v i d u a l s t o c o m p l y w i t h a c a m p a i g n . C o n s i d e r a b l e research r e m a i n s t o b e d o n e in this area. T o s u m m a r i z e : Positive affect f o u n d in e m o t i o n a l benefit appeals a n d heuristic appeals can facilitate cognitive a n d behavioral responses to messages. T a b l e 5.1 s u m m a r i z e s t h e relative effectiveness of t h e s e t w o types of a p p e a l . H e u r i s t i c appeals target i n d i v i d u a l s w h o d o n o t h a v e t h e t i m e , skill, o r m o t i v a t i o n t o evaluate t h e a t t r i b u t e s a n d benefits of a p a r t i c u l a r c a m p a i g n . H e u r i s t i c a p p e a l s a t t e m p t t o m a k e t h e message r e c i p i e n t feel g o o d b y u s i n g m u s i c , artwork, o r b a c k g r o u n d t o evoke positive imagery o r t o create a favorable m o o d . T h e s t r e n g t h of h e u r i s t i c appeals is t h a t t h e y a r e p a r t i c u l a r l y effective in c a p t u r i n g t h e a u d i e n c e ' s a t t e n t i o n . Because s u c h a p p e a l s rely o n i m a g e r y a n d feeling r a t h e r t h a n o n c o n t e n t , h o w e v e r , t h e a u d i e n c e s p e n d s m i n i m a l t i m e p r o c e s s i n g t h e message. A l t h o u g h i n d i v i d u a l s s h o w e n h a n c e d recall for t h e i m a g e r y a n d g o o d feelings, h e u r i s t i c a p p e a l s d o n o t r e s u l t in e n h a n c e d recall for t h e content of t h e c a m p a i g n . In a d d i t i o n , s u c h m e s s a g e s a r e likely t o result in s h o r t - l i v e d o r fleeting a t t i t u d e c h a n g e , u n l e s s m e s s a g e ^ ) are r e p e a t e d several t i m e s . Little t o n o w o r k h a s b e e n r e p o r t e d t h a t e x a m i n e s t h e effects of h e u r i s t i c appeals o n c o m p l i a n c e b e h a v i o r s . E m o t i o n a l benefit appeals c o m b i n e r a t i o n a l a n d affective c o m p o n e n t s in o r d e r t o create affective r e s p o n s e s t o a message. Such messages illustrate t h e e m o t i o n a l , psychological, or experiential benefits of c o m p l y i n g w i t h a c a m p a i g n . Positive e m o t i o n a l benefit appeals can b e effective at c a p t u r i n g a t t e n t i o n ; h o w e v e r , t h e y are n o t as effective as h e u r i s t i c a p p e a l s in t h e a t t e n t i o n - g e t t i n g stage. Because of t h e i r c o m b i n a t i o n of r a t i o n a l a n d affective c o m p o n e n t s , e m o t i o n a l benefit appeals a r e m o r e likely t h a n h e u r i s t i c a p p e a l s t o p r o v o k e t h o u g h t f u l p r o c e s s i n g , e n h a n c e d recall, a n d stable a t t i t u d e shifts. Finally, a small n u m b e r of studies indicate e m o t i o n a l benefit a p p e a l s result in i n c r e a s e d c o m p l i a n c e w i t h t h e message of a c a m p a i g n .

Conclusions I n this chapter the benefits a n d perils of positive affect w e r e briefly e x a m i n e d . Z a j o n c ' s t h e o r y suggests t h a t affective r e s p o n s e s t o messages are p r i m a r y : W e feel, t h e n w e t h i n k . Positive affect is h y p o t h e s i z e d t o result in a p p r o a c h

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Positive Emotional Benefit Appeals

Highly effective Tends to elicit Recall enhanced minimal processing for feelings but not message content Effective if Elicits more thoughtful Recall for both feelings incorporates processing and message is heuristic enhanced component

Recall

Positive Heuristic Appeals

Depth of Processing

Attention-Getting

Type of Message

TABLE 5.1 Effect of Positive Message Appeals on Cognitive and Behavioral Responses

More likely to result in short-lived, fleeting effects Results in more stable long-lasting effects

Attitude Change

Increased compliance

Effects unknown

Compliance

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b e h a v i o r s t h a t e n a b l e an a u d i e n c e t o feel o p e n m i n d e d a n d positively t o w a r d a n issue o r c a m p a i g n . Affect can b e directly a t t a c h e d t o a n issue t h r o u g h t e s t i m o n i a l s , d e m o n s t r a t i o n s , slice-of-life a d s , o r a n y o t h e r f o r m of e m o tional benefit appeal. Positive affect can also be indirectly attached to an issue t h r o u g h t h e use of h e u r i s t i c appeals like a r t w o r k , m u s i c , a n d b a c k g r o u n d t o create a m o o d o r a positive uplifting feeling. Regardless of w h e t h e r it is d i r e c t o r i n d i r e c t , positive affect h a s s h o w n t o e n c o u r a g e p e o p l e t o recall p l e a s a n t t h i n g s , t o j u d g e things positively, t o m a k e faster d e c i s i o n s , t o b e m o r e b e n e v o l e n t t o w a r d o t h e r s , a n d t o b e m o r e c o m p l i a n t (Isen, 1987). Positive affect has t o o often b e e n an u n d e r u t i l i z e d tactic in c o m m u n i c a t i o n c a m p a i g n s . T h i s c h a p t e r e n d s w i t h a few s u g g e s t i o n s for w h e n a n d h o w t o use positive appeals: 1. When the intended audience is unfamiliar with an issue, use emotional benefit appeals in the form of comparison, demonstration, satisfaction, and testimonials. 2. Use heuristic or indirect affective appeals once message recipients are familiar with an issue or campaign. H u m o r or other positive feelings are very effective in overcoming selective attention due to boredom and overexposure. 3. Use positive affect very carefully once an issue is associated with strong negative feelings. It is difficult to use positive feelings to change strongly held negative attitudes. Moreover, using positive affect in these circumstances may backfire, making the negative attitudes even more firmly entrenched. 4. Use positive affect to change the focus of a campaign. When it is important to get the audience to view an issue in a new light, positive affect maybe instrumental in shifting the mental frame that audiences use to understand an issue. 5. In order to increase compliance, stress positive outcomes rather than negative ones and emphasize control over an issue rather than helplessness. 6. Whenever the intended audience is undecided or confused (as is so often the case with health issues), positive affect is an excellent strategy. The most consistent and effective findings for positive affect changing behavior and attitudes are under these circumstances. Positive affect c a n b e u s e d to stress t h e benefits of h e a l t h y b e h a v i o r , t o give i n d i v i d u a l s a sense of c o n t r o l , a n d to r e d u c e a n x i e t y o r fear. All of t h e s e tactics are likely to e n h a n c e t h e success of a c o m m u n i c a t i o n c a m p a i g n .

Note 1. Early evaluations of this campaign were obtained via a personal correspondence from the account executive for Team Rideshare, Pam Hill.

Using Positive Affect

97

References Arkin, Ε. B. (1989). Making health communication programs work: A planner's guide (NIH Publication No. 89-1493). Washington, DC: U.S. Department of Health and Human Services. Atkin C. (1979). Research evidence on mass mediated health communication campaigns. In D. Nimmo (Eds.), Communication yearbook, 3 (pp. 655-668). New Brunswick, NJ: Transaction-International Communication Association. Batra, R. (1986). Affective advertising: Role, processes, and measurement. In R. A. Peterson, W. D. Hoyer, 8c W. R. Wilson (Eds.), The role of affect in consumer behavior: Emerging theories and applications (pp. 53-87). Lexington, MA: Lexington Books. Batra, R., 8c Stayman, D. M. (1990). The role of mood in advertising effectiveness. Journal of Consumer Research, 17, 203-214. Bless, H., Bohner, G., Schwarz, Ν., 8c Strack, F. (1990). Mood and persuasion: Cognitive response analysis. Personality and Social Psychology Bulletin, 16, 332-346. Cacioppo, J. T., 8c Petty, R. E. (1989). The elaboration likelihood model: The role of affect and affect-laden information processing in persuasion. In P. Cafferata 8c A. Tybout (Eds.), Cognitive and affective responses to advertising (pp. 69-90). Lexington, MA: Lexington Books. Clark, M. S., 8c Isen, A. M. (1982). Toward understanding the relationship between feeling states and social behavior. In A. Hastorf 8c A. Isen (Eds.), Cognitive social psychology. New York: Elsevier-North Holland. Crockett, W. H. (1988). Schemas, affect and communication. In L. Donohew, Η. E. Sypher, 8c Ε. T. Higgins (Eds.), Communication, social cognition, and affect (pp. 33-52). Hillsdale, NJ: Lawrence Eribaum. Evans, R I . , et al. (1970). Fear arousal, persuasion and actual versus implied behavioral change: New perspectives utilizing a real-life dental hygiene program. Journal of Personality and Social Psychology, 16,220-227. Flora, J. Α., 8c Maibach, E. W. (1990). Cognitive responses to AIDS information: The effects of issue involvement and message appeal. Communication Research, 17, 759-774. Forest, D., Clark, M. S., Mills, J., 8c Isen, A. M. (1979). Helping as a function of feeling state and nature of the helping behavior. Motivation and Emotion, 3, 161-169. Freimuth, V. S., Hammond, S. L., Edgar, T., 8c Monahan, J. L. (1990). Reaching those at risk: A content-analytic study of AIDS PSAs. Communication Research, 17, 775-791. Isen, A. M. (1987). Positive affect, cognitive processes, and social behavior. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 20, pp. 203-254). New York: Academic Press. Isen, A. M. (1989). Some ways in which affect influences cognitive processes: Implications for advertising and consumer behavior. In P. Cafferata 8c A. Tybout (Eds.), Cognitive and affective responses to advertising (pp. 91-118). Lexington, MA: Lexington Books. Janis, I. L., Kay, D., & Kirschner, P. (1965). Facilitating effects of "eating while reading" on responsiveness to persuasive communications. Journal of Personality and Social Psychology, 1, 181-186. Madden, T. J., 8c Weinberger, M. G. (1984). Humor in advertising: A practitioner view. Journal of Advertising Research, 24, 23-29. McGuire, W. J., (1985). Attitudes and attitude change. In G. Lindsey & E. Aronson (Eds.), The handbook of social psychology (3rd ed.) (Vol. 2, pp. 233-346). New York: Random House.

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Monahan, J. L., 8c Collins-Jarvis, L. A. (1992). Personalizing risk for college students: The effects of identification strategies. Annenberg Working Paper, University of Southern California. Murphy, S. T. (1990). The primacy of affect: Evidence and extension. Unpublished doctoral dissertation, University of Michigan. Murphy, S. T., Monahan, J. L., 8c Zajonc, R. B. (1992, May). The role of affect in the mere exposure paradigm. Paper presented to the 42nd Annual Convention of the International Communication Association, Miami. Murphy, S. T., 8c Zajonc, R. B. (1993). Affect, cognition, and awareness: Affective priming with suboptimal and optimal stimulus. Journal of Personality and Social Psychology, 64(5), 723-739. Ogilvy, D., 8c Raphaelson, J. (1982, July-August). Research advertising techniques that work— and don't work. Harvard Business Review, pp. 14-18. Park, C , 8c Thorson, E. (1990). Influences on emotional response to commercials of different executional styles. In S. J. Agres, J. A. Edell, 8c Τ. M. Dubitsky (Eds.), Emotion in advertising: Theoretical and practical explorations (pp. 161-174). New York: Quorum. Pechman, C , 8c Stewart, D. W. (1989). The multidimensionality of persuasive communications: Theoretical and empirical foundations. In P. Cafferata 8c A. Tybout (Eds), Cognitive and affective responses to advertising (pp. 31-66). Lexington, MA: Lexington Books. Petty, R. E., 8c Cacioppo, J. T. (1986). Communication and persuasion: Central and peripheral routes to attitude change. New York: Springer. Petty, R. E., Schumann, D. W., Richman, S. Α., 8c Strathman, A. (1993). Positive mood and persuasion: Different roles for affect under high and low elaboration conditions. Journal of Personality and Social Psychology, 64, 5-20. Ray, M. L. (1977). When does consumer information processing research actually have anything to do with consumer information processing. In W. D. Perreault, Jr. (Ed.), Advances in Consumer Research, 4, 372-375. Reeves, B., Newhagen, J., Maibach, E., Basil, M., 8c Kurz, Κ. (1991). Negative and positive television messages: Effects of message type and context on attention and memory. American Behavioral Scientist, 34, 679-694. Romano, R. M. (1986). The Cancer Prevention Awareness Program: Approaching public understanding with good news. In D. S. Leathar, G. B. Hastings, K. O'Reilly, 8c J. K. Davies (Eds.), Health education and the media II. Oxford: Pergamon. Schiffenbauer, A. (1974). Effect of observer's emotional state on judgments of the emotional state of others. Journal of Personality and Social Psychology, 30, 31-36. Stewart, D. W., 8c Furse, D. H. (1986). Effective television advertising: A study of1,000 commercials. Lexington, MA: Lexington Books. Thorson, E., 8c Friestad, M. (1989). The effects of emotion on episodic memory for television commercials. In P. Cafferata 8c A. Tybout (Eds.), Cognitive and affective responses to advertising (pp. 305-326) Lexington, MA: Lexington Books. Zajonc, R. B. (1980). Feeling and thinking: Preferences need no inferences. American Psychologist, 35, 151-175.

6

Designing Messages for Behavioral Inoculation

MICHAEL PFAU

A body of research dealing with the techniques for inducing resistance to change has accumulated. We view this research as a valuable, largely ignored contribution to the literature of persuasion. —Gerald R. Miller and Michael Burgoon, Communication Professors (Miller 8c Burgoon, 1973, p. 6) Inoculation [is the] best way to protect kids. —Ann Landers, Syndicated Advice Columnist (Landers, 1992; Permission granted by Ann Landers and Creators Syndicate)

D

espite t h e o v e r w h e l m i n g e v i d e n c e d o c u m e n t i n g t h e a d v e r s e c o n s e q u e n c e s of cigarette s m o k i n g , a l c o h o l c o n s u m p t i o n , d r u g u s e , a n d o t h e r d e l e t e r i o u s b e h a v i o r s , all t o o m a n y a d o l e s c e n t s still s u c c u m b t o o n e o r m o r e of t h e s e b e h a v i o r s , w i t h often d e v a s t a t i n g results in t e r m s of s h o r t a n d l o n g - t e r m m o r b i d i t y a n d m o r t a l i t y (Atkin, 1 9 9 1 ; U . S . D e p a r t m e n t of H e a l t h a n d H u m a n Services, 1989; D o n o v a n , Jessor, 8c Jessor, 1983). F u r t h e r m o r e , o n c e t h e s e b e h a v i o r s a r e a d o p t e d t h e y a r e e x t r e m e l y difficult t o A U T H O R S NOTE: The author is grateful to Jong G. Kang, Associate Professor of Communication at Illinois State University, Julia Pachoud, Assistant Professor of Theatre at Augustana College, and Brian Sather, a former cameraman at KELO television, for creative contributions. Professors Kang and Pachoud wrote and produced the smoking prevention inoculative messages that are described in this chapter.

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c h a n g e ( R e a r d o n , 1988), p r o m p t i n g m u c h greater e m p h a s i s a m o n g h e a l t h educators a n d practitioners on preventive approaches targeting increasingly y o u n g e r age c o h o r t s (Einsiedel 8c C o c h r a n e , 1988). T h i s c h a n g e in e m p h a s i s is c o n s i s t e n t w i t h a g r a d u a l shift in t h e overall h e a l t h care s y s t e m f r o m a c u r a t i v e t o a p r e v e n t i v e focus (Einsiedel 8c C o c h r a n e , 1988), m o t i v a t e d b y c o n s i d e r a t i o n s of cost a n d efficacy ( H u n t , B a r n e t t , 8c B r a n c h , 1971). This chapter examines the n a t u r e , potential, a n d use of o n e specific p r e v e n t i o n strategy: i n o c u l a t i o n . I n o c u l a t i o n seeks t o s t r e n g t h e n existing a t t i t u d e s , r e n d e r i n g t h e m less susceptible t o c h a n g e . As a p r e v e n t i o n a p p r o a c h , i n o c u l a t i o n can b e e m p l o y e d to target y o u n g c h i l d r e n a n d s t r e n g t h e n t h e i r a t t i t u d e s o p p o s i n g s m o k i n g , d r i n k i n g , d r u g use, o r o t h e r d e l e t e r i o u s b e h a v iors, t h u s r e n d e r i n g t h e m m o r e resistant t o s u b s e q u e n t p r e s s u r e t o e n g a g e in t h e s e risky practices. Syndicated advice c o l u m n i s t A n n L a n d e r s u r g e s A m e r i c a ' s p a r e n t s t o m a k e s u r e t h a t their c h i l d r e n are i n o c u l a t e d , t h u s p r o t e c t i n g t h e m from c o m m o n physical diseases. T h i s c h a p t e r m a i n t a i n s t h a t s i m i l a r c o n c e r n s h o u l d b e e x t e n d e d t o c o m m o n "societal d i s e a s e s " — p a r t i c u l a r l y s m o k i n g , d r i n k i n g , a n d d r u g u s e — t h a t exact a m u c h m o r e d e v a s t a t i n g toll. S m o k i n g p r e v e n t i o n research s u p p o r t s t h e b r o a d e r a p p l i c a t i o n of A n n L a n d e r s ' s advice that, " I n o c u l a t i o n [is t h e ] b e s t w a y t o p r o t e c t k i d s " ( 1 9 9 2 , p . 5B). T h e c h a p t e r d e m o n s t r a t e s h o w h e a l t h c a m p a i g n e r s can design a n d i m p l e m e n t i n o c u l a t i o n messages t o confer resistance.

Nature of Inoculation T h e i n o c u l a t i o n a p p r o a c h has its o r i g i n s in early r e s e a r c h o n t h e relative superiority of o n e - versus two-sided messages. O n e of t h e u n e x p e c t e d findings of this research was t h a t t h e use of t w o - s i d e d messages r e n d e r e d receivers m o r e r e s i s t a n t t o s u b s e q u e n t a t t e m p t s at c o u n t e r p e r s u a s i o n ( L u m s d a i n e 8c Janis, 1953). T h i s finding, a l t h o u g h i n t e r e s t i n g , r e q u i r e d a t h e o r e t i c a l c o n s t r u c t in o r d e r t o explain w h y t w o - s i d e d messages p r o m o t e d r e s i s t a n c e t o s u b s e q u e n t a t t i t u d e c h a n g e . T h e theoretical r a t i o n a l e for this finding was p r o v i d e d b y social psychologist W i l l i a m J. M c G u i r e , w h o i n t r o d u c e d t h e inoculation construct a n d s u p p o r t e d it in a series of laboratory studies s p a n n i n g nearly a decade (McGuire, 1970). Inoculation is based o n a biological a n a l o g y . As M c G u i r e (1970) describes t h e i n o c u l a t i o n process: We can develop belief resistance in people as we develop disease resistance in biologically overprotected man or animal; by exposing the person to a weak dose of the attacking material strong enough to stimulate his defenses but not strong enough to overwhelm him. (p. 37)

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T h e i n t e g r a l features of i n o c u l a t i o n are t h r e a t a n d r e f u t a t i o n a l p r e e m p t i o n . T h e t h r e a t c o m p o n e n t of b e h a v i o r a l i n o c u l a t i o n takes t h e f o r m of forew a r n i n g against a n i m p e n d i n g challenge t o existing a t t i t u d e s . T h e receiver is t o l d of p o t e n t i a l challenges t o existing a t t i t u d e s . B e c a u s e t h r e a t is a n i n t e r n a l p r o c e s s , a m a n i p u l a t i o n c h e c k is r e q u i r e d in i n o c u l a t i o n r e s e a r c h i n o r d e r t o i n s u r e t h a t t h e t h r e a t c o m p o n e n t takes h o l d (Pfau, V a n B o c k e r n , 8c K a n g , 1992). T h e refutational p r e e m p t i o n c o m p o n e n t is c o n d u c t e d b y initially raising, a n d t h e n directly refuting, o n e o r m o r e specific challenges t o existing a t t i t u d e s . T h e i n o c u l a t i o n p r o c e s s t h u s consists of p o s i n g a t h r e a t t h e n following w i t h r e f u t a t i o n a l p r e e m p t i o n . T h e t h r e a t c o m p o n e n t is p a r t i c u l a r l y i m p o r t a n t , b e c a u s e it serves as a m o t i v a t i o n a l trigger. T h r e a t involves p e o p l e ' s a c c e p t a n c e o f t h e v u l n e r a b i l ity of t h e i r a t t i t u d e s t o p o t e n t i a l challenges. It should not be confused with t h e c o n c e p t of a t h r e a t e n i n g m e s s a g e , w h i c h is c h a r a c t e r i s t i c of fear a p p e a l s . W h e n receivers accept t h e v u l n e r a b i l i t y of existing a t t i t u d e s , a n d if t h o s e a t t i t u d e s are salient, t h e y will b e m o t i v a t e d t o s t r e n g t h e n t h e m ( A n d e r s o n 8 c M c G u i r e , 1 9 6 5 ; M c G u i r e , 1961a, 1 9 6 2 , 1 9 6 4 , 1 9 7 0 ; P a p a g e o r g i s 8 c M c G u i r e , 1961). In this m a n n e r t h e i n o c u l a t i o n p r o c e s s w o r k s b y m o t i v a t i n g receivers to bolster their attitudes, not by simply providing answers to potential c o u n t e r a r g u m e n t s . As M c G u i r e (1962) describes: " T h e resistance c o n f e r r e d b y t h e r e f u t a t i o n a l defense . . . derives n o t o n l y f r o m t h e a s s i m i l a t i o n a n d r e t e n t i o n of t h e b o l s t e r i n g m a t e r i a l . . . b u t also from t h e m o t i v a t i o n effect of p r e e x p o s u r e t o t h e t h r e a t e n i n g m a t e r i a l " ( p . 2 4 8 ) . T h e t h r e a t c o m p o n e n t triggers t h e receiver's m o t i v a t i o n t o b o l s t e r a t t i t u d e s a n d gives i n o c u l a t i o n its distinctive p o w e r . "If t h e c o n s t r u c t w e r e l i m i t e d t o p r e e m p t i v e r e f u t a t i o n , it w o u l d afford l i m i t e d utility s i n c e c o m m u n i c a t o r s w o u l d n e e d t o p r e p a r e specific p r e e m p t i v e m e s s a g e s c o r r e s p o n d i n g t o e a c h a n d every a n t i c i p a t e d a t t a c k " (Pfau 8c Kenski, 1990, p . 7 5 ) . I n s t e a d , b y first m o t i v a t i n g receivers a n d o n l y t h e n p r e e m p t i v e l y r e f u t i n g o n e or m o r e potential counterarguments, inoculation spreads a b r o a d u m b r e l l a of p r o t e c t i o n , s a f e g u a r d i n g against b o t h t h o s e c o u n t e r a r g u m e n t s addressed by refutational p r e e m p t i o n and those n o t addressed. R e s e a r c h o n i n o c u l a t i o n s u p p o r t s this p o s i t i o n . B o t h t h e early l a b o r a t o r y r e s e a r c h ( M c G u i r e , 1961b, 1962; P a p a g e o r g i s 8c M c G u i r e , 1961) a n d s u b s e q u e n t field research (Pfau 8c B u r g o o n , 1988; Pfau, Kenski, Nitz, 8c S o r e n s o n , 1990; Pfau et al., 1992) f o u n d t h a t i n o c u l a t i o n confers resistance t o b o t h s a m e ( t h o s e specifically p r e e m p t e d in t h e p r e t r e a t m e n t s ) a n d n o v e l ( t h o s e n o t specifically p r e e m p t e d ) c o u n t e r a r g u m e n t s . T h e s e findings affirm t h a t t h e t h r e a t c o m p o n e n t of inoculation is the underlying basis of t h e c o n s t r u c t ' s

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p o w e r , serving as t h e motivational trigger for strengthening existing a t t i t u d e s , t h u s c o n f e r r i n g resistance. I n o c u l a t i o n differs f r o m social i n o c u l a t i o n , a n a p p r o a c h w i t h o r i g i n s in E v a n ' s social i n o c u l a t i o n t h e o r y (Wallack 8c C o r b e t t , 1987). Social i n o c u l a t i o n t h e o r y m e l d s M c G u i r e ' s i n o c u l a t i o n c o n s t r u c t a n d B a n d u r a ' s social l e a r n i n g t h e o r y , placing p r i m a r y e m p h a s i s o n t h e c o n s t r u c t of r e f u t a t i o n a l p r e e m p t i o n . Social i n o c u l a t i o n a p p r o a c h e s typically use a c o m b i n a t i o n of strategies, such as peer-led discussions, peer modeling, slide shows, a n d v i d e o s . A n u m b e r o f t h e p r o g r a m s a p p l y i n g social i n o c u l a t i o n h a v e d e m o n s t r a t e d m o d e s t success (Flay 8c B u r t o n , 1990). T h i s c h a p t e r ' s focus, h o w e v e r , will b e o n t h e u s e of i n o c u l a t i o n r a t h e r t h a n social i n o c u l a t i o n .

Application to Smoking Prevention I n o c u l a t i o n strategies s h o u l d b e c o n s i d e r e d w h e n e v e r s u p p o r t i v e prevaili n g a t t i t u d e s a r e subject t o serious challenges. T h i s will often b e t h e case w h e n conducting primary prevention a m o n g youth, particularly w h e n targ e t i n g p r e v e n t i o n of s m o k i n g , d r i n k i n g , d r u g use, violence, a n d a c c i d e n t s . As a r e s u l t of t h e efforts of p a r e n t s a n d t e a c h e r s , m o s t c h i l d r e n d e v e l o p s t r o n g attitudes in opposition to these harmful behaviors that extend t h r o u g h t h e i r e l e m e n t a r y s c h o o l years. H o w e v e r , t h e t r a n s i t i o n t o t h e m i d d l e g r a d e s , w h i c h is c h a r a c t e r i z e d b y " f a r - r e a c h i n g physiological u p h e a v a l s " in m a n y y o u t h ( H a m b u r g , 1 9 7 9 , p . 1031), a n d t h e d e c l i n i n g influence of p a r e n t s a n d g r o w i n g i m p a c t of p e e r s ( R o s e n b e r g , 1965), is often difficult, p r o d u c i n g an e r o s i o n of a t t i t u d e s o p p o s i n g s m o k i n g , d r i n k i n g , a n d d r u g u s e . T h e attitudinal p a t t e r n of children regarding s m o k i n g has b e e n well d o c u m e n t e d . Y o u n g c h i l d r e n ' s a t t i t u d e s o p p o s i n g s m o k i n g are often s t r o n g , so m u c h so t h a t m a n y will overtly chastise t h e i r s m o k i n g p a r e n t s a n d o l d e r siblings. M o s t adolescents begin the transition from p r i m a r y t o m i d d l e s c h o o l w i t h t h e i r s t r o n g a t t i t u d e s o p p o s i n g s m o k i n g i n t a c t (Pfau et al., 1992). D u r i n g t h e t r a n s i t i o n from t h e p r i m a r y t o m i d d l e g r a d e s , h o w e v e r , s u c h a t t i t u d e s d e t e r i o r a t e (Evans 8c Raines, 1982; Killen, 1985; Pfau et al., 1992), w h i c h p r o d u c e s in some adolescents a g r o w i n g c h a n c e of e x p e r i m e n t a l a n d r e g u l a r s m o k i n g , a n d in most an i n c r e a s i n g t o l e r a n c e of s m o k i n g b y p e e r s (Pfau 8c V a n B o c k e r n , 1994). D u r i n g this critical t r a n s i t i o n p e r i o d , a d o l e s cents develop an indifference t o t h e health consequences of s m o k i n g ( R o k e a c h , 1987) a t t h e s a m e t i m e t h e y b e c o m e increasingly v u l n e r a b l e to t h e i n f l u e n c e

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o f p e e r p r e s s u r e (Flay, d ' A v e r n a s , Best, Kersell, & R y a n , 1983; F r i e d m a n , L i c h t e n s t e i n , 8c Biglan, 1985; G o t t l i e b 8c Baker, 1986). As a result, p u b l i c h e a l t h officials a c k n o w l e d g e t h a t " s m o k i n g is a b e h a v i o r t h a t is initiated p r i m a r i l y d u r i n g t h e a d o l e s c e n t y e a r s " ( C h a s s i n et al., 1 9 8 1 , p . 4 4 5 ) , specifically, d u r i n g t h e early a d o l e s c e n t years. P r e v e n t a t i v e efforts s h o u l d b e g e a r e d t o sixth a n d s e v e n t h g r a d e c h i l d r e n b e c a u s e " m o r e t h a n half o f all c u r r e n t y o u n g p e o p l e w h o a d o p t t h e h a b i t of daily s m o k i n g d o so b e f o r e o r d u r i n g t h e i r n i n t h g r a d e s c h o o l y e a r " (McAlister, P e r r y , 8c M a c c o b y , 1979, p . 6 5 1 ) . T h i s s c e n a r i o carries i m p o r t a n t i m p l i c a t i o n s for t h e m o s t a p p r o p r i a t e a p p r o a c h t o s m o k i n g p r e v e n t i o n . T h e q u e s t i o n is n o t w h e t h e r h e a l t h e d u cators s h o u l d b e targeting y o u n g e r adolescents. T h a t q u e s t i o n has b e e n r e s o u n d i n g l y a n s w e r e d : T h e y s h o u l d ( C h a s s i n et a l , 1981; Elder 8c S t e r n , 1986; H a m b u r g , 1979; J o h n s o n , 1982; Killen, 1985; Pfau et a l , 1992)! I n s t e a d , t h e crucial issue is w h e t h e r a p e r s u a s i o n o r a n i n o c u l a t i o n a p p r o a c h s h o u l d b e u s e d in p r e v e n t i o n efforts. A p e r s u a s i o n a p p r o a c h is a p p r o p r i a t e in t h o s e c i r c u m s t a n c e s w h e n r e ceiver a t t i t u d e s a n d / o r b e h a v i o r s r e q u i r e c h a n g e . T h e d a t a i n d i c a t e , h o w ever, t h a t a d o l e s c e n t s c o m m e n c e t h e t r a n s i t i o n f r o m t h e p r i m a r y t o m i d d l e grades w i t h s t r o n g a t t i t u d e s o p p o s i n g s m o k i n g . " T h e y h a v e already been persuaded t h a t s m o k i n g is b a d . T h e q u e s t i o n is w h e t h e r t h e s e a t t i t u d e s will p e r s i s t " [ e m p h a s i s in original] (Pfau 8c V a n B o c k e r n , 1994, p . 4 2 0 ) . I n o n e s t u d y , t h e d a t a s h o w t h a t t h e s e a t t i t u d e s often d o n o t persist d u r i n g t h e 2 years following t h e t r a n s i t i o n f r o m e l e m e n t a r y s c h o o l t o j u n i o r h i g h s c h o o l . T h e large m a j o r i t y o f a d o l e s c e n t s b e g a n this t r a n s i t i o n w i t h n e g a t i v e a t t i tudes toward smoking, b u t those attitudes deteriorated during the next 2 y e a r s . A d o l e s c e n t s g r e w m o r e positive t o w a r d s m o k i n g , m o r e p o s i t i v e t o w a r d p e e r s m o k i n g , a n d less likely t o o v e r t l y resist s m o k i n g ( P f a u 8c V a n B o c k e r n , 1994). P e r h a p s m o s t telling, a d o l e s c e n t s ' p e r c e p t i o n o f t h e i r likel i h o o d t o s m o k e rose steadily d u r i n g 2 t w o years, " f r o m a l o w o f 4 % at t h e s t a r t of s e v e n t h g r a d e t o m o r e t h a n 2 2 % n e a r t h e c o n c l u s i o n of e i g h t h g r a d e " (Pfau 8c V a n Bockern, 1994, p . 424). These results are consistent w i t h b e h a v ioral d a t a f r o m o t h e r s o u r c e s ( J o h n s o n , 1982) s h o w i n g s m o k i n g rates of 4 % - 8 % p r i o r t o ages 12 a n d 13, a n d 2 2 % b y h i g h s c h o o l . T h e s e findings s u p p o r t t h e use of a n i n o c u l a t i o n a p p r o a c h t o s m o k i n g p r e v e n t i o n . T h e i n o c u l a t i o n strategy is t h e a p p r o p r i a t e c h o i c e b e c a u s e , at t h e p o i n t of transition from t h e p r i m a r y to m i d d l e school grades, adolescents possess r e a s o n a b l y established a t t i t u d e s o p p o s i n g s m o k i n g . W h a t is n e e d e d

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at this p o i n t is a strategy to protect these a n t i s m o k i n g attitudes from d e t e r i o r a t i o n d u r i n g t h e t u r b u l e n t m i d d l e s c h o o l years.

Inoculation Versus "Social Inoculation" B e c a u s e studies o n s m o k i n g o n s e t identify peer p r e s s u r e as t h e m o s t powerful p r e d i c t o r of adolescent s m o k i n g ( G o r d o n , 1986; M c C a u l , Glasgow, O ' N e i l l , F r e e b o r n , 8c R u m p , 1982; M e t t l i n , 1976), a n u m b e r of r e s e a r c h e r s h a v e e x a m i n e d t h e p o t e n t i a l of w h a t is t e r m e d a "social i n o c u l a t i o n " s t r a t e g y t o foster resistance t o a d o l e s c e n t s m o k i n g . "Social i n o c u l a t i o n " features a p e r m u t a t i o n of M c G u i r e ' s i n o c u l a t i o n c o n s t r u c t , w h i c h e m p h a s i z e s resist a n c e , a n d B a n d u r a ' s social l e a r n i n g t h e o r y , " w h i c h e m p h a s i z e s t h e role of t h e social c o n t e x t a n d t h e relevance of social skills t o s m o k i n g b e h a v i o r " ( W a l l a c k 8c C o r b e t t , 1987, p . 235). "Social i n o c u l a t i o n , " h o w e v e r , e m p l o y s o n l y o n e of t w o essential c o m p o n e n t s of t h e i n o c u l a t i o n c o n s t r u c t : n a m e l y , refutational preemption. "Social i n o c u l a t i o n " typically relies o n a s m o r g a s b o r d of t a c t i c s — t e a c h e r a n d peer-led discussion, peer modeling, slide shows, videos, school-wide c a m p a i g n s , a n d o t h e r s . D e s p i t e t h e m o d e s t success of "social i n o c u l a t i o n " a p p r o a c h e s (see Flay 8c B u r t o n , 1900), t h e y offer l i m i t e d utility t o h e a l t h campaigners. T h e e x t e n s i v e n e s s a n d variability of t h e varied c o m p o n e n t s i n c l u d e d u n d e r t h e r u b r i c "social i n o c u l a t i o n " u n d e r m i n e t h e i r usefulness, b e c a u s e it is difficult t o d i s c e r n t h e specific tactics t h a t are r e s p o n s i b l e for t h e success of t h e s e c a m p a i g n s ( F o o n , 1986). T h i s p r o m p t e d Flay (1985) t o c o n c l u d e , following his extensive review of t h e "social i n o c u l a t i o n " r e s e a r c h , t h a t , " w e really k n o w v e r y little at this t i m e a b o u t w h i c h of these p r o g r a m c o m p o n e n t s a r e n e c e s s a r y for p r o g r a m effectiveness or h o w o t h e r c o m p o n e n t s . . . m i g h t o r m i g h t n o t a d d t o p r o g r a m effectiveness" ( p . 3 7 8 ) . F u r t h e r c o m p o u n d i n g t h e p r o b l e m , these studies failed t o o p e r a t i o n a l i z e a n d confirm threat, the c o m p o n e n t that truly distinguishes inoculation f r o m o t h e r resistance a p p r o a c h e s . As n o t e d previously, t h r e a t is an i n t r i n s i c feature of i n o c u l a t i o n , p r o v i d i n g t h e m o t i v a t i o n a l catalyst for receivers t o s t r e n g t h e n existing a t t i t u d e s ( M c G u i r e , 1962; P a p a g e o r g i s 8c M c G u i r e , 1961). T h i s raises a d i s t i n c t possibility t h a t tactics o t h e r t h a n t h e p r e e m p t i v e c o m p o n e n t of "social i n o c u l a t i o n " m a y h a v e actually a c c o u n t e d for t h e i r results. T h i s c o n c e r n has m o t i v a t e d s o m e scholars t o q u e s t i o n t h e p o t e n t i a l

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of this a p p r o a c h in s m o k i n g p r e v e n t i o n (Flay, 1985; F o o n , 1986; M c C a u l 8c G l a s g o w , 1985).

Inoculation Message Construction I n o c u l a t i o n m e s s a g e c o n s t r u c t i o n t e c h n i q u e s e m p l o y e d in a l o n g i t u d i n a l s t u d y of i n o c u l a t i o n a n d s m o k i n g p r e v e n t i o n (Pfau et al., 1992; Pfau 8c V a n B o c k e r n , 1994) can i n f o r m h e a l t h e d u c a t o r s a n d p r a c t i t i o n e r s w h o seek t o u s e t h i s strategy in h e a l t h c a m p a i g n s . T h i s i n v e s t i g a t i o n of s m o k i n g p r e v e n t i o n e m p l o y e d v i d e o t a p e s as t h e c o m m u n i c a t i o n m o d a l i t y , a l t h o u g h i n o c u l a t i o n has b e e n o p e r a t i o n a l i z e d in o t h e r a p p l i e d s t u d i e s u s i n g p r i n t a n d d i r e c t m a i l m o d a l i t i e s (Pfau, 1992; Pfau 8c B u r g o o n , 1988; Pfau et a l , 1990). N o m a t t e r w h a t m o d a l i t y is c h o s e n , t h e basic a p p r o a c h t o m e s s a g e d e s i g n is basically t h e s a m e , a l t h o u g h t h e messages n e e d t o b e a d a p t e d t o t h e c h a n n e l characteristics of t h e c h o s e n m o d a l i t y for o p t i m a l efficacy. T w o steps s h o u l d b e t a k e n as a p r e l u d e t o m e s s a g e d e s i g n . First, e x i s t i n g h e a l t h messages d e s i g n e d for late p r i m a r y a n d early m i d d l e g r a d e s t u d e n t s should be previewed. These m a y include pamphlets, books, videotapes, a n d films. T h i s assists m e s s a g e d e s i g n e r s in a p p r e c i a t i n g b o t h t h e l a n g u a g e level a n d c o m m u n i c a t i o n styles a p p r o p r i a t e for t h e age c o h o r t , w h i c h d e t e r m i n e s a d o l e s c e n t m e s s a g e e x p e c t a t i o n s . S e c o n d , a p a n e l of e x p e r t s , late p r i m a r y a n d early m i d d l e g r a d e h e a l t h e d u c a t o r s , s h o u l d b e a s s e m b l e d . T h e y a r e in a u n i q u e p o s i t i o n t o p r o v i d e valuable advice d u r i n g t h e m e s s a g e d e s i g n p r o c e s s . I n a d d i t i o n , t h e y can p r o v i d e a n o n g o i n g c h e c k a g a i n s t t h e n a t u r a l tendency of m a n y health campaigners to overestimate younger adolescent l a n g u a g e capabilities a n d m e s s a g e i n v o l v e m e n t levels.

I N O C U L A T I O N MESSAGE DESIGN I n o c u l a t i o n message design requires t w o message types: a set of initial i n o c u l a t i o n messages as well as f o l l o w - u p r e i n f o r c i n g m a t e r i a l s . T h e initial inoculation messages require two c o m p o n e n t s : threat plus refutational preemption. I n t h e t h r e a t e n i n g c o m p o n e n t of t h e messages, a d o l e s c e n t s a r e c a u t i o n e d t h a t , in spite of t h e i r p r e s e n t a t t i t u d e s o p p o s i n g s m o k i n g a n d a l t h o u g h t h e y m a y n o t b e able t o i m a g i n e t h e m s e l v e s as s m o k e r s , as a result o f significant peer pressure d u r i n g t h e c o m i n g weeks a n d m o n t h s , m a n y of t h e m will b e c o m e i n c r e a s i n g l y u n c e r t a i n a b o u t s m o k i n g , a n d s o m e of t h e m will a c t u a l l y

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change their m i n d s and try smoking. T h e threat c o m p o n e n t needs to be h a n d l e d realistically, c a u s i n g adolescents t o e x p e r i e n c e s o m e d e g r e e of a n x i e t y a b o u t t h e future stability of t h e i r c u r r e n t a t t i t u d e s . I n t h e p e e r - v i d e o , Why Start? It's Your Choice, t h r e a t w a s e m b e d d e d early in t h e m e s s a g e . D u r i n g t h e o p e n i n g s e g m e n t , a n a d o l e s c e n t s p e a k s of h e r o l d e r sister's s m o k i n g h a b i t . After a largely visual lead, t h e t e e n a g e r l a m e n t s : My sister smokes and I hate it! I tell her that all the time, but I keep finding her stupid cigarettes everywhere. She says nobody cares, but I do. It stinks up the house and makes my eyes water. I think it's a gross habit. My parents smoke too, but if they found out about her, I bet they'd kill her. She doesn't care; she says she's hooked And she used to complain that they smoked. What happened? Junior high is what happened. Did you know that of all kids who enter junior high, almost three out of every four will try smoking at least once. No matter how you feel about smoking now, n o matter how bad you think it is, or even if you swear you'll never start, almost a third of you will become experimental smokers, and many of you will end up as regular smokers! Federal officials say that 3,000 teens start smoking each day, and you can count on the fact that most of them thought smoking was a stupid habit to pick up. But something or someone convinced them otherwise.

T h i s o p e n i n g scene is d e s i g n e d t o cause a d o l e s c e n t s t o e x p e r i e n c e i n v o l v e m e n t w i t h , a n d s o m e a n x i e t y a b o u t , t h e beliefs t h e y n o w h o l d d e a r in t h e face of f u t u r e challenges. I n t h e a d u l t - l e d v i d e o , Up in Smoke, following a n o p e n i n g scene d e s i g n e d t o i n t r o d u c e t h e character, t h e a c t o r p l a y i n g t h e role of a t e a c h e r w a r n s : Stupid habit! I don't know why people waste their breath on these things— literally. We used to call them "cancer sticks." I know that you think that smoking is a messy habit, right? It stinks, it's bad for you, and it costs bucks. As they say in baseball, "three strikes and you're out." (Pitches cigarette in the trash) N o matter how much you want to stay a nonsmoker, the truth is that the pressure to smoke in junior high is greater than it will be at any other time of your life. Three out of four young adults (points to camera)—and thafsyou—will pick u p a cigarette and let curiosity take over. Think about it. N o matter how you feel about smoking now, no matter how bad you think it is, or even if you swear you'll never start, three of every four of you will try it at least once. Almost a third of you will become experimental smokers, and many of you will end u p with a pack and a lighter full time. Research tells us that 3,000 teens start smoking each day, and you can count

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on the fact that most of them, like you, once thought that smoking was something that they'd never do. But something or someone convinced them otherwise. T h e s e s e g m e n t s w e r e d e s i g n e d t o c o n v i n c e n o n s m o k e r s t h a t t h e y will face s e r i o u s t h r e a t s t o existing a t t i t u d e s o p p o s i n g s m o k i n g . I n o r d e r t o assess w h e t h e r o r n o t messages attain this goal, message designers m u s t pretest t h e i r m e s s a g e s o n a d o l e s c e n t s . A t h r e a t m a n i p u l a t i o n , c o n s i s t i n g of five 7 - i n t e r v a l s e m a n t i c differential scales d e s i g n e d t o assess p e r c e p t i o n s of t h e v i d e o ( s a f e / d a n g e r o u s , n o t risky/risky, n o n t h r e a t e n i n g / t h r e a t e n i n g , u n i n t i m i d a t i n g / i n t i m i d a t i n g , a n d u n h a r m f u l / h a r m f u l ) , h a s b e e n e m p l o y e d in p a s t i n o c u l a t i o n research. T h i s p a r t i c u l a r t h r e a t m a n i p u l a t i o n i n s t r u m e n t h a s a c h i e v e d excellent reliability ratings in p a s t s t u d i e s (Pfau, 1992; Pfau et al., 1990; P f a u e t a l . , 1992). T h e t h r e a t m a n i p u l a t i o n e m p l o y e d in t h e s m o k i n g p r e v e n t i o n investigat i o n w a s effective in t h a t a d o l e s c e n t s p e r c e i v e d t h e v i d e o t o b e t h r e a t e n i n g . T h e first- a n d s e c o n d - y e a r results i n d i c a t e d t h a t t h o s e a d o l e s c e n t s w h o r e p o r t e d h i g h e s t p e r c e i v e d t h r e a t following a d m i n i s t r a t i o n of t h e p r e t r e a t m e n t s w e r e m o s t resistant t o s m o k i n g o n s e t d u r i n g each o f t h e a s s e s s m e n t s o v e r t h e following 2 years (Pfau et al., 1992; Pfau 8c V a n B o c k e r n , 1994). T h e refutational p r e e m p t i o n aspect of inoculation messages is m o r e o b v i o u s o n its face. M e s s a g e d e s i g n e r s n e e d t o e x a m i n e a l r e a d y p u b l i s h e d r e s e a r c h a n d c o n d u c t s o m e f o r m a t i v e s t u d y t o identify t h e c o u n t e r a r g u m e n t s t h a t m e s s a g e r e c i p i e n t s will e n c o u n t e r . T h e p r o c e s s of r e f u t a t i o n a l p r e e m p t i o n involves identifying a n d refuting as m a n y o f t h e s e c o u n t e r a r g u m e n t s as p o s s i b l e w i t h i n t h e c o n s t r a i n t s o f t i m e a n d receiver a t t e n t i o n s p a n . T h e m e s s a g e s e m p l o y e d in t h e i n o c u l a t i o n p r e t r e a t m e n t s in t h e s m o k i n g prevention videotapes featured the three m o s t c o m m o n c o u n t e r a r g u m e n t s , including: smoking is "cool"; experimental smoking is not addicting; and smoking won't harm me. F o r e x a m p l e , t h e v i d e o Up in Smoke a d d r e s s e d t h e c o u n t e r a r g u m e n t t h a t s m o k i n g is " c o o l . " T h e a c t o r , playing t h e role of a y o u n g , a t t r a c t i v e t e a c h e r explains: Half of all smokers say they started between sixth and ninth grades, most because they thought it might bring acceptance; like maybe, if you smoke people won't make fun of you, or at least they won't look down on you.

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Hey, nobody wants to be left out. Those feelings are normal. What isn't normal is risking your life for other peoples' acceptance. It is definitely not cool for friends to expect you to do something stupid. Real friends will respect your decision to live a healthy life, because they will want what's best for you. What is "cool" is knowing your mind and doing what you feel is right for you—and nobody else but you. So, how do you stick to your guns when the odds are against you? Well, you might run into this crowd [Shot of kids hanging out, smoking, being "cool"]. Do they look cool to you? Putting a lit stick up to your mouth is not cool. It's extremely unattractive—What you might call "gross." It causes bad breath, yellow teeth, and smelly clothes and hair [a male, smoking a cigarette, walks by an attractive female, waves at her, and coughs. He looks for a response, b u t realizes that he struck out because of the cigarette. Others, looking on, flick out their cigarettes, looking down]. Try asking someone out after you've smoked. They might say no because you smell. And how about kissing? You might as well lick an ashtray. The distant look may be "a ten," but the "close-up and personal" rates "a zero." N o t i c e t h e a b s e n c e of h a r d d a t a in s u p p o r t of t h e r e f u t a t i o n a l claim in t h e p r e c e d i n g m e s s a g e s e g m e n t . Effective messages a r e t a i l o r e d t o t a r g e t e d receivers ( A t k i n 8c F r e i m u t h , 1989; Flay 8c B u r t o n , 1990; K o t l e r 8c R o b e r t o , 1989; Pfau 8c P a r r o t t , 1993), a n d f o r m a t i v e d a t a in this case i n d i c a t e d t h a t a d o l e s c e n t s r e s p o n d t o t h e c o u n t e r a r g u m e n t t h a t " s m o k i n g is c o o l " e m o tionally, n o t cognitively. H e n c e , t h e r e f u t a t i o n a l r e s p o n s e s w e r e g r o u n d e d w i t h e m o t i o n a l s r a t h e r t h a n facts, at b o t h t h e verbal a n d visual levels. It is n o t n e c e s s a r y t o refute all p o t e n t i a l c o u n t e r a r g u m e n t s . As d i s c u s s e d p r e v i o u s l y , t h e s t r e n g t h of t h e i n o c u l a t i o n a p p r o a c h is t h a t it confers resistance to b o t h same and novel counterarguments. Health message designers m a y b e successful even with a limited n u m b e r of c o u n t e r a r g u m e n t s . T h e m o s t c o m m o n a n d m o s t p e r s u a s i v e c o u n t e r a r g u m e n t s s h o u l d b e refuted first. O t h e r c o n s i d e r a t i o n s for c o u n t e r a r g u m e n t s selected for r e f u t a t i o n i n c l u d e o p t i m a l message length, which is a function of receiver attention, a n d m o d a l i t y e x p e c t a t i o n s (e.g., s h o r t e r p u b l i c service a n n o u n c e m e n t s [PSAs] typically receive m o r e r a d i o a n d television air t i m e ) , s u c h as t h e p a r t i c u l a r s o u r c e t o b e u s e d t o deliver t h e message. SOURCE CONSIDERATIONS T h e issue of m o s t a p p r o p r i a t e s p o k e s p e r s o n h a s g e n e r a t e d m u c h a t t e n t i o n in p a s t i n o c u l a t i o n a n d "social i n o c u l a t i o n " research. P e e r a n d a d u l t

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s p o k e s p e r s o n s h a v e b e e n e m p l o y e d in p a s t research, a n d t h e t w o c o m p a r e d . T h e peer-led a p p r o a c h has b e e n m o r e c o m m o n in "social i n o c u l a t i o n " efforts. H o w e v e r , t h e results c o m p a r i n g the relative superiority of t h e t w o a p p r o a c h e s h a s p r o v e n e q u i v o c a l (Best, T h o m p s o n , Santi, S m i t h , 8c B r o w n , 1988). S o m e "social i n o c u l a t i o n " research i n d i c a t e s t h a t p e e r - l e d s p o k e s p e r s o n s a r e s u p e r i o r ( B o t v i n , Baker, R e n i c k , Filazzola, 8c B o t v i n , 1984; L u e p k e r , J o h n s o n , M u r r a y , 8c Pechacek, 1983; M u r r a y , Luepker, J o h n s o n , 8c M i t t e l m a r k , 1984). O n e of t h e first s t u d i e s c o m p a r i n g p r o g r a m p r o v i d e r s , h o w e v e r ( I r w i n , Creswell, 8c Stauffer, 1970), r e p o r t e d t h e p e e r - l e d a p p r o a c h w a s least effective, w h e r e a s o t h e r studies revealed t h a t s p o k e s p e r s o n a p p r o a c h i n t e r acts w i t h receiver g e n d e r (Clarke, M a c P h e r s o n , H o l m e s , 8c Jones, 1986; Fisher, A r m s t r o n g , 8c d e Klerk, 1985). T h e results of t h e 2-year i n o c u l a t i o n s t u d y described in this chapter s u p p o r t s t h e Best et al. (1988) conclusion: First- a n d s e c o n d - y e a r findings i n d i c a t e t h a t both p e e r a n d a d u l t a p p r o a c h e s p r o v e d m o d e r a t e l y effective, w i t h n o m a i n o r i n t e r a c t i o n effects for s p o k e s p e r s o n e v i d e n t (Pfau et al., 1992; Pfau 8c V a n B o c k e r n , 1994).

BOOSTER MESSAGE A P P R O A C H As w i t h all messages, it s h o u l d b e e x p e c t e d t h a t t h e i m p a c t o f a n i n o c u l a t i o n m e s s a g e will d e t e r i o r a t e o v e r t i m e . A l t h o u g h p a s t i n o c u l a t i o n r e s e a r c h suggests considerable persistence for inoculative materials (Pfau 8c B u r g o o n , 1988; Pfau et al., 1990; Pfau 8c V a n B o c k e r n , 1994) a n d suggests m i n i m a l efficacy for r e i n f o r c e m e n t ( M c G u i r e , 1961b; T a n n e n b a u m , M a c a u l a y , 8c N o r r i s , 1966; Pfau et a l , 1990; Pfau 8c V a n B o c k e r n , 1994), m e s s a g e d e s i g n ers a r e a d v i s e d t o p r e p a r e a n d utilize a s e c o n d m e s s a g e t y p e c o n s i s t i n g of r e i n f o r c i n g m a t e r i a l s . T h e t i m i n g of t h e a d m i n i s t r a t i o n of t h e r e i n f o r c i n g m a t e r i a l s in p r e v i o u s research m a y h a v e d i m i n i s h e d t h e i r effect b y p r e s e n t i n g t h e messages t o o s o o n after t h e i n o c u l a t i v e p r e t r e a t m e n t s (Pfau et al., 1992). T h e r e i n f o r c i n g messages s h o u l d focus o n t h e c o n t e n t c o v e r e d in t h e i n o c u l a t i o n p r e t r e a t m e n t s , e m p l o y i n g t h e s a m e d e s i g n in t e r m s of l e n g t h , language use, a n d a r r a n g e m e n t of a r g u m e n t s . If t h e initial i n o c u l a t i o n p r e t r e a t m e n t s u s e d b o t h peer a n d a d u l t s p o k e s p e r s o n s , r e i n f o r c i n g m a t e r i a l s c o u l d also utilize a c o m b i n a t i o n a p p r o a c h . T h e s m o k i n g p r e v e n t i o n s t u d y d e s c r i b e d in this c h a p t e r e m p l o y e d a c o m b i n e d a p p r o a c h in t h e r e i n f o r c e m e n t v i d e o b y f e a t u r i n g an i n t e r a c t i o n of t h e p e e r a n d a d u l t s p o k e s p e r s o n s . M o r e r e s e a r c h is r e q u i r e d t o p i n p o i n t t h e o p t i m a l use of r e i n f o r c i n g m a t e r i a l s .

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Conclusion P r e l i m i n a r y research indicates t h a t i n o c u l a t i o n is a viable strategy in s m o k i n g p r e v e n t i o n c a m p a i g n s t a r g e t i n g y o u n g s t e r s at t h e p o i n t of t r a n s i t i o n f r o m p r i m a r y t o m i d d l e grades, precisely b e c a u s e t h e y possess a t t i t u d e s o p p o s i n g s m o k i n g , w h i c h are u n d e r increasing p r e s s u r e d u r i n g adolescence. T h e initial inoculation p r e t r e a t m e n t s s h o u l d include threat a n d r e f u t a t i o n a l p r e e m p t i o n c o m p o n e n t s , m a y feature p e e r o r a d u l t s p o k e s p e r s o n s , a n d can b e d e l i v e r e d via a n y n u m b e r of c o m m u n i c a t i o n m e d i a , a l t h o u g h v i d e o s m a y p r o v e t h e m o s t cost effective. Initial p r e t r e a t m e n t s s h o u l d b e r e i n f o r c e d , u s i n g m e s s a g e s similar in design t o t h e originals. Q u e s t i o n s a b o u t t i m i n g a n d efficacy o f t h e r e i n f o r c i n g materials r e m a i n u n r e s o l v e d , h o w e v e r . I n a d d i t i o n t o its use in s m o k i n g p r e v e n t i o n c a m p a i g n s , h e a l t h m e s s a g e d e s i g n e r s s h o u l d c o n s i d e r t h e use of i n o c u l a t i o n in o t h e r h e a l t h c a m p a i g n contexts, including those involving prevention of adolescent d r u g a n d a l c o h o l u s e , v i o l e n c e a n d conflict r e s o l u t i o n , a n d a c c i d e n t p r e v e n t i o n . T h e c i r c u m stances d i c t a t e t h e a p p r o p r i a t e message strategy. W h e n a t t i t u d e s n e e d t o b e s t r e n g t h e n e d , i n o c u l a t i o n is a p r o m i s i n g b u t often o v e r l o o k e d a p p r o a c h (Miller 8c B u r g o o n , 1973).

References Anderson, L. R., 8c McGuire, W. J. (1965). Prior reassurance of group consensus as a factor in producing resistance to persuasion. Sociometry, 28, 44-56. Atkin, C. K. (1991). Be smart, don't start. In R. E. Rice 8c C. K. Atkin (Eds.), Public communication campaigns (2nd ed.) (pp. 224-226). Newbury Park, CA: Sage. Atkin, C , 8c Freimuth, V. (1989). Formative evaluation research in campaign design. In R. E. Rice 8c C. K. Atkin (Eds.), Public communication campaigns (2nd ed.) (pp. 131-150). Newbury Park, CA: Sage. Best, J. Α., Thompson, S. J., Santi, S. M., Smith, Ε. Α., 8c Brown, K. S. (1988). Preventing cigarette smoking among school children. Annual Review of Public Health, 9, 161-201. Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., 8c Botvin, Ε. M. (1984). A cognitivebehavioral approach to substance abuse prevention. Addictive Behavior, 9, 137-147. Chassin, L., Corty, E., Presson, C. C , Olshavsky, R. W., Bensenberg, Μ., 8c Sherman, S. J. (1981). Predicting adolescents' intentions to smoke cigarettes. Journal of Health and Social Behavior, 22,445-455. Clarke, J. J., MacPherson, B., Holmes, D. R., 8c Jones, R. (1986). Reducing adolescent smoking: Comparison of peer-led, teacher-led, and expert interventions. Journal of School Health, 56, 102-106. Donovan, J. E., Jessor, R., 8c Jessor, L. (1983). Problem drinking in adolescents and young adulthood: A follow-up study. Journal of Studies on Alcohol, 44,189-237.

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Einsiedel, Ε. F., & Cochrane, Κ. (1988, June). Using social marketing and theoretical perspectives for health comparisons to adolescents. Paper presented to the annual meeting of the International Communication Association, New Orleans. Elder, J. P., 8c Stern, R. A. (1986). The ABCs of adolescent smoking prevention: An environment and skills model. Health Education Quarterly, 13, 181-191. Evans, R. I., 8c Raines, Β. E. (1982). Control and prevention of smoking in adolescents: A psychosocial perspective. In T. J. Coates, A. C. Petersen, 8c C. Perry (Eds.), Promoting adolescent health: A dialogue on research and practice (pp. 101-136). New York: Academic Press. Fisher, D. Α., Armstrong, Β. K., 8c de Klerk, Ν. H. (1985). A randomized-controlled trial of education for prevention of smoking in 12-year-old children. In W. F. Forbes, R. C. Frecker, 8c D. Nostbakken (Eds.), Proceedings of the 5th World Conference on Smoking and Health (pp. 263-270). Ottawa: Canadian Council on Smoking and Health. Flay, B. R. (1985). Prosocial approaches to smoking prevention: A review of findings. Health Psychology, 4,449-488. Flay, B. R , 8c Burton, D. (1990). Effective mass communication strategies for health campaigns. In C. Atkin 8c L. Wallack (Eds.), Mass communication and public health: Complexities and conflicts (pp. 129-146). Newbury Park, CA: Sage. Flay, B. R., d'Avernas, R J., Best, J. Α., Kersell, M. W., 8c Ryan, Κ. B. (1983). Cigarette smoking: Why young people do it and ways of preventing it. In P. J. McGrath 8c P. Firestone (Eds.), Pediatric and adolescent behavioral mediane (pp. 132-183). New York: Springer. Foon, A. E. (1986). Smoking prevention programs for adolescents: The value of social psychological approaches. The International Journal of the Addictions, 21,1017-1029. Friedman, L. S., Lichtenstein, Ε., 8c Biglan, A. (1985). Smoking onset among teens: An empirical analysis of initial situations. Addictive Behaviors, JO, 1-13. Gordon, N. P. (1986). Never smokers, triers, and current smokers: Three distinct groups for school-based antismoking programs. Health Education Quarterly, 13,163-179. Gottlieb, N., 8c Baker, J. (1986). The relative influence of health beliefs, parental and peer behaviors and exercise program participation on smoking, alcohol use and physical activity. Social Science and Medicine, 22, 915-927. Hamburg, D. A. (1979). Disease prevention: The challenge of the future. American Journal of Public Health, 69,1026-1033. Hunt, W., Barnett, L., 8c Branch, L. G. (1971). Relapse rates in addiction programs. Journal of Clinical Psychology, 27,455-456. Irwin, R P., Cresswell, W., Jr., 8c Stauffer, D. J. (1970). The effect of the teacher on three different classroom approaches on seventh grade students' knowledge, attitudes and beliefs about smoking. Journal of School Health, 40, 355-359. Johnson, C. A. (1982). Untested and erroneous assumptions underlying antismoking programs. In T. J. Coates, A. C. Petersen, 8c C. Perry (Eds.), Promoting adolescent health: A dialogue on research and practice (pp. 149-165). New York: Academic Press. Killen, J. D. (1985). Prevention of adolescent tobacco smoking: The social pressure resistance training approach. Journal of Child Psychology and Psychiatry, 26,7-15. Kotier, P., 8c Roberto, E. L. (1989). Social marketing Strategies for changing public behavior. New York: Free Press. Landers, A. (1992, March 18). Inoculation best way to protect kids. Sioux Falb Argus Leader, p. 5B.

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Luepker, R. V., Johnson, C. Α., Murray, D. M., 8c Pechacek, T. F. (1983). Prevention of cigarette smoking: Three-year follow-up of an education program for youth. Journal of Behavioral Medicine, 6, 53-62. Lumsdaine, Α. Α., 8c Janis, I. L. (1953). Resistance to "counterpropaganda" produced by one-sided and two-sided "propaganda" presentations. Public Opinion Quarterly, 17, 311-318. McAlister, A. L., Perry, C , 8c Maccoby, N. (1979). Adolescent smoking: Onset and prevention. Pediatrics, 63, 650-658. McCaul, K. D., 8c Glasgow, R. E. (1985). Preventing adolescent smoking: What have we learned about treatment construct validity? Health Psychology, 4, 361-387. McCaul, K. D., Glasgow, R., O'Neill, Η. K., Freeborn, V., 8c Rump, B. S. (1982). Predicting adolescent smoking. The Journal of School Health, 52, 342-346. McGuire, W. J. (196 la). The effectiveness of supportive and refutational defenses in immunizing and restoring beliefs against persuasion. Sociometry, 24, 184-197. McGuire, W. J. (1961b). Resistance to persuasion conferred by active and passive prior refutation of the same and alternative counterarguments. Journal of Abnormal and Social Psychology, 63, 326-332. McGuire, W. J. (1962). Persistence of the resistance to persuasion induced by various types of prior belief defenses. Journal of Abnormal and Social Psychology, 64, 241-248. McGuire, W. J. (1964). Inducing resistance to persuasion. Some contemporary approaches. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 1, pp. 191-229). New York: Academic Press. McGuire, W. J. (1970, February). A vaccine for brainwash. Psychology Today, 3, pp. 36-39, 63-64. Mettlin, C. (1976). Peer and other influences on smoking behavior. The Journal of School Health, 46, 529-536. Miller, G. R., 8c Burgoon, M. (1973). New techniques of persuasion. New York: Harper 8c Row. Murray, D. M., Luepker, R. V., Johnson, C. Α., 8c Mittelmark, Μ. Β. (1984). The prevention of cigarette smoking in children: A comparison of four strategies. Journal ofApplied Social Psychology, 14, 274-288. Papageorgis, D., 8c McGuire, W. J. (1961). The generality of immunity to persuasion produced by pre-exposure to weakened counterarguments. Journal of Abnormal and Social Psychology, 62, 475-481. Pfau, Μ. (1992). The potential of inoculation in promoting resistance to the effectiveness of comparative advertising messages. Communication Quarterly, 40, 26-44. Pfau, Μ., 8c Burgoon, M. (1988). Inoculation in political campaign communication. Human Communication Research, 15, 91-111. Pfau, Μ., 8c Kenski, Η. C. (1990). Attack politics: Strategy and defense. New York: Praeger. Pfau, Μ., Kenski, Η. C , Nitz, Μ., 8c Sorenson, J. (1990). Efficacy of inoculation strategies in promoting resistance to political attack messages: Application to direct mail. Communication Monographs, 57, 25-43. Pfau, Μ., 8c Parrott, R. (1993). Persuasive communication campaigns. Boston: Allyn 8c Bacon. Pfau, Μ., 8c Van Bockern, S. (1994). The persistence of inoculation in conferring resistance to smoking initiation among adolescents: The second year. Human Communication Research, 20, 413-430. Pfau, Μ., Van Bockern, S., 8c Kang, J. G. (1992). Use of inoculation to promote resistance to smoking initiation among adolescents. Communication Monographs, 59, 213-230.

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Reardon, Κ. K. (1988). The role of persuasion in health promotion and disease prevention: Review and commentary. In J. A. Anderson (Ed.), Communication yearbook 11 (pp. 277297). Newbury Park, CA: Sage. Rokeach, M. (1987). Health values. Paper presented to the Institution for Health Promotion and Disease Prevention, Pasadena, CA. Rosenberg, M. (1965). Society and adolescent self-image. Princeton, NJ: Princeton University Press. Tannenbaum, P. H., Macaulay, J. R., 8c Norris, E. L. (1966). Principle of congruity and reduction in persuasion. Journal of Personality and Social Psychology, 2, 223-238. U.S. Department of Health and Human Services. (1989). 1989 Surgeon General's report: Redudngthe health consequences of smoking. 25 years of progress (DHHS Publication N o . CDC 89-8411). Washington, DC: Government Printing Office. Wallack, L., 8c Corbett, K. (1987). Alcohol, tobacco and marijuana use among youth: An overview of epidemiological, program and policy trends. Health Education Quarterly, 14, 223-249.

7

Reaching Young Audiences DEVELOPMENTAL CONSIDERATIONS IN DESIGNING HEALTH MESSAGES

ERICA WEINTRAUB AUSTIN

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h i l d r e n a n d adolescents w e l c o m e h e a l t h i n f o r m a t i o n t h e y p e r c e i v e as s u b s t a n t i v e , p r o v i d e d t h a t i n f o r m a t i o n is p r e s e n t e d in a relevant, c o m p r e h e n s i b l e , a n d realistic form. U n f o r t u n a t e l y , t o o m a n y c a m p a i g n s g e a r e d t o y o u n g p e o p l e h a v e offered o n l y simplistic, s h o r t - t e r m assistance t h a t leaves c h i l d r e n w h o are seeking effective s o l u t i o n s t o difficult p r o b l e m s t o lose h o p e o f finding real h e l p . This c h a p t e r will a r g u e t h a t t o a v o i d e n c o u r a g i n g c h i l d r e n t o settle for t r y i n g t o "live fast, die y o u n g a n d leave a g o o d looking corpse" (Kassebaum, 1990, p . 88), health c o m m u n i c a t i o n c a m p a i g n s n e e d t o a d o p t b r o a d e r a n d m o r e aggressive strategies t h a n h a s b e e n t h e case historically. Specifically, effective h e a l t h c a m p a i g n s m u s t (a) t a r g e t c h i l d r e n y o u n g e r t h a n h a s b e e n t h e n o r m ; (b) m i c r o target strategies t o t h e n e e d s a n d interests of different ages a n d e n v i r o n m e n t s ; (c) provide consistent messages f r o m a v a r i e t y of s o u r c e s a n d over a l o n g p e r i o d of t i m e ; a n d ( d ) e m p h a s i z e giving c h i l d r e n c o n t r o l a n d o w n e r s h i p of their o w n destinies.

General Principles for Targeting Children and Adolescents A c o m m o n m i s t a k e in c a m p a i g n design has b e e n t o a s s u m e t h a t p o r t r a y i n g a b e h a v i o r as b a d or u n h e a l t h y (such as b i n g e d r i n k i n g o r u n p r o t e c t e d sex) will cause c h i l d r e n t o reject it. T h i s fails t o r e c o g n i z e t h a t s o m e of t h e a p p e a l of c e r t a i n b e h a v i o r s m a y lie in t h e i r f o r b i d d a n c e ( M c G u i r e , 1989). K n o w l e d g e - b a s e d c a m p a i g n s t h u s rarely affect y o u n g p e o p l e ' s a t t i t u d e s a n d behaviors a n d often just serve as p r i m e r s o n h o w to d o t h e d a n g e r o u s b e h a v i o r ( G o o d s t a d t & Mitchell, 1990; K a s s e b a u m , 1990). N o t c o i n c i d e n t a l l y , p u b l i c 114

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service a n n o u n c e m e n t s (PSAs) s h o w i n g b e h a v i o r s s u c h as s m o k i n g a n d d r i n k i n g as "only for a d u l t s " — s o m e p r o d u c e d b y i n d u s t r y — m a k e t h e m e v e n m o r e a p p e a l i n g ( D i F r a n z a 8c McAfee, 1992). In general, health message designers need to d o m o r e listening to children a n d less p r e a c h i n g t o t h e m . C h i l d r e n — e s p e c i a l l y o l d e r c h i l d r e n — r e s p o n d b e s t w h e n i n v o l v e d in t h e i r o w n d e c i s i o n m a k i n g . T h e y r e s p e c t rules t h e y h a v e a p a r t in m a k i n g a n d get m o r e o u t of p r o g r a m s t h e y h a v e h a d a p a r t in p r o d u c i n g . T h u s , i n s t e a d of v i e w i n g c h i l d r e n a n d a d o l e s c e n t s o n l y as t h e c a m p a i g n target, p l a n n e r s s h o u l d view t h e m also as o n e of t h e i r m o s t p o t e n t resources. Fortunately, c a m p a i g n s based o n moralizing, scare tactics, a n d k n o w l e d g e o n l y a p p r o a c h e s a r e b e g i n n i n g t o b e r e c o g n i z e d as c o u n t e r p r o d u c t i v e o r of l i m i t e d effectiveness. M o r e p r o m i s i n g a n d c o m p r e h e n s i v e h e a l t h c o m m u n i c a t i o n strategies w i t h a n e m p h a s i s o n social influences a n d social a n d c o g n i t i v e skills are b e i n g d e v e l o p e d in their place. T h e d r i v i n g force in t h i s e v o l u t i o n in c a m p a i g n strategy is t h e r e c o g n i t i o n t h a t effective p r e v e n t i o n efforts m u s t a d d r e s s b o t h i n d i v i d u a l s a n d t h e e n v i r o n m e n t s i n w h i c h t h e y live. T o m o t i v a t e behavior change, campaigns n e e d t o address b o t h t h e i n t e r n a l ( p e r s o n a l ) a n d e x t e r n a l ( e n v i r o n m e n t a l ) forces t h a t g u i d e a child's b e h a v i o r ( M c G u i r e , 1989). T o target internal o r personal factors, c a m p a i g n designers m u s t u n d e r s t a n d a n d r e s p e c t t h e child's p e r s p e c t i v e , e x p l a i n i n g specific effects of risk t a k i n g a n d s h o w i n g b o t h physical a n d social c o n s e q u e n c e s relevant t o t h e child ( B a u m r i n d , 1985). It is b e t t e r t o e m p h a s i z e s h o r t - t e r m n e g a t i v e effects rather than long-term abstract dangers, because children a n d adolescents striving for physical a t t r a c t i v e n e s s a n d social p o w e r care m o r e t h a t s m o k i n g will m a k e t h e i r b r e a t h smell b a d t h a n t h a t t h e y c o u l d d e v e l o p c a n c e r ( K u t n e r , 1991). O n e well-received p o s t e r d e v e l o p e d b y t h e N a t i o n a l C o u n c i l o n A l c o h o l i s m , for e x a m p l e , s h o w e d B r o o k e Shields d e c l a r i n g t h a t " a l c o h o l is fattening" (Kassebaum, 1990). It is b o t h ineffective a n d unethical, h o w e v e r , t o p u t all of t h e r e s p o n s i b i l i t y o r b l a m e for risk t a k i n g o n t h e child, w h o s e resistance skills can b r e a k d o w n u n d e r e x t r e m e social p r e s s u r e ( W a l l a c k 8c Corbett, 1990). T h u s , campaigns also need t o target external o r e n v i r o n m e n t a l factors. T o d o so, c a m p a i g n s m u s t c o n s i d e r h o w a p a r t i c u l a r p r o b l e m relates t o a child's resources, needs, goals, a n d conflicting interests. M i x e d messages f r o m t h e c o m m u n i t y f r e q u e n t l y leave c h i l d r e n c o n f u s e d , skeptical, a n d disillus i o n e d . I n o n e t o w n , for e x a m p l e , p a r e n t s , c o m m u n i t y , a n d law e n f o r c e m e n t tell c h i l d r e n t h a t s u b s t a n c e a b u s e is b a d b u t h a v e a n n u a l l y t a k e n u p a collection t o s p o n s o r a g r a d u a t i o n all-night keg party m o n i t o r e d b y t h e s h e r i f f s

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d e p a r t m e n t (Free, 1993). W h e n t h e social n o r m is t o d r i n k , 7 5 % of s t u d e n t s will b e d r i n k i n g b y t h e t i m e t h e y a r e h i g h s c h o o l s e n i o r s ( J o h n s t o n , O ' M a l ley, 8c B a c h m a n , 1991). T h i s m a k e s it i n c u m b e n t o n c a m p a i g n d e s i g n e r s t o cultivate p a r t n e r s h i p s a m o n g c o m m u n i t y g r o u p s . O n e c a m p a i g n a t t e m p t i n g to a d d r e s s t h e i n t e r p l a y of i n t e r n a l a n d external forces is t h e STAR ( S t u d e n t s T a u g h t Awareness a n d Resistance) p r o g r a m , w h i c h c o r r e c t s c h i l d r e n ' s m i s p e r c e p t i o n s a n d a c k n o w l e d g e s m e d i a , family, a n d p e e r influences. S t u d e n t s are e n c o u r a g e d t o talk a b o u t effects of s u b s t a n c e use t h a t s e e m positive, n o t just t h o s e t h a t s e e m negative. T h e y t h e n role play h o w to r e s p o n d to situations, a n d they receive a five-session b o o s t e r p r o g r a m t h e following year (Falco, 1992; J o h n s o n , P e n t z , & W e b e r , 1990; P e n t z , D w y e r , 8c M a c k i n n o n , 1989; P e n t z , T r e b o w , 8c H a n s e n , 1990). T h e p r o g r a m also e m p h a s i z e s s c h o o l a n d c o m m u n i t y i n v o l v e m e n t , s u c h as c o n v i n c i n g c o n v e n i e n c e s t o r e o w n e r s n o t t o sell alcohol t o h i g h s c h o o l s t u d e n t s (Falco, 1992). T h e following sections focus o n four p r i n c i p l e s t h a t can g u i d e t h e d e s i g n of c o m p r e h e n s i v e h e a l t h c a m p a i g n s g e a r e d t o y o u n g p e o p l e . E a c h section discusses a variety of considerations involved in taking a d e v e l o p m e n t a l a p p r o a c h t o m e s s a g e design, w h i c h h a v e b e e n s u m m a r i z e d for q u i c k r e f e r e n c e in t h e A p p e n d i x following this c h a p t e r . I m p o r t a n t issues affected b y t h e age of t h e m e s s a g e recipient i n c l u d e : relevant risk factors t o target; c h i l d r e n ' s o r i e n t a t i o n s t o w a r d h e a l t h ; t h e credibility of v a r i o u s i n f o r m a t i o n s o u r c e s ; t h e relative influence of parents, peers, media, a n d others; i m p o r t a n t s o u r c e s of m o t i v a t i o n ; effective t e a c h i n g strategies, tactics, a n d m e d i a c h a n n e l s ; u n d e r s t a n d i n g of the motives behind broadcast p r o g r a m m i n g a n d advertising; t e c h n i q u e s for a t t r a c t i n g c h i l d r e n ' s a n d a d o l e s c e n t s ' a t t e n t i o n ; h o w a n d h o w well y o u n g p e o p l e u n d e r s t a n d c a m p a i g n messages; t h e d e v e l o p m e n t of inferential abilities; t h e d e v e l o p m e n t of s k e p t i c i s m t o w a r d m e s sages; a n d t h e ability t o i n t e g r a t e e l e m e n t s of a m e s s a g e .

P R I N C I P L E 1: B E G I N P R E V E N T I O N EARLIER Generally, h e a l t h c a m p a i g n s focus o n o n e or m o r e of t h r e e goals. T h e first ( p r e v e n t i o n ) a i m s to delay or p r e v e n t e x p e r i m e n t a t i o n a n d p r o m o t e wellness; t h e s e c o n d ( m o d e r a t i o n ) strives t o d e v e l o p strategies t h a t l i m i t h e a l t h e n d a n g e r i n g b e h a v i o r t o a safer level, such as t h e d e s i g n a t e d d r i v e r c o n c e p t ; a n d t h e t h i r d ( i n t e r v e n t i o n ) focuses o n r e d u c i n g h a b i t u a l a c t i o n s t h a t a r e h e a l t h e n d a n g e r i n g , such as d r i n k i n g a n d s m o k i n g t o g e t h e r (Jessor, 1982). A l t h o u g h p r e v e n t i o n can b e t h e least costly c a m p a i g n , b o t h in e c o n o m i c

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a n d social t e r m s (Falco, 1992), it n e e d s t o b e g i n s u r p r i s i n g l y early, b e c a u s e c h i l d r e n b e g i n l e a r n i n g a b o u t h e a l t h issues f r o m b i r t h . W e l l b e f o r e c h i l d r e n can drive a car, swig a b e e r , o r s m o o c h i n a m o v i e theater, they learn h o w a n d why people d o these things by observing family, peers, o t h e r individuals, a n d the m e d i a ( B a n d u r a , 1986; C h r i s t i a n s e n , G o l d m a n , 8c I n n , 1982; M c C a r t h y , 1985; R o b e r t s , 1989; W a l l a c k , C a s s a d y , 8c G r u b e , 1990). By 4 m o n t h s of age, for e x a m p l e , t h e y a l r e a d y p e r c e i v e cigarettes in t h e i r e n v i r o n m e n t (Barie 8c Fischer, 1979). T h e y c a n n o t c h o o s e n u t r i t i o u s foods o r r e a c h for a cigarette, b u t even infants i m i t a t e televised m o d e l s ( B a n d u r a , 1986; H o l l e n b e c k 8c Slaby, 1979). By 18 m o n t h s , c h i l d r e n learn "strategically" ( G e l m a n 8c B r o w n , 1986), a n d b y age 2 t h e y w a t c h television p u r p o s e f u l l y , i n c l u d i n g a n e s t i m a t e d 3 h o u r s of a d v e r t i s i n g p e r w e e k (Adler et a l , 1979). As a result, a few p r e v e n t i o n p r o g r a m s t a r g e t i n f a n t s as y o u n g as 3 m o n t h s (e.g., Steele, 1989), focusing o n self a w a r e n e s s , c o m m u n i c a t i o n a n d b o n d i n g , p r o b l e m solving, a n d t h e d e v e l o p m e n t of h e a l t h y perspectives. As c h i l d r e n b e c o m e a w a r e of n e e d s , t h e y seek ways of r e s o l v i n g t h e m , developing attitudes surprisingly early that can predict later b e h a v i o r ( G l y n n , Leventhal, 8c H i r s c h m a n , 1985; Kandel 8c Logan, 1984; K a n d e l 8c Y a m a g u c h i , 1985). E x p e c t a n c i e s for alcohol, " i f - t h e n " beliefs c o n c e r n i n g t h e p e r c e i v e d physical a n d social c o n s e q u e n c e s of d r i n k i n g , h a v e b e e n f o u n d as early as first g r a d e (Miller, S m i t h , 8c G o l d m a n , 1989). M o r e o v e r , t h e s e e x p e c t a n c i e s h a v e b e e n s h o w n t o p r e d i c t alcohol use ( C h r i s t i a n s e n 8c G o l d m a n , 1983; G o l d m a n , B r o w n , 8c Christiansen, 1987). Because earlier use of m i n d - a l t e r i n g s u b s t a n c e s creates a m o r e d a n g e r o u s a n d difficult p r o b l e m ( B a r r i n g e r , 1990; C o n r o y , 1988), it is i m p o r t a n t t o delay initial use ( R o b i n s 8c P r y z b e c k , 1985). F o r t u n a t e l y , well before c h i l d r e n b e g i n e x p e r i m e n t i n g w i t h d a n g e r o u s substances a n d u n p r o t e c t e d sex, p r e v e n t i o n p r o g r a m s can identify a n d t a r g e t p r e d i c t i v e risk factors. As s u m m a r i z e d in t h e A p p e n d i x , d a n g e r signs i n c l u d e u n d e r a c h i e v e m e n t as early as first grade a n d m a r k e d l y antisocial b e h a v i o r s u c h as " a c t i n g o u t " b e f o r e age 10 ( G o r d o n 8c McAlister, 1982; N a t i o n a l I n s t i t u t e o n D r u g A b u s e [ N I D A ] , 1988). O t h e r factors i n c l u d e m a l e aggressiveness, especially c o m b i n e d w i t h shyness (Kellam 8c B r o w n , 1982); l o w e x p e c t a t i o n s ; l o w resistance t o p e e r influences; a lack of p a r e n t a l s u p p o r t ; a n d a generally d e p r i v e d e n v i r o n m e n t ( D r y f o o s , 1990). U n f o r t u n a t e l y , i n t e r v e n t i o n also n e e d s t o begin early. O n e n a t i o n a l s t u d y ( P R I D E , 1992) r e p o r t e d 1 5 % of sixth g r a d e c h i l d r e n u s e d b e e r b e f o r e age 10. T h e M o k u l e l e E l e m e n t a r y School in H a w a i i l a u n c h e d a c o m p r e h e n s i v e p r o g r a m after a s t u d e n t s u r v e y s h o w e d t h a t 6 6 % of t h e sixth g r a d e r s h a d c o n s u m e d a l c o h o l a n d 2 3 % h a d t r i e d o t h e r d r u g s ( " S o l u t i o n s , " 1993). M o r e

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APPROACHES

t h a n half of t h e c h i l d r e n w h o b e c o m e daily s m o k e r s d o so b e f o r e o r d u r i n g n i n t h g r a d e (McAlister, 1981). A t t i t u d e s t o w a r d d r i n k e r s a r e e s t a b l i s h e d b y age 6 (Spiegler, 1983), although still in flux. Six-year-olds w h o k n o w t h e signs o f d r u n k e n n e s s ( J a h o d a 8c C r a m o n d , 1972) a n d u n d e r s t a n d social n o r m s a b o u t d r i n k i n g ( Z u c k e r , 1979) d o n o t yet h a v e s t r o n g p e r s o n a l o p i n i o n s . B e c a u s e c h i l d r e n m a y n o t view d r i n k e r s negatively, great p o t e n t i a l exists for b o t h positive a n d negative influences, c r e a t i n g a n e e d a n d a n o p p o r t u n i t y for early i n t e r v e n t i o n (Spiegler, 1983). T h e l i k e l i h o o d of i m p r o v i n g a child's e n v i r o n m e n t also is h i g h e r w h e n a d d r e s s e d early. As K a s s e b a u m (1990) n o t e s , p a r e n t s of y o u n g c h i l d r e n often a r e m o r e h o p e f u l a n d flexible, w h e r e a s p a r e n t s m a y h a v e given u p o n a n o l d e r , difficult child. In a d d i t i o n , b y a d o l e s c e n c e m a n y risk factors a n d p e e r g r o u p s are well e n t r e n c h e d a n d m a n y y o u n g p e o p l e difficult t o r e a c h . T h i s d o e s n o t m e a n t h e c a m p a i g n e r s h o u l d give u p o n t h e o l d e r child, of c o u r s e , b u t it d o e s m e a n t h a t strategies will n e e d t o c h a n g e a n d i m p r o v e m e n t s likely will b e m o r e g r a d u a l .

P R I N C I P L E 2: M I C R O T A R G E T T O AGE A N D E N V I R O N M E N T A L DIFFERENCES As c h i l d r e n d e v e l o p cognitive a n d physical skills, t h e y l e a r n n e w t h i n g s in n e w ways. Stage t h e o r i e s of child d e v e l o p m e n t h a v e b e e n largely rejected, b u t scholars still p o i n t to possible "critical p e r i o d s " w h e n m a j o r skills c o m e i n t o place a n d n e w k i n d s of decisions a r e b e i n g m a d e . T h u s , t o assist t h e design of d e v e l o p m e n t a l l y a p p r o p r i a t e messages, this c h a p t e r a n d t h e A p p e n d i x a r e o r g a n i z e d b y age ranges identified as critical p e r i o d s in d e v e l o p m e n t . E a c h p e r i o d r e p r e s e n t s a distinct c o n t e x t for h e a l t h p r o m o t i o n , c o n s i s t i n g o f c h a n g e s in m o t i v a t i o n s , i n f o r m a t i o n p r o c e s s i n g , a n d i n t e r a c t i o n s w i t h e n v i r o n m e n t a l influences. As t h e A p p e n d i x s h o w s , for e x a m p l e , w e all strive for r e w a r d s ( B a n d u r a , 1986), w h i c h w e can receive from o t h e r s , e x p e r i e n c e vicariously b y w a t c h i n g o t h e r s s u c h as o n television, o r a w a r d o u r s e l v e s from w i t h i n ( H e a t h 8c Bryant, 1992). B u t y o u n g e r c h i l d r e n are less able t o r e w a r d t h e m s e l v e s , seeking i n s t e a d r e w a r d s from o t h e r s a n d striving t o a v o i d negative, often physical, c o n s e q u e n c e s ( K o h l b e r g , 1976).

The Age

Groups

Preschoolers (0-5). It is in t h e p r e s c h o o l p e r i o d t h a t a child b e g i n s t o b e c o m e a w a r e of h e a l t h a t t i t u d e s a n d b e h a v i o r s . C h i l d r e n d o n o t yet u n d e r -

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s t a n d h e a l t h as a c o n c e p t b u t nevertheless a r e l e a r n i n g a n d i m i t a t i n g w h a t t h e y see, p a r t i c u l a r l y at h o m e . A w a r m a n d s t i m u l a t i n g e n v i r o n m e n t is t h e i r m o s t b a s i c n e e d , t o h e l p t h e m d e v e l o p a positive self-image a n d b a s i c social a n d c o g n i t i v e skills. Early School Age (5-7). T h e j u m p from preschool t o school age m a r k s o n e critical p e r i o d of c o n c e r n . At t h i s age c h i l d r e n b e g i n t o d e v e l o p p e e r g r o u p s a n d m u s t deal w i t h n e w s o u r c e s of influence (e.g., t e a c h e r s ) , n e w roles, a n d p r e s s u r e t o fit sex roles ( H i g g i n s 8c P a r s o n s , 1983). T h e y a r e b e g i n n i n g t o u n d e r s t a n d t h a t p e r s p e c t i v e s o t h e r t h a n t h e i r o w n exist (Flavell, M i l l e r , 8c Miller, 1993) a n d can take a n o t h e r ' s perspective with help ( G e l m a n 8c B r o w n , 1 9 8 6 ) . As a r e s u l t , t h e y c a n u n d e r s t a n d o t h e r p e o p l e ' s i n t e n t i o n s w h e n d e s c r i b e d clearly, s u c h as t h r o u g h p i c t u r e s i n s t e a d of w o r d s ( C h a n d l e r , G r e e n s p a n , 8c B a r e n b o i m , 1973). T h e y have developed a keen interest in c a u s e a n d effect ( G e l m a n 8c B r o w n , 1986) a n d r e s p o n d well b y age 5-7 t o m o r a l i t y labels a n d c o n v e n t i o n a l rules ( K o h l b e r g , 1976). Middle Childhood (7-10). A n o t h e r possibly critical age occurs a r o u n d 7-10. At this p o i n t c h i l d r e n n o l o n g e r a u t o m a t i c a l l y a c c e p t p a r e n t a l a u t h o r i t y , increasingly a c c e p t p e e r values a n d t h o s e of slightly o l d e r c h i l d r e n p e r c e i v e d as role m o d e l s , b e t t e r u n d e r s t a n d s y m b o l s a n d m e t a p h o r s in m e s s a g e s , a n d can better express themselves (Miller et al., 1989; W o r t h 8c Gross, 1974). T h e y also b e g i n t o establish friendships b a s e d o n a d m i r a t i o n of a n o t h e r ' s d i s p o s i t i o n s o r traits ( H i g g i n s 8c P a r s o n s , 1983). Early Adolescence (10-13). A t h i r d critical p e r i o d o c c u r s a r o u n d t h e transition from middle school or junior high school to high school. N o w adolescents are t h r o w n into situations that expose t h e m to a wider variety o f p e o p l e . By this t i m e t h e y a r e g o o d at u n d e r s t a n d i n g p e r s p e c t i v e a n d i n t e n t ( C h r i s t e n s o n 8c R o b e r t s , 1990; Flavell et al., 1993; H i g g i n s 8c P a r s o n s , 1983), w h i c h m a k e s t h e i r w o r l d infinitely m o r e c o m p l i c a t e d . T h e y m u s t n e g o t i a t e t h e i r w a y t h r o u g h a p e r i o d of e n o r m o u s u n c e r t a i n t y t h a t leads t o i n t e n s e i n f o r m a t i o n seeking, m e d i a use, a n d e x p e r i m e n t a t i o n ( B a u m r i n d , 1985; R o b e r t s , 1 9 7 1 , 1973; S c h r a m m , 1965). Mid- to Late Adolescence (13-16,16+). F r o m mid-adolescence o n , c h i l d r e n focus o n a c h i e v i n g i n d e p e n d e n c e b y f o r m i n g a n i d e n t i t y , d e v e l o p i n g a p o s i t i v e b o d y i m a g e , d e v e l o p i n g a n i n n e r c o n s c i e n c e , d e f i n i n g sex roles a n d l e a r n i n g a b o u t cross-sex r e l a t i o n s h i p s , p r e p a r i n g for f u t u r e family a n d civic roles, a n d d e v e l o p i n g m o r e s o p h i s t i c a t e d p r o b l e m - s o l v i n g capabilities

120

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( C h r i s t e n s o n 8c R o b e r t s , 1990; K o h l b e r g , 1976). I n t h e m e a n t i m e , t h e y still realize t h a t ultimately teachers, counselors, p a r e n t s , a n d o t h e r adults are still in c h a r g e . T o avoid s e e m i n g d e p e n d e n t or c o n t r o l l e d b y a d u l t s , t h e y t e n d t o reject explicit a c c e p t a n c e or a p p r o v a l of a d u l t - s p o n s o r e d interests ( B a u m r i n d , 1985). N o w b e y o n d s i m p l e physical r e w a r d s a n d p u n i s h m e n t s b u t n o t yet fully able to r e w a r d themselves from w i t h i n , a d o l e s c e n t s seek social r e w a r d s a n d strive t o avoid social t h r e a t s (Pfau 8c V a n B o c k e r n , 1993; S c h o e n b a c h l e r , 1993).

Targeting

Different

Age

Groups

Targeting the Preschooler. A l t h o u g h a t t i t u d e s a n d risk factors a l r e a d y are d e v e l o p i n g in p r e s c h o o l e r s , c h i l d r e n this y o u n g are n o t r e a d y for c a m p a i g n messages e m p h a s i z i n g abstractions such as cause, hypothetical dangers, inferences, o r p e r s o n a l feelings as m o t i v a t i o n s for h e a l t h b e h a v i o r ( B a u m r i n d , 1985). Failing t o see g o o d a n d ill h e a l t h as a c o n t i n u u m ( H a w k i n s , L i s h n e r , 8c C a t a l a n o , 1985), y o u n g c h i l d r e n focus m o r e o n wellness t h a n o n illness ( B u s h 8c I a n o t t i [1985] discussing p a p e r b y V o g t , L i e b e r m a n , I v e r s o n , 8c W a l t e r , 1983). C a m p a i g n s for p r e s c h o o l c h i l d r e n n e e d t o e m p h a s i z e t h e positive, s u c h as w h a t k i n d s of things are g o o d t o p u t i n t o o u r b o d i e s , g e n e r a l skill d e v e l o p m e n t , a n d t h e d e v e l o p m e n t of a s u p p o r t i v e e n v i r o n m e n t . P r o g r a m s for y o u n g c h i l d r e n n e e d t o b e e x p e r i e n t i a l r a t h e r t h a n "acad e m i c . " BABES ( 1 9 7 8 ) — B e g i n n i n g A l c o h o l 8c A d d i c t i o n s Basic E d u c a t i o n S t u d i e s — f o r e x a m p l e , teaches cognitive a n d i n t e r p e r s o n a l p r o b l e m - s o l v i n g skills (Spivak 8c Shure, 1982) via g a m e playing, songs, a n d p u p p e t s . T h e p r o g r a m h e l p s c h i l d r e n identify p r o b l e m s , helps t h e m l e a r n a b o u t self-image a n d feelings, teaches c o p i n g skills, a n d s h o w s t h e m h o w t o get h e l p . Because y o u n g c h i l d r e n are so d e p e n d e n t o n t h e i r caregivers, p a r e n t a n d t e a c h e r t r a i n i n g is especially i m p o r t a n t t o i n c l u d e . M a n y scholars r e c o m m e n d h e l p i n g p a r e n t s d e v e l o p g o o d family c o m m u n i c a t i o n skills, p o s i t i v e p a r e n t i n g styles, a n d k n o w l e d g e a b o u t risk factors a n d p r o t e c t i v e factors ( K a s s e b a u m , 1990; K u m p f e r 8c D e M a r s h , 1984). T h e BABES p r o g r a m , for e x a m p l e , p r o v i d e s special assistance t o families w i t h c u r r e n t p r o b l e m s a n d provides training a n d s u p p o r t g r o u p s for parents. A l t h o u g h l o n g - t e r m evalua t i o n is difficult t o p e r f o r m , this t y p e of p r o g r a m s h o w s m u c h p r o m i s e . T h e P e r r y P r e s c h o o l P r o g r a m , w h i c h helps p a r e n t s w i t h family m a n a g e m e n t a n d i n c l u d e s w e e k l y h o m e visits, h a s successfully p r e d i c t e d fewer a d o l e s c e n t p r e g n a n c i e s ( B e r r u e t a - C l e m e n t , S c h w e i n h a r t , B a r n e t t , 8c W e i k h a r d , 1983).

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Targeting in Early School Age and in Middle Childhood. D u r i n g t h e early s c h o o l age a n d m i d d l e c h i l d h o o d p e r i o d c h i l d r e n b e g i n t o d e v e l o p p a t t e r n s o f success o r failure, b o t h academically a n d socially. As a result, c a m p a i g n s m u s t b e g i n b y assisting w i t h cognitive a n d social skill d e v e l o p m e n t a n d b y i n c l u d i n g stress r e d u c t i o n t r a i n i n g t o teach c h i l d r e n h o w t o h a n d l e frustrat i o n ( M u r r a y 8c Perry, 1985). U n t i l children can m a s t e r basic skills, s u c h as starting a conversation a n d h o w t o act w h e n s o m e o n e is r u d e to t h e m , t h e h e a l t h e d u c a t o r c a n n o t b e g i n t o a d d r e s s t o u g h e r issues s u c h as h o w t o "say n o " t o sexual o v e r t u r e s o r p r e s s u r e t o use d r u g s (Botvin, 1990). C h i l d r e n believe this is a g o o d p e r i o d for c l a s s r o o m - b a s e d i n s t r u c t i o n , r e c o m m e n d i n g p r e s e n t a t i o n s , c o u n s e l o r s , a n d o u t s i d e s p e a k e r s (Billings, B u r t o n , M e r t e n s , 8c Strong, 1993). An informal teaching style is best, f e a t u r i n g a g r a d u a l transfer o f responsibility t o s t u d e n t s t h r o u g h " n a t u r a l t u t o r i n g " ( P a l i n c s a r 8c B r o w n [1984] as reviewed b y G e l m a n 8c B r o w n , 1986). As c h i l d r e n b e c o m e c o m f o r t a b l e w i t h each challenge p r e s e n t e d a n d m o d e l e d b y a t e a c h e r a n d t h e n p r a c t i c e d b y t h e c h i l d r e n , t h e r e s p o n s i b i l i t y for l e a r n i n g is t r a n s f e r r e d t o t h e s t u d e n t , instilling b o t h t h e n e w skill a n d a s e n s e of confidence a n d control. By taking t u r n s as a discussion leader, for e x a m p l e , c h i l d r e n c a n h e l p m o d e l refusal strategies o r p i n p o i n t w e a k n e s s e s in a p e r s u a s i v e m e s s a g e , i n c r e a s i n g t h e i r o w n c o n f i d e n c e in t h e skill. A l t h o u g h t h e h o m e e n v i r o n m e n t r e m a i n s a n i m p o r t a n t factor at this age, a n d families a r e still frequently cited as a r e s o u r c e b y sixth g r a d e r s (Billings et al., 1993), peers are gaining in influence. As a result, peer l e a d e r s — w h o can b e t h e s a m e a g e — a l s o a r e a useful t o o l ( P e r r y 8c Jessor, 1985). P e e r d i s c u s s i o n , for e x a m p l e , h a s h e l p e d s t u d e n t s r e d u c e s m o k i n g ( P e t e r s o n 8c C l a r k , 1986). T h e d a n g e r of d i s c u s s i o n t e c h n i q u e s , h o w e v e r , is t h a t c h i l d r e n can b e h e s i t a n t t o a p p e a r u n k n o w l e d g a b l e o r v u l n e r a b l e in f r o n t of t h e i r p e e r s . A less t h r e a t e n i n g d i s c u s s i o n f o r m a t , s u c h as w a t c h i n g similar c h i l d r e n a s k i n g t h e difficult q u e s t i o n s via t h e m a s s m e d i a , as well as i n t e r a c t i v e m e d i a in a m o r e p r i v a t e setting s u c h as b y v i d e o g a m e , c a n p r o v e helpful as a result. By m i d d l e c h i l d h o o d , c h i l d r e n v o r a c i o u s l y c o n s u m e m a s s m e d i a , i n c l u d ing television, r a d i o , a n d — b y a b o u t age 9 o r 1 0 — m a g a z i n e s . By t h i r d o r f o u r t h g r a d e , c h i l d r e n a r e q u i t e i n t e r e s t e d in r a d i o , w h i c h is p e e r c e n t e r e d (Christenson, DeBenedittis, 8c Lindloff, 1985), b y adolescence they are listeni n g 2-5 h o u r s a day. C h i l d r e n at this age also are at t h e i r p e a k of television w a t c h i n g (Lyle 8c H o f f m a n , 1972; V a n d e r V o o r t , 1986), w h i c h t h e y t e n d t o d o m o r e w i t h family ( C h r i s t e n s o n et al., 1985). As a result, as t h e A p p e n d i x s h o w s , c a m p a i g n s c a n m a k e g o o d use of t h e m a s s m e d i a t o t e a c h facts a n d social n o r m s , b u t t h e y also n e e d t o a d d r e s s t h e c o u n t e r - m e s s a g e s p r e s e n t in

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m u c h p r o g r a m m i n g a n d advertising. C h i l d r e n a p p e a r to b e v u l n e r a b l e t o televised p o r t r a y a l s of n o r m s s u r r o u n d i n g h e a l t h issues. Y o u n g c h i l d r e n , especially t h o s e y o u n g e r t h a n a b o u t age 8, for e x a m p l e , are n o t as g o o d at u n d e r s t a n d i n g the persuasive intent of commercials (Blosser 8c R o b e r t s , 1985), a n d c h i l d r e n y o u n g e r t h a n 5 o r 6 often confuse a d s a n d p r o g r a m s ( W a r d 8c W a c k m a n , 1973). B u t l e a r n i n g t h e i n t e n t i o n s b e h i n d ads a n d p r o g r e s s i n g t o w a r d disbelief m a y n o t b e e n o u g h t o p r o t e c t child r e n f r o m a l c o h o l a d s ' a p p e a l s ( A u s t i n 8c N a c h - F e r g u s o n , 1995; Jeffrey, McLellarn, 8c Fox, 1982). Teenagers overwhelmingly r e p o r t t h a t even t h o u g h t h e y k n o w a d s m a k e d r i n k i n g l o o k b e t t e r t h a n it really is t h e y n e v e r t h e l e s s r e s p o n d t o t h e a d v e r t i s e m e n t s (Billings et a l , 1993), a self-diagnosis s u p p o r t e d b y o t h e r research (e.g., A t k i n , H o c k i n g , 8c Block, 1984; A u s t i n 8c Meili, in p r e s s ) . T h u s , m e d i a literacy skills n e e d t o b e i n c l u d e d in c a m p a i g n s (e.g., A u s t i n 8c N a c h - F e r g u s o n , 1995; G r u b e , 1993). Targeting the Early Adolescent. M i d d l e school a n d j u n i o r h i g h r e p r e s e n t a last chance for c a m p a i g n designers to reach m a n y at-risk y o u t h in a t r a d i t i o n a l setting, b e c a u s e at-risk y o u t h t e n d t o b e g i n d r o p p i n g o u t of s c h o o l . At this t i m e , c o g n i t i v e skills are fairly s o p h i s t i c a t e d a n d m o s t a t - r i s k c h i l d r e n h a v e n o t yet given u p a n d d r o p p e d o u t (Falco, 1992). At-risk generally refers t o a child f r o m a d i s a d v a n t a g e d e n v i r o n m e n t , s u c h as l o w i n c o m e , c r i m e - r i d d e n areas, o r from a family in w h i c h a m e m b e r abuses a s u b s t a n c e ( K a s s e b a u m , 1990), factors t h a t t e n d t o c o n t r i b u t e t o a loss of h o p e in t h e f u t u r e (Ezekoye, K u m p f e r , 8c Bukosi, 1985; H u r s t - P a l e r m o , 1992). A m o n g 10- t o 17-yearo l d s , D r y f o o s (1990) h a s e s t i m a t e d o n e in four t o b e at risk for m u l t i p l e problem behaviors. T h e m e s s a g e designer, h o w e v e r , m u s t r e m e m b e r t h a t t h e o t h e r t h r e e of e a c h four also m a y e x p e r i m e n t w i t h risky b e h a v i o r s s u c h as d r u g use b u t will n o t c o n t i n u e past a b o u t age 2 3 ( K u m p f e r , 1986; Y a m a g u c h i 8c K a n d e l , 1984). As B a u m r i n d (1985) notes, m e r e e x p e r i m e n t a t i o n is typical a n d develo p m e n t a l l y n o r m a l . C a m p a i g n s i m p l y i n g t h a t risk takers a r e d e v i a n t can p r o d u c e a self-fulfilling p r o p h e c y , especially a m o n g t h o s e w h o a l r e a d y h a v e lost h o p e for themselves ( B a u m r i n d , 1985). T h u s , o v e r r e a c t i o n b y a d u l t s c a n b a c k f i r e ( K u m p f e r , 1986; T o b l e r , 1986; Y a m a g u c h i 8c K a n d e l , 1 9 8 4 ) . K a s s e b a u m (1990) also r e c o m m e n d s a v o i d i n g h e t e r o s e x i s m , b e c a u s e h i g h e r risk b e h a v i o r is m o r e c o m m o n a m o n g h o m o s e x u a l p o p u l a t i o n s ; c a m p a i g n s n e e d t o c o m b a t , n o t exacerbate, c u l t u r a l stereotypes t h a t c o n t r i b u t e t o t h e i r feelings of failure. In early a d o l e s c e n c e , c h i l d r e n still t u r n to family, b u t t h e y o v e r w h e l m ingly credit s c h o o l w i t h t e a c h i n g t h e m t h e m o s t a b o u t d r u g s a n d d r i n k i n g

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(Billings et a l , 1993). A d o l e s c e n t s t e n d t o o v e r e s t i m a t e t h e p r e v a l e n c e of d r u g use a n d rarely discuss it with each o t h e r (Falco, 1992). As a result, c a m p a i g n s n e e d t o t e a c h facts; c o r r e c t m i s p e r c e p t i o n s ; a n d a d d r e s s t h e m y r i a d o f m e d i a , family, a n d p e e r influences faced b y t h e a d o l e s c e n t . T h e S T A R ( S t u d e n t s T a u g h t A w a r e n e s s a n d Resistance) p r o g r a m , for e x a m p l e , t e a c h e s resistance skills in j u n i o r h i g h via 13 sessions t h a t i n c l u d e d i s c u s s i o n , r o l e p l a y i n g , a n d a five-session b o o s t e r p r o g r a m t h e following year (Falco, 1992; J o h n s o n et a l , 1990; P e n t z et al., 1989; P e n t z et al., 1990). L o n g - t e r m r e i n f o r c e m e n t b e c o m e s especially i m p o r t a n t as societal p r e s sures t o t a k e risks b e c o m e m o r e i n t e n s e . Even w i t h t h e S T A R p r o g r a m , l a u d e d as o n e o f t h e m o s t successful p r o g r a m s in t h e c o u n t r y , g a i n s t e n d t o s h r i n k w i t h t i m e . O n e w a y t o reinforce lessons o v e r a l o n g e r p e r i o d of t i m e is t o give t e a c h e r s " o w n e r s h i p " of t h e p r o g r a m b y t r a i n i n g t h e m t o i n t r o d u c e d i s c u s s i o n of a l c o h o l a n d o t h e r d r u g s i n t o daily activities. T e a c h e r s t h u s can r e i n f o r c e lessons o v e r t i m e a n d in a variety of c o n t e x t s (Fagin 8c S a u e r [ 1990] as r e v i e w e d b y Falco, 1992). D e c i s i o n - m a k i n g skill d e v e l o p m e n t , for e x a m ple, w h i c h h e l p s y o u n g p e o p l e weigh o p t i o n s , goals, a n d u n c e r t a i n t y , c a n b e applied to nearly any topic. Helping children develop good decision-making skills is of t h e u t m o s t i m p o r t a n c e b e c a u s e t h e y will find t h a t p r e v e n t i o n messages often p r o v i d e conflicting advice (Fischhoff, 1993). M e d i a messages for t h i s age g r o u p s h o u l d m a k e u s e o f r a d i o , television, a n d t e e n o r s p o r t s m a g a z i n e s , focusing o n t e a c h i n g facts, d i s p r o v i n g m y t h s , a n d a d v o c a t i n g moderation. Targeting the Mid- to Late Adolescent. By m i d - t o late a d o l e s c e n c e a great d e a l of e x p e r i m e n t a t i o n is t a k i n g place, so c a m p a i g n s n e e d t o e m p h a s i z e m o d e r a t i o n a n d i n t e r v e n t i o n m o r e t h a n p r e v e n t i o n . A d o l e s c e n t s seek s o l u t i o n s , n o t p r e a c h i n g , a n d t h e y w a n t t o b e p a r t of t h e s o l u t i o n r a t h e r t h a n v i e w e d o n l y as t h e p r o b l e m ( W a s h i n g t o n State Association of B r o a d c a s t e r s [ W S A B ] , 1990). T h e y n e e d t o h e a r messages f r e q u e n t l y t o c o u n t e r b a l a n c e t h e f r e q u e n t p r e s s u r e s t h e y face, b u t t h e y t h i n k n e w s stories e x a g g e r a t e a n d m o s t PSAs a r e silly ( W S A B , 1990). M a s s m e d i a b e c o m e a m o r e i m p o r t a n t t o o l for this age g r o u p , b e c a u s e t h e m o s t at-risk y o u t h are already o u t of school a n d o n the streets. Mass m e d i a that m a y reach t h e m include heavy metal radio stations, afternoon soap operas, Oprah, M T V a n d micro-targeted cable, teenage radio stations, s u b w a y a d s , a n d p o s t e r s at h a n g o u t s s u c h as v i d e o a r c a d e s a n d malls ( C h r i s t e n s o n 8c R o b e r t s , 1990; K a s s e b a u m , 1990). H a w k i n s a n d colleagues ( 1 9 8 5 ) r e c o m m e n d u s i n g local s p o r t s h e r o e s , p o p u l a r d r u g - f r e e celebrities, a n d o l d e r p e e r s , b u t e x p l o i t a t i o n of celebrities can backfire: T e e n a g e r s r e p o r t t h a t

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celebrities' m o t i v e s are suspect, t h a t r o c k stars are hypocritical, a n d t h a t t o o m a n y athletes h a v e " m e s s e d u p " (WSAB, 1990). S o m e a d o l e s c e n t s r e s p o n d to their n e e d for " s e n s a t i o n , " or e x c i t e m e n t , b y u s i n g m o r e d r u g s a n d u s i n g t h e m earlier ( D o n o h e w , 1988; D o n o h e w , L o r c h , 8 c P a l m g r e e n , 1993). U n h e a l t h y o r risky b e h a v i o r for 14- t o 16-yearo l d s also correlates w i t h m o r e r a d i o use, m o r e use of m u s i c v i d e o , a n d m o r e T V m o v i e s . As a result, use of these m e d i a t o p r o d u c e n o v e l , d r a m a t i c , a n d s t i m u l a t i n g m e s s a g e s c a n m o t i v a t e s e n s a t i o n s e e k e r s t o call a h o t l i n e ( P a l m g r e e n et a l , 1993), w h i c h — a f t e r p e e r s — i s t h e m o s t p r e f e r r e d s o u r c e of i n f o r m a t i o n for this age g r o u p (Billings et al., 1993). Effective messages a c k n o w l e d g e t h e n a t u r a l appeals of d a n g e r o u s h e a l t h b e h a v i o r s ("you p r o b ably t h i n k y o u ' l l seem m o r e g r o w n u p o r a d v e n t u r o u s " ) a n d t h e n refute t h e m , s h o w i n g h o w to achieve similar goals via realistic a n d a p p e a l i n g b e h a v i o r a l alternatives (Tobler, 1986). A m a s s m e d i a c a m p a i g n , h o w e v e r , serves m o r e as a catalyst t o d i r e c t a d o l e s c e n t s t o s o u r c e s of h e l p (such as 1-800 n u m b e r s ) t h a n as a s o l u t i o n t o a n y p r o b l e m . T h e m a j o r effect of m a s s m e d i a t e n d s t o b e m o r e c o m m u n i c a t i o n (Chaffee, 1982; C h r i s t e n s o n 8c R o b e r t s , 1990). A c o m p e t i t i o n for s o n g w r i t e r s in Latin A m e r i c a t o p r o m o t e sexual a b s t i n e n c e a m o n g t e e n a g ers, for e x a m p l e , e n c o u r a g e d teens t o talk m o r e freely a n d o p e n l y a b o u t s e x - r e l a t e d issues. T h e c a m p a i g n r e i n f o r c e d t e e n s w h o a l r e a d y w a n t e d t o u s e r e s t r a i n t a n d sensitized y o u n g e r t e e n s t o t h e i m p o r t a n c e of t h e t o p i c (Singhal 8c Rogers, 1989). A similar A m e r i c a n c a m p a i g n (Rock Against D r u g s [ R A D ] , 1988) also m a y p r o v e effective in this way.

P R I N C I P L E 3: MAKE SURE C O N S I S T E N T M E S S A G E S C O M E F R O M A VARIETY O F SOURCES A N D OVER A LONG PERIOD OF T I M E D e s p i t e t h e m a n y differences in strategy r e q u i r e d for t a r g e t i n g c h i l d r e n at v a r i o u s d e v e l o p m e n t a l p e r i o d s , t h e c o m m o n t h r e a d is t h a t n o o n e - s h o t m e s s a g e f r o m a n y single s o u r c e can d o t h e j o b . I n t e r p e r s o n a l s o u r c e s u l t i m a t e l y a r e m o r e i m p o r t a n t t h a n t h e m e d i a , b u t t h e relative p o w e r of e a c h p r i m a r y i n f l u e n c e r — m a s s m e d i a , family, a n d p e e r s — w i l l c h a n g e , as will strategies t h a t m a x i m i z e t h e i r influence. A t a d o l e s c e n c e , for e x a m p l e , c h i l d r e n m o v e a w a y f r o m p a r e n t s t o w a r d peers as sources of attitudes a n d values (Glynn, 1981; Lull, 1985). At n o p o i n t a r e c h i l d r e n w h o l l y i n f l u e n c e d b y peers o r family, h o w e v e r , a n d a c c e p t a n c e o f o n e influence d o e s n o t m e a n rejection of t h e o t h e r . S o u r c e s of i n f l u e n c e can differ d e p e n d i n g o n t h e s i t u a t i o n ( K a n d e l , Kessler, 8c M a r g u l i e s , 1978)

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a n d a c r o s s types of s u b s t a n c e s ( G l y n n , 1981). W h e r e s t r o n g i n t e r p e r s o n a l s o u r c e s d o n o t exist, m a s s m e d i a fill t h e gap. Mass Media as an Influence. C h i l d r e n t e n d t o l e a r n f r o m w h a t t h e y see b u t i m i t a t e o n l y w h a t t h e y see r e w a r d e d ( B a n d u r a , 1986; B a n d u r a , Ross, 8c R o s s , 1963). T h u s , d e s p i t e society's f r e q u e n t c o n d e m n a t i o n s of television, p r o s o c i a l m e d i a messages t e n d t o h a v e a s t r o n g e r effect t h a n antisocial o n e s ( H e a r o l d , 1986). Because television selectively amplifies a n d reinforces t e n d e n c i e s a l r e a d y p r e s e n t in society (Gitlin, 1989), it is n o t u n r e a s o n a b l e for 9- t o 15-year-olds t o r e p o r t l e a r n i n g a b o u t t h i n g s a n d t h e m s e l v e s as t h e i r m o s t c o m m o n r e a s o n for liking t o w a t c h T V ( G r e e n b e r g , 1974). H o w a n d w h a t t h e y l e a r n , h o w e v e r , c h a n g e s greatly w i t h age. A m a t u r e u n d e r s t a n d i n g of m a s s m e d i a messages r e q u i r e s t h e ability t o p a y a t t e n t i o n selectively, t o u n d e r s t a n d i m p l i c i t as well as explicit i n f o r m a t i o n , t o u n d e r s t a n d t h e p e r s p e c t i v e a n d i n t e n t i o n s of p r o g r a m d e v e l o p e r s a n d c h a r a c t e r s , a n d t o u n d e r s t a n d t h e m e a n i n g b e h i n d t e c h n i q u e s s u c h as slow m o t i o n a n d flashbacks ( D o r r , 1980; Miller et a l , 1989). A n d e r s o n a n d Collins (1988) s u r m i s e t h a t y o u n g c h i l d r e n h a v e t r o u b l e u n d e r s t a n d i n g television messages b e c a u s e p r o g r a m m i n g often is g e a r e d t o a d u l t s o r o l d e r c h i l d r e n a n d c o n t a i n s u n f a m i l i a r l a n g u a g e , s i t u a t i o n s , ideas, a n d a c t i o n s . As t h e A p p e n d i x illustrates, a d u l t levels of u n d e r s t a n d i n g — i n c l u d i n g c o m p r e h e n s i o n a n d inferential a b i l i t i e s — m a y n o t b e n o t r e a c h e d u n t i l a b o u t e i g h t h g r a d e ( C o l l i n s , 1982), a n d even a d o l e s c e n t s often m i s i n t e r p r e t ( o r a t least i n t e r p r e t in m y r i a d ways) p o p u l a r m u s i c lyrics ( C h r i s t e n s o n 8c R o b e r t s , 1990). As a result, m e s s a g e d e s i g n e r s n e e d t o u n d e r s t a n d a child's skills a n d p e r s p e c t i v e in o r d e r t o p r e p a r e m e d i a messages t h e child will u n d e r s t a n d as intended. P r e s c h o o l e r s , for e x a m p l e , p a y m o r e a t t e n t i o n t o d i a l o g u e w i t h i m m e d i ate ( h e r e - a n d - n o w ) referents ( A n d e r s o n , Lorch, Field, 8c Sanders, 1981). T h e y a r e a t t r a c t e d t o a n i m a t i o n , striking voices, lively m u s i c , r h y m i n g , s o u n d effects, r a p i d p a c i n g , r e p e t i t i o n , alliteration, w o m e n , c h i l d r e n , a n d p u p p e t s ( A n d e r s o n 8c Levin, 1976; C a l v e r t 8c G e r s h , 1987). T h e y t e n d t o p a y less a t t e n t i o n t o m e n , animals, inactivity, a n d still drawings. PSAs o n g o o d n u t r i t i o n , for e x a m p l e , w e r e b e t t e r u n d e r s t o o d b y y o u n g c h i l d r e n w h e n t h e y i n c l u d e d a n i m a t i o n , sprightly voices, a n d lively b a c k g r o u n d m u s i c i n s t e a d o f live p h o t o g r a p h y of real p e o p l e a n d n a r r a t i o n b y a d u l t m a l e s in a s e r i o u s t o n e ( C a m p b e l l , W r i g h t , 8c H u s t o n [in press] as d i s c u s s e d b y A n d e r s o n 8c C o l l i n s , 1988). O l d e r c h i l d r e n learn t o p a y a t t e n t i o n for i n t e r e s t i n g inform a t i o n ( W r i g h t 8c H u s t o n , 1981) as o p p o s e d t o m e r e l y p r o v o c a t i v e visual

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a n d s o u n d effects. P r o d u c t i o n values, h o w e v e r , r e m a i n an i m p o r t a n t d r a w (Basil, 1993). C h i l d r e n t e n d t o u n d e r s t a n d b e t t e r w h e n settings a n d c h a r a c t e r s s e e m familiar ( N e w c o m b 8c Collins, 1979). Because t h e y h a v e difficulty seeing b e y o n d t h e surface m e a n i n g of a message, y o u n g c h i l d r e n will d e p e n d m o r e o n stereotypes t o predict likely o u t c o m e s if the context is less familiar (Collins 8c W e l l m a n , 1982). I n a d d i t i o n , as t h e A p p e n d i x illustrates, y o u n g c h i l d r e n a r e less able t o m a k e inferences a n d i n t e g r a t e d i s p a r a t e pieces of i n f o r m a t i o n s e p a r a t e d b y t i m e o r c o n t e x t . As a result, t h e y h a v e t r o u b l e sifting o u t i r r e l e v a n t i n f o r m a t i o n (Collins, 1975). F o r t h e message d e s i g n e r , t h i s m e a n s t h a t w h a t c h a r a c t e r s say a n d w h a t t h e y d o m u s t b e clearly c o n s i s t e n t for t h e i n t e n d e d message to b e learned (Liss, Reinhardt, 8c Fredriksen, 1983). C h i l d r e n will m o r e likely r e m e m b e r actions t h a n utterances (Gibbons, A n d e r s o n , S m i t h , Field, 8c Fischer, 1986), w h i c h c a n lead t h e m t o focus m o r e o n p o r t r a y e d conflict t h a n o n its r e s o l u t i o n (Silverman 8c Sprafkin, 1980; Singer, 1980). Y o u n g c h i l d r e n m a y t h u s t h i n k t h i n g s o t h e r t h a n t h e m a i n m e s s a g e are t h e m o s t i m p o r t a n t aspects (Collins, 1 9 8 2 , 1 9 8 3 b ; Cullingsford, 1984). A n a d u l t will realize t h a t Winnie the Pooh and the Honey Tree teaches that b e i n g piggish c a n get y o u s t u n g b y bees a n d m a k e y o u t o o fat t o fit t h r o u g h d o o r w a y s . T o a y o u n g child, h o w e v e r , it m a y teach m e r e l y t h a t b e i n g piggish is c u t e a n d funny. P r e s c h o o l e r s can u n d e r s t a n d a c e n t r a l message a n d m a k e s o m e inferences if p r o g r a m s are s h o r t a n d d i r e c t ( A n d e r s o n 8c C o l l i n s , 1 9 8 8 ) . B u t y o u n g c h i l d r e n a r e less able t o u n d e r s t a n d cause a n d effect, p a r t i c u l a r l y w h e n s e p a r a t e d b y c o m m e r c i a l s o r s u b p l o t s (Collins, 1981, 1983b). Fast p a c i n g c a n f u r t h e r interfere w i t h their u n d e r s t a n d i n g ( W r i g h t et al., 1984). T h e y r e m e m b e r verbal messages b e t t e r w i t h o u t t h e i n t e r f e r e n c e of visual effects (MeringofF, 1980). T h e y can cope with s o m e cuts a n d edits, w h i c h t h e c a m p a i g n t a r g e t i n g m o r e t h a n o n e age g r o u p n e e d s t o use t o a t t r a c t o l d e r c h i l d r e n . B u t fancy p r o d u c t i o n t e c h n i q u e s will fail w i t h a y o u n g e r a u d i e n c e if t h e effects get t o o c o m p l e x , s u c h as w i t h c h a n g e s in t i m e , d i s t o r t i o n t o c o n v e y d r u n k e n n e s s , o r i n s t a n t replays (see A n d e r s o n 8c Collins, 1988). R e d u n d a n c y can h e l p y o u n g c h i l d r e n u n d e r s t a n d m o r e c o m p l e x m a t e rial. A v e r b a l label, for e x a m p l e , helps t h e m u n d e r s t a n d a c o m p l e x visual (Ball 8cBogatz, 1970; W a t k i n s , Calvert, H u s t o n - S t e i n , 8c W r i g h t , 1980), a n d c o n g r u e n c e of a u d i o a n d visual i n f o r m a t i o n h e l p s t h e m r e m e m b e r a m e s sage ( A n d e r s o n 8c C o l l i n s , 1988; S a d o w s k i , 1972). R e d u n d a n c y also h e l p s y o u n g c h i l d r e n m a k e p r e d i c t i o n s a b o u t cause a n d effect ( W i n i c k 8c W i n i c k , 1979).

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M o m e n t o u s a d v a n c e s in u n d e r s t a n d i n g take place b y a b o u t age 8 a n d can b e t r a c e d t o c h a n g e s in c h i l d r e n ' s abilities t o e n g a g e in c o n t r o l l e d , d e l i b e r a t e i n f o r m a t i o n p r o c e s s i n g . T h e y learn h o w t o reflect o n l a n g u a g e a n d t h i n k i n g processes—enabling them to understand metaphors, consider motives, and a p p r e c i a t e i r o n y a n d s a r c a s m . As a result, as s h o w n in t h e A p p e n d i x , a b i g j u m p o c c u r s b e t w e e n s e c o n d a n d fifth g r a d e in c h i l d r e n ' s u n d e r s t a n d i n g of i m p l i c i t i n f o r m a t i o n (i.e., t h e ability t o go b e y o n d t h e i n f o r m a t i o n g i v e n ) ( C o l l i n s , 1983a). Before t h i s skill d e v e l o p s , t h e i r u n d e r s t a n d i n g of m e s s a g e s c a n b e "exotically different" f r o m a d u l t s ' (Collins, 1983a; Y o u n g , 1990). O n e w a y t h e y c h a n g e is t o b e c o m e m o r e skeptical a b o u t television r e a l i s m as t h e y g r o w o l d e r . P r e s c h o o l e r s t e n d t o believe T V c h a r a c t e r s a r e real ( D o r r , 1980) a n d m a y e v e n t h i n k t h a t " B a r n e y t h e D i n o s a u r " lives in t h e T V set. K i n d e r g a r t n e r s use a p p e a r a n c e s s u c h as a n i m a t i o n t o d e t e r m i n e r e a l i s m , a l t h o u g h even y o u n g c h i l d r e n realize t h a t fantastic f o r m s s u c h as c a r t o o n s c a n p r o v i d e real-life i n f o r m a t i o n ( D o r r , 1983). By a b o u t age 8 t h e y m a k e a b i g j u m p in u n d e r s t a n d i n g t h a t television is fabricated a n d w i t h a g e u s e i n c r e a s i n g l y m o r e c o n t e n t - r e l a t e d cues t o j u d g e realism ( D o r r , 1983; Y o u n g , 1990). Overall, c h i l d r e n b e g i n b y c h e c k i n g w h e t h e r a p o r t r a y a l is "physically p o s s i b l e " t o w h e t h e r it is " p r o b a b l e " o r " r e p r e s e n t a t i v e " b y a b o u t sixth g r a d e ( D o r r , 1983). T h u s e v e n y o u n g c h i l d r e n d o n o t a c c e p t o r act o n e v e r y t h i n g t h e y see, a n d they apply m o r e weight to real-world impressions gained from personal e x p e r i e n c e t h a n t o conflicting p o r t r a y a l s seen o n l y via t h e m e d i a w o r l d . As a result, s t r u c t u r e d , d i r e c t e x p e r i e n c e s a n d i n f o r m a t i o n c a m p a i g n s c a n b e u s e d t o e d u c a t e c h i l d r e n t o b e m o r e skeptical of u n h e a l t h y m e d i a p o r t r a y a l s ( A u s t i n , R o b e r t s , 8c Nass, 1990; Y o u n g , 1990). M e s s a g e characteristics t h a t p r e d i c t i m i t a t i o n i n c l u d e p e r c e p t i o n s of realism ( H a w k i n s 8c P i n g r e e , 1982; Reeves, 1978), similarity, a n d identification w i t h c h a r a c t e r s ( A u s t i n et al., 1990; Reeves 8c G a r r a m o n e , 1982); frequent e x p o s u r e t o consistent messages ( G e r b n e r , G r o s s , M o r g a n , 8c Signorielli, 1986); messages seen as r e i n f o r c e d in real life ( A u s t i n et al., 1990; D e F l e u r 8c B a l l - R o k e a c h , 1982) a n d b y significant o t h e r s ( A u s t i n et al., 1990); a n d for t o p i c s a b o u t w h i c h c h i l d r e n get little i n f o r m a t i o n f r o m o t h e r s o u r c e s (Miller 8c Reese, 1982; R o s e n g r e n 8c W i n d a h l , 1972). Overall, children t e n d t o imitate portrayals seen frequently a n d t h a t s e e m relevant, useful, realistic, a n d r e w a r d i n g ( B a n d u r a , 1988). A d u l t s can h e l p c h i l d r e n i n t e r p r e t m o r e critically w h a t t h e y see in m e d i a p o r t r a y a l s ( A u s t i n , 1993a; C o r d e r - B o l z , 1980; S a l o m o n , 1981). Issues s u c h as p e r c e i v e d realism, fantasy, stereotypes, violence, a n d aggression o n television h a v e b e e n p u t i n t o lessons for c h i l d r e n f r o m k i n d e r g a r t e n t h r o u g h

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fifth g r a d e (Singer, Z u c k e r m a n , 8c Singer, 1980). In 1983, for e x a m p l e , H u e s m a n , E r o n , Klein, Brice, a n d Fischer successfully u s e d critical v i e w i n g skills t r a i n i n g t o h e l p c h i l d r e n r e c o g n i z e a n d deal w i t h televised v i o l e n c e . As a result, a d u l t s m a y b e able t o help c h i l d r e n see a l c o h o l a d s as less r e l e v a n t , useful, realistic, a n d r e w a r d i n g . T h e Scott N e w m a n C e n t e r , for e x a m p l e , has b e e n d e v e l o p i n g a n A d S m a r t s c a m p a i g n t o teach m e d i a literacy a n d a c t i o n skills t o m i d d l e s c h o o l c h i l d r e n for a l c o h o l a n d t o b a c c o a d s . C r e a t i v e tactics t o get c h i l d r e n involved i n c l u d e newsletters w i t h articles a n d c a r t o o n s c r e a t e d b y c h i l d r e n , m i x e d w i t h statistics o n s u b s t a n c e use g a t h e r e d b y a d u l t s ; m a k i n g PSAs, l e a r n i n g m o d e l s , a n d v i d e o t a p e s for i n - s c h o o l use; a n d role playing. Ideally, t h e p r o g r a m s h o u l d b e e x p a n d e d to target even y o u n g e r c h i l d r e n , b e c a u s e t h o s e w h o h a v e t h e m o s t to learn t e n d t o benefit t h e m o s t from s u c h t r a i n i n g (Roberts, Christenson, Gibson, M o o s e r , 8c Goldberg, 1980). Family as an Influence. O n t h e w h o l e , family influences a r e t h e m o s t e n d u r i n g . F a m i l y c o m m u n i c a t i o n b e g i n s to exert its influence early, a n d g o o d c o m m u n i c a t i o n p a t t e r n s i m p r o v e t h e c h a n c e s t h a t familial s u p p o r t will e n d u r e w h e n a d o l e s c e n t s face t o u g h d e c i s i o n s ( G l y n n , 1981). I n t h e a b s e n c e of s t r o n g family o r o t h e r significant a d u l t influences, c h i l d r e n t u r n t o m e d i a messages or appealing role models. Ironically, health c a m p a i g n s h a v e rarely t a r g e t e d o r involved p a r e n t s (Barnea, T e i c h m a n , 8c R a h a v , 1992). H o w a family interrelates is m o r e i m p o r t a n t t h a n family s t r u c t u r e (Baran o w s k i 8c N a d e r , 1985). P a r e n t s influence t h e ways c h i l d r e n d e v e l o p s t r a t e gies t o seek a n d analyze i n f o r m a t i o n in general ( A u s t i n , 1993a; M c L e o d 8c Chaffee, 1972), a n d p a r e n t s also influence h o w c h i l d r e n a p p r o a c h i n f o r m a t i o n a b o u t serious topics (Austin, in p r e s s ) . T h e ability t o c o m m u n i c a t e o p e n l y w i t h a p a r e n t , for e x a m p l e , can h e l p a child d e v e l o p c o n f i d e n c e in t h e ability t o resist social p r e s s u r e s a n d p r e d i c t s i n f o r m a t i o n s e e k i n g a b o u t d r u g s a n d A I D S (Austin, in press; Jessor 8c Jessor, 1975). Strict c o n t r o l s a n d p a r e n t a l d i s a g r e e m e n t a b o u t discipline i n c r e a s e child r e n ' s risk ( G l y n n , 1981). S h a r p increases in p a r e n t a l c o n t r o l at t h e o n s e t of a d o l e s c e n c e also can b e c o u n t e r p r o d u c t i v e ( G l y n n , 1981). P e r m i s s i v e strategies—warm b u t noncontrolling approaches to parenting—also place a child a t risk ( B a u m r i n d , 1985). A p a r e n t i n g style e m p h a s i z i n g r e a s o n i n g r a t h e r t h a n strict rules is m o s t successful, especially w h e n d e v e l o p e d before a d o l e s c e n c e ( B a u m r i n d , 1985; G l y n n , 1981). R e s p o n s i v e a n d n e g o t i a t e d c o n t r o l s u c c e e d s b e c a u s e c h i l d r e n view it as legitimate. W h e n it c o m e s t o e x e r t i n g c o n t r o l o v e r o t h e r i n f o r m a t i o n s o u r c e s r a t h e r t h a n over the child directly, p a r e n t s t o o frequently miss an i m p o r t a n t o p p o r t u n i t y . P a r e n t s generally d o n o t talk often a b o u t television w i t h t h e i r chil-

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d r e n ( A u s t i n et a l , 1990; W a r d , W a c k m a n , 8c W a r t e l l a , 1977). T h i s lack of familial c o m m u n i c a t i o n a b o u t television c o n t e n t gives television m e s s a g e s g r e a t e r influence t h a n t h e y m i g h t o t h e r w i s e h a v e . As a result, h e a l t h c a m p a i g n s n e e d t o p e r s u a d e p a r e n t s t o talk w i t h t h e i r c h i l d r e n a b o u t difficult issues, t o talk a b o u t w h a t their c h i l d r e n see o n television, a n d t o d o s o early. S u c h c o n v e r s a t i o n s m a y increase s k e p t i c i s m ( A u s t i n , 1993a), k e e p t h e p a r e n t ' s i n f l u e n c e a h e a d of t h e T V ' s ( A u s t i n et al., 1990; C o r d e r - B o l z , 1980), h e l p c h i l d r e n u n d e r s t a n d c o n t e n t ( C o r d e r - B o l z , 1980), a n d p r o v i d e o p p o r t u n i t i e s t o p r a c t i c e b e t t e r w a y s of i n t e r r e l a t i n g w i t h each o t h e r . A W a s h i n g t o n State c a m p a i g n , for e x a m p l e , targets t h e n e e d for p a r e n t a l d i s c u s s i o n of television a n d a l c o h o l via a c o m p r e h e n s i v e c a m p a i g n , l a u n c h e d b y c o o r d i n a t i n g t h e s u p p o r t of state agencies, c o m m u n i t y g r o u p s , b r o a d c a s t e r g r o u p s , t h e G o v e r n o r ' s Office, a c a d e m i c i a n s , a n d s c h o o l s . T a r g e t i n g p a r e n t s o f 3 - t o 10-year-olds, it features slogans s u c h as " M a k e s u r e t h e m o s t i m p o r t a n t messages a b o u t a l c o h o l c o m e f r o m y o u . " Besides r e c o m m e n d i n g d i s c u s s i o n , h o w e v e r , c a m p a i g n e r s n e e d t o p r o v i d e p a r e n t s w i t h realistic a n d n o n t h r e a t e n i n g o p p o r t u n i t i e s t o d e v e l o p t h e i r o w n k n o w l e d g e a n d c o m m u n i c a t i o n skills. P a r e n t s a p p e a r i n a d v e r tently t o reinforce t h e w r o n g things (Austin, 1993a; Austin 8c N a c h - F e r g u s o n , 1995; D e s m o n d , Singer, 8c Singer, 1990), a n d u n c l e a r messages f r o m a p a r e n t c a n b e p e r c e i v e d differently b y t h e child t h a n t h e p a r e n t i n t e n d s ( A u s t i n , 1993b). P a r e n t s t e n d t o e x p l a i n t h e i r views m o r e t h a n t h e y t r y t o u n d e r s t a n d t h e adolescent's views ( H u n t e r , 1985). T h e y also are m o r e f u t u r e o r i e n t e d t h a n t h e i r c h i l d r e n are, w h i c h can m a k e c o m m u n i c a t i o n m o r e difficult. F u t u r e orientation makes parents better suited to c o m m u n i c a t e a b o u t p r e v e n t i o n , w h i c h is f u t u r e o r i e n t e d , t h a n i n t e r v e n t i o n , w h i c h a d d r e s s e s t h e p r e s e n t . D i r e c t p a r e n t a l influence o n a t - p r e s e n t issues w a n e s b y a d o l e s c e n c e , w i t h t h e m a j o r i t y of t h e p a r e n t s ' influence o n t h e i r c h i l d r e n b e c o m i n g m o r e i n d i r e c t (Lull, 1985). T h i s d o e s n o t m a k e it less i m p o r t a n t for child r e n ' s well-being; children's long-term attachment to their parents r e m a i n s a m o r e p o w e r f u l influence t h a n c h i l d r e n ' s m o r e t r a n s i t i o n a l r e l a t i o n s h i p s w i t h p e e r s ( B u r k e 8c W e i r , 1978, 1979; G r e e n b e r g , Siegel, 8c Leitch, 1983). T h u s , a l t h o u g h i n d i r e c t , p a r e n t a l s u p p o r t r e m a i n s crucial. Peer Influence. By p r e a d o l e s c e n c e , p e e r s e m e r g e as critical influences for ( p r e s e n t - o r i e n t e d ) i n t e r v e n t i o n . Peers can b e a positive as well as a n e g a t i v e influence (Clasen 8c B r o w n , 1985), a n d they are perceived as credible ( W S A B , 1990). P e e r p r e s s u r e h a s b e e n called t h e p i v o t a l force for a n a d o l e s c e n t o n t h e e d g e ( O e t t i n g 8c Beauvais, 1988).

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A d o l e s c e n t s adjust their p r e s e n t values a n d style t o m a t c h t h o s e t h a t r e p r e s e n t t h e status t o w a r d w h i c h t h e y aspire, w i t h i n v o l v e m e n t in c e r t a i n t e e n g r o u p s a n d m u s i c styles p r o v i d i n g a s y m b o l i c e x p r e s s i o n o f t h o s e values ( R o e , 1985). As a result, adolescents m a y strive t o i m i t a t e " e l i t e " p e e r s m o r e t h a n t h e i r o w n p e e r s . In a d d i t i o n , b e c a u s e t h e y m a y b e d e s p e r a t e l y l o n g i n g t o b e a p a r t of a g r o u p , loners actually m a y b e m o r e influenced b y the p e r c e i v e d n o r m s of o t h e r s t h a n t h o s e already in peer g r o u p s (Clasen 8c B r o w n , 1985). T h e c a m p a i g n designer, as a result, n e e d s t o find o u t w h o m c h i l d r e n a d m i r e , n o t j u s t w i t h w h o m t h e y associate. P e e r influence d o e s n o t a p p e a r t o vary b y SES ( s o c i o e c o n o m i c s t a t u s ) b u t d o e s v a r y b y g e n d e r , age, a n d family s t r u c t u r e . Boys a r e m o r e s u s c e p t i b l e t o negative influences t h a n are girls. Early adolescents are m o r e susceptible t h a n p r e a d o l e s c e n t s o r o l d e r adolescents. C h i l d r e n f r o m s i n g l e - p a r e n t h o u s e h o l d s a n d s t e p p a r e n t h o u s e h o l d s are m o r e susceptible t o p e e r i n f l u e n c e ( p r o b a b l y d u e t o t h e variety of stresses o n t h e family r e l a t i o n s h i p ) , as a r e l a t c h k e y c h i l d r e n (Steinberg, 1986; S t e i n b e r g 8c Silverberg, 1986).

P R I N C I P L E 4: E M P H A S I Z E GIVING CHILDREN CONTROL AND O W N E R S H I P OF T H E I R O W N DESTINIES Because t h e goal of g r o w i n g u p is to b e c o m e self-reliant, h e a l t h p r o m o t i o n c a m p a i g n s s h o u l d facilitate t h a t p r o c e s s b y b u i l d i n g c o n f i d e n c e a n d skills. S o m e d a y , after all, t h e c a m p a i g n will e n d , leaving c h i l d r e n t o c o n t r o l t h e i r o w n b e h a v i o r . P r o m o t i n g t h e d e v e l o p m e n t of skills in n o n t h r e a t e n i n g ways a n d p r o v i d i n g appealing alternatives t o risk taking can h e l p p u t c h i l d r e n in c o n t r o l of s o m e aspect o f their lives, p e r h a p s for t h e first t i m e ( T o b l e r , 1986). As t h e A p p e n d i x suggests, giving y o u n g p e o p l e s o m e i n p u t o r c o n t r o l o v e r t h e c a m p a i g n d e s i g n e d to a c c o m p l i s h this can h e l p c a m p a i g n e r s d e velop a realistic a n d well-received intervention even while it encourages child r e n a n d a d o l e s c e n t s t o take responsibility for t h e m s e l v e s . T h e first step is t o listen carefully t o y o u n g p e o p l e ' s n e e d s a n d desires. C h i l d r e n say t h e y w a n t h e l p early, believing m o r e in t h e effectiveness of p r e v e n t i o n t h a n i n t e r v e n t i o n . M o r e t h a n 4 0 % of W a s h i n g t o n State 6 t h t o 12th g r a d e r s , for e x a m p l e , favor s u b s t a n c e a b u s e e d u c a t i o n b y t h i r d g r a d e , w i t h o n e in five also favoring sex e d u c a t i o n this early (Billings et al., 1993). By 12th g r a d e , h o w e v e r , n e a r l y o n e q u a r t e r (of t h o s e still in s c h o o l ) s e e m t o h a v e lost h o p e t h a t a n y i n t e r v e n t i o n p r o g r a m s c a n h e l p t h e m . T h e n e x t step is t o i n c l u d e y o u n g p e o p l e in p r o g r a m p l a n n i n g . I n c r e a s ingly, locally b a s e d p r o g r a m s are m a k i n g use of p e e r leaders, often i n c l u d i n g

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a d o l e s c e n t s o n t h e p r o g r a m a d v i s o r y b o a r d (Office o f S u b s t a n c e A b u s e P r e v e n t i o n [OSAP], 1989). In the Peer Leaders P r o g r a m in M a i n e , for e x a m p l e , students have contributed to p r o g r a m decision making, survey design, a n d d a t a collection, as well as a t t e n d e d w o r k s h o p s o n s u b s t a n c e a b u s e p r e v e n t i o n a n d helping skills (OSAP, 1989). Inviting at-risk teenagers t o h e l p a n o t h e r , s u c h as a y o u n g e r sibling, r a t h e r t h a n j u s t p o r t r a y i n g t h e m as v i c t i m s o r p r o b l e m s , can instill p u r p o s e , h o p e , a n d self-confidence ( K a s s e b a u m , 1990). I n s o m e cases p r o g r a m s h a v e b e e n i n i t i a t e d b y t e e n a g e r s t o o v e r c o m e d e n i a l a m o n g a d u l t s in t h e c o m m u n i t y (e.g., T e e n s A r e C o n c e r n e d , 1989). C h i l d r e n c a n h e l p g u i d e t h e selection of m e s s a g e s o u r c e s , c h a n n e l s , c o n t e n t , a n d s u p p o r t i n g activities. Television, for e x a m p l e , h a s b e e n cited as a s o u r c e o f i n f o r m a t i o n for a l c o h o l b y 3 7 % of 8- a n d 9 - y e a r - o l d s , m o r e t h a n p a r e n t s o r p e e r s (Aitken, Leathar, 8c Scott, 1988). D e s p i t e t h e p l e t h o r a o f celebrities eager t o l e n d their n a m e s t o a g o o d cause, a d o l e s c e n t s — d e lighted t o h a v e b e e n a s k e d — h a v e suggested u s i n g p e o p l e m o r e like t h e m selves, w i t h w h o m t h e y m o r e likely identify ( W S A B , 1990). T h e y also suggest striving for realism, u s i n g facts, a n d relating t h e m t o t h i n g s a d o l e s c e n t s care d e e p l y a b o u t , s u c h as family a n d friends. Because c u r r e n t slang a n d p o p u l a r activities c h a n g e quickly, c h i l d r e n t h e m s e l v e s a r e b o u n d t o b e t h e p l a n n e r ' s b e s t s o u r c e s for successful ideas, s u c h as all-night alcohol-free p a r t i e s b u r s t i n g w i t h activities t h a t s e e m attractive i n s t e a d of silly. C h i l d r e n w a n t h e l p , b u t t h e y w a n t a n d d e s e r v e t o b e t r e a t e d w i t h r e s p e c t as p a r t n e r s in p r e v e n t i o n a n d i n t e r v e n t i o n efforts.

Summary Early p r e v e n t i o n a n d i n t e r v e n t i o n c a n b e r e m a r k a b l e i n v e s t m e n t s — b o t h in social a n d in m o n e t a r y t e r m s — w h e n d o n e p r o p e r l y . Life Skills T r a i n i n g a n d STAR, t w o o f t h e m o s t effective p r o g r a m s as r e v i e w e d b y Falco ( 1 9 9 2 ) , cost $15 t o $ 2 5 p e r p u p i l , i n c l u d i n g c l a s s r o o m m a t e r i a l s a n d t e a c h e r t r a i n ing. By c o n t r a s t , d r u g t r e a t m e n t in p r i s o n s c a n cost $ 4 , 0 0 0 t o $ 8 , 0 0 0 p e r y e a r p e r i n m a t e , w i t h t h e cost of k e e p i n g d r u g - r e l a t e d c r i m i n a l s b e h i n d b a r s e s t i m a t e d at least $10 billion (Falco, 1992). T o b e effective, h o w e v e r , h e a l t h p r o m o t i o n m u s t address p r o b l e m s rather t h a n focus o n isolated s y m p t o m s . W e l l - m e a n i n g b u t m i s g u i d e d p r o g r a m s risk a b a n d o n i n g c h i l d r e n t o hopelessness. C a m p a i g n d e s i g n e r s h a v e e a r n e d m u c h criticism for u n d e r r e s e a r c h i n g , u n d e r e v a l u a t i n g , a n d o v e r p l a y i n g t h e success of p r o g r a m s s u c h as t h o s e in t h e " J u s t Say N o " g e n r e (e.g., B a n g e r t - D r o w n s , 1988; Elliott, 1993; Falco,

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1992; G o o d s t a d t & Mitchell, 1990; Wallack, 1986). T h e M e d i a - A d v e r t i s i n g P a r t n e r s h i p for a D r u g - F r e e A m e r i c a , for e x a m p l e , h a s b e e n rightly criticized for identifying p r o b l e m s b u t offering n o r e s o l u t i o n s ; p o r t r a y i n g i m p r o b a b l e r a t h e r t h a n m o s t p r o b a b l e c o n s e q u e n c e s ; n a r r o w l y focusing o n less c o m m o n l y a b u s e d s u b s t a n c e s (e.g., c o c a i n e ) i n s t e a d of g a t e w a y d r u g s ( a l c o h o l , t o b a c c o , a n d m a r i j u a n a ) ; a n d m a k i n g use of s h o c k - v a l u e t e c h n i q u e s , w h i c h can backfire ( T o r t u , 1990). T h e P a r t n e r s h i p ' s tactics h a v e h a d s o m e value, however, apparently helping to overcome complacency a n d d e n i a l in c o m m u n i t i e s , w h i c h increasingly a r e g e t t i n g i n v o l v e d in c a m p a i g n p a r t n e r s h i p s (Falco, 1992). T o achieve success a m o n g t h e c h i l d r e n t h e m s e l v e s , h o w e v e r , c a m p a i g n s s h o u l d b e d e s i g n e d t o b e c o m p r e h e n s i v e , l o n g t e r m , a n d b e g u n early. Effective tactics m i c r o t a r g e t t h e n e e d s a n d interests of c h i l d r e n of different ages a n d e n v i r o n m e n t s a n d are realistic, credible, a n d b a l a n c e d . Effective m e s s a g e s c o m e f r o m a variety of s o u r c e s a n d over a l o n g p e r i o d of t i m e . Effective c a m p a i g n p l a n n i n g a c k n o w l e d g e s a n d w o r k s w i t h t h e s e v a r i o u s , often conflicting, s o u r c e s o f i n f o r m a t i o n . I n a d d i t i o n , effective c a m p a i g n s m a k e t h e t a r g e t p a r t of t h e s o l u t i o n b y i n c l u d i n g y o u n g p e o p l e in p r o g r a m d e v e l o p m e n t . T h e inescapable c o n c l u s i o n is t h a t c h i l d r e n a n d a d o l e s c e n t s m a k e c h a l l e n g i n g targets for h e a l t h p r o m o t i o n ; f o r t u n a t e l y , t h e y also p r o v i d e s o m e of t h e m o s t p r o m i s i n g o p p o r t u n i t i e s . T h e m e s s a g e d e s i g n e r ' s r e w a r d is t h a t a d e v e l o p m e n t a l a p p r o a c h t o h e a l t h p r o m o t i o n c a n h e l p c h i l d r e n gain c o n t r o l of t h e i r o w n destinies, u l t i m a t e l y instilling in t h e m t h e p o w e r t o d e v e l o p a h e a l t h y future for t h e m s e l v e s .

References Adler, R. P., Friedlander, Β. Ζ., Lesser, G. S., Meringoff, L., Robertson, T. S., Rossiter, J. R., & Ward, S. (1979). Research on the effects of television advertising on children. Washington, DC: National Science Foundation. Adler, R. P., Lesser, G. S., Meringoff, L. K., Robertson, T. S., Rossiter, J. R., & Ward, S. (1980). The effects of television advertising on children: Review and recommendations. Lexington, MA: Lexington Books. Aitken, P., Leathar, D., 8c Scott, A. (1988). Ten- to sixteen-year-olds' perceptions of advertising for alcoholic drinks. Alcohol and Alcoholism, 23, 491-500. Anderson, D., 8c Collins, P. (1988). The impact on children's education: Television's influence on cognitive development (Working Paper No. 2). Washington, DC: U.S. Department of Education, Office of Educational Research and Improvement. Anderson, D., 8c Levin, S. (1976). Young children's attention to "Sesame Street." Child Development, 47, 806-811.

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Anderson, D., Lorch, Ε., Field, D., & Sanders, J. (1981). The effects of TV program comprehensibility on preschool children's visual attention to television. Child Development, 52, 151-157. Atkin, C , Hocking, J., & Block, M. (1984). Teenage drinking: Does advertising make a difference? Journal of Communication, 34, 157-167. Austin, E. W. (1993a). Exploring the effects of active parental mediation of television content. Journal of Broadcasting & Electronic Media, (Spring), 147-158. Austin, E. W. (1993b). The importance of perspective in parent-child interpretations of family communication patterns. Journalism Quarterly, 70, 558-568. Austin, E. W. (in press). Direct and indirect influences of parent-child communication norms on adolescents' tendencies to take preventive measures for AIDS and drug abuse. In G. Kreps 8c D. O'Hair (Ed.), Relational communication and health outcomes. Creskill, NJ: Hampton Press. Austin, E. W., 8c Meili, Η. K. (in press). Effects of interpretations of televised alcohol portrayals on children's alcohol beliefs. Journal of Broadcasting & Electronic Media. Austin, E. W., 8c Nach-Ferguson, B. (1995). Sources and influences of young school-age children's general and brand-specific knowledge about alcohol. Health Communication, 7,1-20. Austin, E. W., Roberts, D. F., 8c Nass, C. I. (1990). Influences of family communication on children's television-interpretation processes. Communication Research, 17, 545-564. BABES. (1978). Beginning alcohol & addictions basic education studies. National Council on Alcoholism and Other Dependencies in the Greater Detroit, MI, area. Ball, S., 8c Bogatz, G. (1970). The first year of "Sesame Street": An evaluation. Princeton, NJ: Educational Testing Service. Bandura, A. (1986). Social foundations of thought & action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1988). Social cognitive theory of mass communication. In J. Groebel 8c P. Winterhoff (Ed.), Empirische medienpsychologie. Munich: Psychologie Verlags Union. Bandura, Α., Ross, D., 8c Ross, S. (1963). Vicarious reinforcement and imitative learning. Journal of Abnormal and Social Psychology, 67, 601-607. Bangert-Drowns, R. (1988). Effects of school-based substance abuse education—A metaanalysis. Journal of Drug Education, 18, 243-264. Baranowski, T., 8c Nader, P. R (1985). Family health behavior. In D. C. Turk 8c R D. Kerns (Ed.), Health, illness & families: A life-span perspective (pp. 51-80). New York: John Wiley. Barie, L., 8c Fischer, C. (1979). Acquisition of the smoking habit. Health Education Journal, 38, 71-76. Barnea, Z., Teichman, M., 8c Rahav, G. (1992). Personality, cognitive, and interpersonal factors in adolescent substance use: A longitudinal test of an integrative model. Journal of Youth and Adolescence, 21, 187-200. Barringer, F. (1990, August). What is youth coming to? WSCADD Newsletter. (Available from the Washington State Council on Alcoholism and Drug Dependence) Basil, M. D. (1993, May). Targeting: Ethnic match andproduction quality effects on the evaluation of drug abuse messages. Paper presented at the 1993 International Communication Conference, Washington, D.C. Baumrind, D. (1985). Familial antecedents of adolescent drug use: A developmental perspective. In C. L. Jones 8c R. J. Battjes (Eds.), Etiology of drug abuse: Implications for prevention (NIDA Research Monograph 56, pp. 13-44). Washington, DC: Government Printing Office.

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Berrueta-Clement, J. R., Schweinhart, L. J., Barnett, W. S., & Weikhard, D. P. (1983). The effects of early education intervention on crime and delinquency in adolescence and early adulthood. Ypsilanti, MI: Center for the Study of Public Policies for Young Children. Billings, J. Α., Burton, W., Mertens, Β., & Strong, C. R. (1993). Substance use among public school students in Washington state. Olympia, WA: Superintendent of Public Instruction. Blosser, Β. J., 8c Roberts, D. F. (1985). Age differences in children's perceptions of message intent: Responses to TV news, commercials, educational spots, and public service announcements. Communication Research, 12,455-484. Botvin, G. J. (1990). Substance abuse prevention: Theory, practice, and effectiveness. In M. Tonry 8c J. Q. Wilson (Eds.), Drugs and crime (pp. 461-520). Chicago: University of Chicago Press. Burke, R. J., 8c Weir, T. (1978). Benefits to adolescents of informal helping relationships with parents and peers. Psychology Reports, 42, 1175-1184. Burke, R. J., 8c Weir, T. (1979). Helping responses of parents and peers and adolescent well-being. Journal of Psychology, 102, 49-62. Bush, P. J., 8c Ianotti, R. (1985). The development of children's health orientations and behaviors: Lessons for substance abuse prevention. In C. L. Jones 8c R. J. Battjes (Eds.), Etiology of drug abuse: Implications for prevention (NIDA Research Monograph 56, pp. 45-74). Rockville, MD: National Institute on Drug Abuse. Calvert, S. L., 8c Gersh, T. L. (1987). The selective use of sound effects and visual inserts for children's television story comprehension. Journal of Applied Developmental Psychology, 8, 363-375. Campbell, T., Wright, J., 8c Huston, A. (in press). Form cues and content difficulty as determinants of children's cognitive processing of televised educational messages. Journal of Experimental Child Psychology. Chaffee, S. H. (1982). Mass media and interpersonal channels: Competitive, convergent, or complementary? I n j . Gumpert 8c R. Cathcart (Eds.), Inter/media (pp. 57-75). New York: Oxford University Press. Chandler, M. J., Greenspan, S., 8c Barenboim, D. (1973). Judgements of intentionality in response to videotaped and verbally presented moral dilemmas: The medium is the message. Child Development, 44, 315-320. Christenson, P., DeBenedittis, P., 8c Lindloff, Τ. (1985). Children's use of audio media. Communication Research, 12, 327-343. Christenson, P. G., 8c Roberts, D. F. (1990). Popular music in early adolescence. Washington, DC: Carnegie Council on Adolescent Development. Christiansen, Β. Α., 8c Goldman, M. S. (1983). Alcohol related expectancies vs. demographic/ background variables in the prediction of adolescent drinking. Journal of Consulting and Clinical Psychology, 51, 249-257. Christiansen, Β. Α., Goldman, M. S., 8c Inn, A. (1982). The development of alcohol-related expectancies in adolescents: Separating pharmacological from social learning influences. Journal of Consulting and Clinical Psychology, 50, 336-344. Clasen, D. R., 8c Brown, Β. B. (1985). The multidimensionality of peer pressure in adolescence. Journal of Youth and Adolescence, 14, 451-468. Collins, W. A. (1975). The developing child as viewer. Journal of Communication, 25, 35-44. Collins, W. A. (1981). Schemata for understanding television. In H. Kelly 8c H. Gardner (Eds.), Viewing children through television (pp. 31-45). San Francisco: Jossey-Bass.

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Collins, W. A. (1982). Cognitive processing in television viewing. In D. Pearl, L. Bouthilet, 8c J. Lazar (Ed.), Television and behavior: Ten years of scientific progress and implications for the eighties (pp. 9-23). Washington, DC: Government Printing Office. Collins, W. A. (1983a). Interpretation and inference in children's television viewing. In J. Bryant 8c D. R Anderson (Eds.), Children's understanding of television: Research on attention and comprehension (pp. 125-150). New York: Academic Press. Collins, W. A. (1983b). Social antecedents, cognitive processing, and comprehension of social portrayals on television. In Ε. T. Higgings, D. N. Ruble, 8c W. W. Hartup (Eds.), Social cognition and social development: A sociocultural perspective (pp. 110-133). New York: Cambridge University Press. Collins, W., 8c Wellman, H. (1982). Social scripts and developmental changes in representations of televised narratives. Communication Research 9, 380-398. Conroy, M. (1988, May). Is your child an alcoholic? Better Homes and Gardens, p. 72. Corder-Bolz, C. R. (1980). Mediation: The role of significant others. Journal of Communication, (Summer), 106-118. Cullingsford, C. (1984). Children and television. England: Gower. DeFleur, M. L.,8cBall-Rokeach, S. (1982). Theories of mass communication (4th ed.). New York: David McKay. Desmond, R J., Singer, J. L., 8c Singer, D. G. (1990). Family mediation: Parental communication patterns and the influences of television on children. In J. Bryant (Ed.), Television and the American family (pp. 293-310). Hillsdale, NJ: Lawrence Erlbaum. DiFranza, J. R., 8c McAfee, T. (1992). The tobacco institute: Helping youth say "yes" to tobacco. Journal of Family Practice, 34, 694-696. Donohew, L. (1988). Effects of drug abuse message styles: Final report [A report of a study conducted under a grant from the National Institute on Drug Abuse, Rockvüle, M D ] . Donohew, L., Lorch, Ε., 8c Palmgreen, P. (1993). Sensation seeking and targeting of televised antidrug PSAs. In L. Donohew, W. J. Bukoski, 8c Η. E. Sypher (Eds.), Persuasive communication and drug abuse prevention (pp. 209-226). Hillsdale, NJ: Lawrence Erlbaum. Dorr, A. (1980). When I was a child, I thought as a child. In S. Withey 8c R. Abeles (Eds.), Television and social behavior: Beyond violence and children. Hillsdale, NJ: Lawrence Erlbaum. Dorr, A. (1983). N o shortcuts to judging reality. In J. Bryant 8c D. Anderson (Eds.), Children's understanding of television: Research on attention and comprehension. N e w York: Academic Press. Dryfoos, J. G. (1990). Adolescents at risk: Prevalence and prevention. New York: Oxford University Press. Elliott, J. (1993). Just say nonsense. The Washington Monthly, 25, 18-21. Ezekoye, S., Kumpfer, L., 8c Bukoski, W. (1985). Children and chemical abuse: Prevention and intervention. New York: Hawthorn Press. Fagin, J., 8c Sauer, R. (1990). Evaluation report: Project healthy choices. New York: Special Consulting Services. Falco, M. (1992). The making ofa drug-free America: Programs that work. New York Times Books. Fischhoff, Β. (1993). Decisions about alcohol: Prevention, intervention and policy. Alcohol Health & Research World, 16, 257-266. Flavell, J. H., Miller, P. H., 8c Miller, S. A. (1993). Cognitive development (3rd ed.). Englewood Cliffs, NJ: Prentice Hall. Free, C. (1993, July 14). All-night kegger may help save teenager's lives. Spokesman Review, p.Bl.

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Gelman, R., 8c Brown, A. L. (1986). Changing views of cognitive competence in the young. In N. J. Smelser & D. R. Gerstei (Ed.), Behavioral and social science: Fifty years of discovery (pp. 175-207). Washington, DC: National Academy Press. Gerbner, G., Gross, L., Morgan, M., 8c Signorielli, N. (1986). Living with television: The dynamics of the cultivation process. In J. Byrant 8c D. Zillmann (Eds.), Perspectives on media effects (pp. 17-40). Hillsdale, NJ: Lawrence Erlbaum. Gibbons, J., Anderson, D. R., Smith, R., Field, D. E., 8c Fischer, C. (1986). Young children's recall and reconstruction of audio and audiovisual narratives. Child Development, 57, 1014-1023. Gitlin, T. (1989). On drugs and mass media in America's consumer society. In H. Resnik (Ed.), Youth and drugs: Society's mixed messages (OSAP Prevention Monograph 6, pp. 31-52). Rockville, MD: U.S. Department of Health and Human Services. Glynn, T. J. (1981). From family to peer: Transitions of influence among drug-using youth. In D. J. Lehiehi 8c J. P. Ludford (Ed.), Drug abuse and the American adolescent (NIDA Research Monograph 38, pp. 57-81). Washington, DC: Government Printing Office. Glynn, K., Leventhal, Η., 8c Hirschman, R. (1985). A cognitive developmental approach to smoking prevention. In C. S. Bell 8c R. Battjes (Eds.), Prevention research: Deterring drug abuse among children and adolescents (NIDA Research Monograph 63, pp. 130-152). Rockville, MD: U.S. Department of Health and Human Services. Goldman, M., Brown, S., 8c Christiansen, B. (1987). Expectancy theory: Thinking about drinking. In H. Blane 8c D. Leonard (Eds.), Psychological theories of drinking and alcoholism (pp. 181-220). New York: Guilford. Goodstadt, M. S., 8c Mitchell, E. (1990). Prevention theory and research related to high-risk youth. In Ε. N. Goplerud (Ed.), Breaking new ground for youth at risk: Program summaries (pp. 7-23) (Tech. Rep. 1). Washington, DC: Office of Substance Abuse Prevention. Gordon, N., 8c McAlister, A. (1982). Factors related to the onset of drinking and problem drinking. In T. J. Coates, A. C. Petersen, 8c C. Perry (Eds.), Promoting adolescent health: A dialog on research and practice. New York: Academic Press. Greenberg, B. S. (1974). Gratifications of television viewing and their correlates for British children. In J. Blumer 8c E. Katz (Eds.), Annual review of communication research (Vol. 3). Beverly Hills, CA: Sage. Greenberg, Μ. T., Siegel, J. M.,8c Leitch, C. J. (1983). The nature and importance of attachment relationships to parents and peers during adolescence. Journal of Youth and Adolescence, 12, 373-386. Grube, J. W. (1993). Alcohol portrayals and alcohol advertising on television: Content and effects on children and adolescents. Alcohol Health & Research World, 17, 61-66. Hawkins, J. D., Lishner, D., 8c Catalano, R.F.J. (1985). The development of children's health orientations and behaviors: Lessons for substance use prevention. In C. L. Battjes 8c R. J. Jones (Eds.), Etiology of drug abuse: Implications for prevention (NIDA Research Monograph 56, pp. 75-126). Washington, DC: Government Printing Office. Hawkins, R„ 8c Pingree, S. (1982). Television's influence on social reality. Television and behavior: Ten years of scientific progress and implications for the eighties (Technical Reviews 2). Rockville, MD: National Institute of Mental Health. Hearold, S. (1986). A synthesis of 1043 effects of television on social behavior. In G. Comstock (Ed.), Public communications and behavior (Vol. 1, pp. 65-133). New York: Academic Press. Heath, R. L., 8c Bryant, J. (1992). Human communication theory and research: Concepts, contexts and challenges. Hillsdale, NJ: Lawrence Erlbaum.

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Higgins, Ε. T., & Parsons, J. E. (1983). Social cognition and the social life of the child: Stages as subcultures. In Ε. T. Higgins, D. N. Ruble, & W. W. Hartup (Eds.), Social cognition and social development: A socio-cultural perspective (pp. 15-61). Cambridge: Cambridge University Press. Hollenbeck, Α., & Slaby, R (1979). Infant visual and vocal responses to television. Child Development, 50, 41-45. Huesman, L. R., Eron, L. D., Klein, R , Brice, P., 8c Fischer, P. (1983). Mitigating the imitation of aggressive behaviors by changing children's attitudes about media violence. Journal of Personality and Social Psychology, 44(5), 899-910. Hunter, F. T. (1985). Adolescents' perception of discussions with parents and friends. Developmental Psychology, 21, 443-440. Hurst-Palermo, K. (1992, February). Speech communication at LeMoore High School Paper presented at the annual meeting of the Western Speech Communication Association, Boise, ID. Jahoda, G., 8c Cramond, J. (1972). Children and alcohol London: HMSO. Jeffrey, D. B., McLellarn, R. W., 8c Fox, D. T. (1982). The development of children's eating habits: The role of television commercials. Health Education Quarterly, 9, 78-93. Jessor, R. (1982). Critical issues in research on adolescent health promotion. In T. J. Coates, A. C. Perry, 8c C. L. Peterson (Ed.), Promoting adolescent health: A dialog on research and practice (pp. 447-465). New York: Academic Press. Jessor, R., 8c Jessor, S. L. (1975). Adolescent development and the onset of drinking: A longitudinal study. Journal of Studies on Alcohol, 36, 27-51. Johnson, C. Α., Pentz, Μ. Α., 8c Weber, M. (1990). Relative effectiveness of comprehensive community programming for drug abuse prevention with high-risk adolescents. Journal of Consulting and Clinical Psychology, 58, 447-456. Johnston, L. D., O'Malley, P. O., 8cBachman, J. G. (1991). Drug use among American high school seniors, college students, and young adults, 1975-1990. Rockville, MD: National Institute on Drug Abuse. Kandel, D. B., 8c Logan, J. A. (1984). Patterns of drug use from adolescence to young adulthood-I. Periods of risk for initiation, stabilization and decline in use. American Journal of Public Health, 74, 660-666. Kandel, D., Kessler, R C , 8c Margulies, R Z. (1978). Adolescent initiation into stages of drug use: A developmental analysis. In D. Kandel (Ed.), Longitudinal research on drug use: Empirical findings and methodological issues (pp. 73-99). New York: John Wiley. Kandel, D. B., 8c Yamaguchi, K. (1985). Developmental patterns of the use of legal, illegal and medically prescribed psychotropic drugs from adolescence to young adulthood. In C. L. Jones 8c R. J. Battjes (Eds.), Etiology of drug abuse: Implications for prevention (NIDA Research Monograph 56, pp. 193-235). Washington, DC: Government Printing Office. Kassebaum, P. (1990). Reaching families and youth from high-risk environments. In Ε. B. Arkin 8c J. E. Funkhouser (Eds.), Communicating about alcohol and other drugs: Strategies for reaching populations at risk (OSAP Prevention Monograph 5, pp. 11-120). Rockville, MD: Office of Substance Abuse Prevention. Kellam, S., 8c Brown, H. (1982). Sodal adaptational and psychological antecedents of adolescent psychopathology ten years later. Baltimore, MD: Johns Hopkins University Press. Kohlberg, L. (1976). Moral stages and moralization: The cognitive-developmental approach. In T. Lickona (Ed.), Moral development and behavior: Theory, research and social issues (pp. 31-53). New York: Holt, Rinehart 8c Winston.

138

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Kumpfer, K. L. (1986). Special populations: Etiology and prevention of vulnerability to chemical dependency in children of substance abusers. In B. S. Brown 8c A. R. Mills (Eds.), Youth athigh risk for substance abuse (pp. 1 -72). Rockville, MD: National Institute on Drug Abuse. Kumpfer, K. L., 8c DeMarsh, J. P. (1984). Genetic and family environmental influences on children's future chemical dependency. Journal of Children in Contemporary Society, 3, 117-151. Kutner, L. (1991, December 19). Holiday drinking opens adolescents' eyes to alcohol. The New York Times, p. C9. (Available from National Council on Alcoholism and Drug Dependence) Liss, Μ. B., Reinhardt, L. C , 8c Fredriksen, S. (1983). TV heroes: The impact of rhetoric and deeds. Journal of Applied Developmental Psychology, 4, 175-187. Lull, J. (1985). On the communicative properties of music. Communication Research, 12, 363-372. Lyle, J., 8c Hoffman, H. R. (1972). Children's use of television and other media. In E. A. Rubinstein, G. A. Murphey, 8c J. P. Comstock (Eds.), Television and social behavior: Vol. 4. Television in day-to-day life: Patterns of use (pp. 129-256). Washington, DC: Government Printing Office. McAlister, A. (1981). Antismoking campaigns: Progress in developing effective communications. In R. E. Rice 8c W. J. Paisley (Eds.), Public communication campaigns (pp. 91-103). Beverly Hills, CA: Sage. McCarthy, W. J. (1985). The cognitive developmental model and other alternatives to the social skills deficit model of smoking onset. In C. S. Bell 8c R. Battjes (Eds.), Prevention research: Deterring drug abuse among children and adolescents (NIDA Research Monograph 63, pp. 153-169). Rockville, MD: U.S. Department of Health and Human Services. McGuire, W. J. (1989). Theoretical foundations of campaigns. In R. E. Rice 8c C. K. Atkin (Eds.), Public communication campaigns (pp. 43-65). Newbury Park, CA: Sage. McLeod, J. M., 8c Chaffee, S. H. (1972). The construction of social reality. In J. Tedeschi (Ed.), The social influence process (pp. 50-59). Chicago: Aldine-Atherton. Meringoff, L. K. (1980). Influence of the medium on children's story apprehension. Journal of Educational Psychology, 72, 240-249. Miller, Μ. M., 8c Reese, S. D. (1982). Media dependency as interaction: Effects of exposure and reliance on political activity and efficacy. Communication Research, 9, 227-248. Miller, P. M., Smith, G. T., 8c Goldman, M. S. (1989). Emergence of alcohol expectancies in childhood: A possible critical period. Journal of Studies on Alcohol, 51, 343-349. Murray D. M., 8c Perry, C. L. (1985). The prevention of adolescent drug abuse: Implications of etiological, developmental, behavioral, and environmental models. In C. R. Jones 8c R. J. Battjes (Eds.), Etiology of drug abuse: Implications for prevention (NIDA Research Monograph 56, pp. 236-256). Washington, DC: Government Printing Office. Newcomb, Α., 8c Collins, W. A. (1979). Children's comprehension of family role portrayals in televised drama: Effects of socioeconomic status, ethnicity, and age. Developmental Psychology, 15, 417-423. National Institute on Drug Abuse. (1988). Highlights of a national adolescent school health survey on drug and alcohol use. (Available from U.S. Department of Health and Human Services, Alcohol, Drug Abuse and Mental Health Administration, Rockville, MD) Oetting, E. R., 8c Beauvais, K. L. (1988). Peer cluster theory, socialization characteristics, and adolescent drug use: A path analysis. Journal of Counseling Psychology, 34, 205-213.

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Office for Substance Abuse Prevention. (1989). Stopping alcohol and other drug use before it starts: The future of prevention (OSAP Monograph 1). Rockville, MD: U.S. Department of Health and Human Services. Palincsar, A. S., 8c Brown, A. L. (1984). Reciprocal teaching of comprehension-fostering and monitoring activities. Cognition and Instruction, 1, 117-175. Palmgreen, P., Lorch, Ε. P., Donohew, L., Harrington, N. G., Dsilva, M., 8c Helm, D. (1993, May). Reaching at-risk popufotions in a mass media drug abuse prevention campaign: Sensation seeking as a targeting variable. Paper presented at the 1993 International Communication Association Annual Conference, Washington, DC. Pentz, Μ. Α., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., Hansen, W. B., Wang, E.Y.I., 8c Johnson, C. A. (1989). A multi-community trial for primary prevention of adolescent drug abuse: Effects on drug use prevalence. Journal of the American Medical Association, 261, 3259-3266. Pentz, Μ. Α., Trebow, Ε. Α., 8c Hansen, W. B. (1990). Effects of program implementation on adolescent drug use behavior: The Midwestern prevention project (MPP). Evaluation Review, 14, 264-289. Perry, C , 8c Jessor, R. (1985). The concept of health promotion and the prevention of adolescent drug abuse. Health Education Quarterly, 12,169-184. Peterson, A. J., 8c Clark, A. W. (1986). Using group decision to reduce adolescent girls' smoking. Psychological Reports, 58,179-185. Pfau, Μ., 8c Van Bockern, S. (1993, May). The persistence of inoculation in conferring resistance to smoking initiation among adolescents: The second year. Paper presented at the annual meeting of the International Communication Association Annual Conference, Washington, DC. PRIDE, I. (1992). High school student drug use rose in 91 for most drugs; in junior high usage climbed in all drug types (1991-1992 National Summary Report 4-6). Adanta, GA: Parents' Resource Institute for Drug Education. Reeves, B. (1978). Perceived reality as a predictor of children's social behavior. Journalism Quarterly, 55, 682-689, 695. Reeves, B., 8c Garramone, G. (1982). Children's person perception: The generalization from television people to real people. Human Communication Research, 8, 317-326. Roberts, D. (1971). The nature of communication effects. In W. Schramm 8c D. F. Roberts (Eds.), The process and effects of mass communication (2nd ed.). Urbana: University of Illinois Press. Roberts, D. F. (1973). Communication and children: A developmental approach. In I. deSola Pool, W. Schramm et al. (Eds.), Handbook of communication (pp. 174-215). Chicago: Rand McNally. Roberts, D. (1989). The impact of media portrayals of risky driving on adolescents: Some speculation. Alcohol, Drugs and Driving, 4, 13-20. Roberts, D. F., Christenson, P., Gibson, W. Α., Mooser, L., 8c Goldberg, Μ. E. (1980). Developing discriminating consumers. Journal of Communication, 30, 94-105. Robins, L. N., 8c Pryzbeck, T. R. (1985). Age of onset of drug use as a factor in drug and other disorders. In C. L. Jones 8c R. J. Battjes (Eds.), Etiology of drug abuse: Implications for prevention (NIDA Research Monograph 56, pp. 178-192). Washington, DC: Government Printing Office. Rock Against Drugs. (1988). Rock Against Drugs (RAD) foundation kicks-off1988 public service campaign with mini-video by Siedah Garrett [Press Release, January 26, as reported in y

140

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Christenson, P. G., 8c Roberts, D. F. (1990). Popular music in early adolescence. Washington, DC: Carnegie Council on Adolescent Development]. Roe, K. (1985). Swedish youth and music: Listening patterns and motivations. Communication Research, 12, 353-362. Rosengren, Κ. E., & Windahl, S. (1972). Mass media as a functional alternative. In D. McQuail (Ed.), Sociology of mass communications (pp. 166-194). Middlesex, England: Penguin. Sadowski, R. P. (1972). Immediate recall of TV commercial elements—revisited. Journal of Broadcasting, 16, 277-287. Salomon, G. (1981). Introducing AIME: The assessment of children's mental involvement with television. In H. Kelly 8c H. Gardner (Eds.), Viewing children through television (pp. 89-102). San Francisco: Jossey-Bass. Schoenbachler, D. (1993, May). The effectiveness of varying levels of physically and socially threatening fear appeals in anti-drug public service announcements. Paper presented at the 1993 International Communication Association, Washington, D.C. Schramm, W. (1965). Communication in crisis. In W. Schramm 8c Ε. B. Parker (Eds.), The Kennedy assassination and the American public: Social communication in crisis. Stanford, CA: Stanford University Press. Silverman, L. T., 8c Sprafkin, J. N. (1980). The effects of Sesame Street's prosocial spots on cooperative play between young children. Journal of Broadcasting, 24, 135-147. Singer, D. G., Zuckerman, D. M., 8c Singer, J. L. (1980). Helping elementary school children learn about TV. Journal of Communication, 30(3), 84-93. Singer, J. L. (1980). The power and limitations of television: A cognitive-affective analysis. In P. H. Tannenbaum (Ed.), The entertainment functions of television (pp. 31-65). Hillsdale, NJ: Lawrence Erlbaum. Singhal, Α., 8c Rogers, R. (1989). Prosocial television for development in India. In R. Rice 8c C. Atkin (Eds.), Public communication campaigns (pp. 331-350). Newbury Park, CA: Sage. Solutions: Six schools that got it right. (1993, September). Parenting, pp. 80-85. Spiegler, D. (1983). Children's attitudes toward alcohol. Journal of Studies on Alcohol 44, 545-552. Spivak, G., 8c Shure, Μ. B. (1982). The cognition of social adjustment: Interpersonal cognitive problem-solving thinking. In Β. B. Lahly 8c A. E. Kazdin (Eds.), Advances in child psychology. New York: Plenum. Steele, C. (1989). Early beginnings. An early years substance abuse prevention curriculum for infants, toddlers' η twos. Rensselaer County [New York] Department of Mental Health. Steinberg, L. (1986). Latchkey children and susceptibility to peer pressure: An ecological analysis. Developmental Psychology, 22, 433-439. Steinberg, L., 8c Silverberg, S. (1986). The vicissitudes of autonomy in early adolescents. Child Development, 57, 841-851. Teens Are Concerned. (1989). Teens are concerned. In Prevention plus II: Tools for creating and sustaining drug-free communities (pp. 256-257). Rockville, MD: Office for Substance Abuse Prevention. Tobler, N. (1986). Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program participants compared to a control or comparison group. Journal of Drug Issues, 16, 537-67. Tortu, S. (1990). The utility of drug research. Paper presented at Narcotic 8c Drug Research, Inc., New York. Van der Voort, T.H.A. (1986). Television violence: A child's eye view. Amsterdam: North-Holland.

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Vogt, Κ., Lieberman, L. R , Iverson, D„ & Walter, H. (1983). What it means to be healthy: Concepts and constructs of children ages 6-8. Paper presented at the annual meeting of the American Public Health Association, Dallas, TX. Wallack, L. (1986). Mass media, youth and the prevention of substance abuse: Towards an integrated approach. In Childhood and chemical abuse (pp. 153-180). New York: Haworth. Wallack, L., Cassady, D., 8c Grube, J. (1990). TV beer commercials and children: Exposure, attention, beliefs and expectations about drinking as an adult. Washington, DC: AAA Foundation for Traffic Safety. Wallack, L., 8c Corbett, K. (1990). Illicit drug, tobacco, and alcohol use among youth: Trends and promising approaches in prevention. In H. Resnik (Ed.), Youth and drugs: Society's mixed messages (OSAP Prevention Monograph 6, pp. 5-29). Rockville, MD: U.S. Department of Health and Human Services. Ward, S., 8c Wackman, D. B. (1973). Children's information processing of television advertising. In P. Clarke (Ed.), New models for mass communication research (pp. 119-146). Beverly Hills, CA: Sage. Ward, S., Wackman, D., 8c Wartella, Ε. (1977). How children learn to buy: The development of consumer information-processing skills. Beverly Hills, CA: Sage. Washington State Association of Broadcasters. (1990). Community outreach handbook: Tough choices: Tackling the teen alcohol problem. Olympia: Washington State Association of Broadcasters, Alcohol Task Force. Watkins, B., Calvert, S., Huston-Stein, Α., 8c Wright, J. C. (1980). Children's recall of television material: Effects of presentation mode and adult labeling. Developmental Psychology, 16, 672-679. Winick, M. P., 8c Winick, C. (1979). The television experience: What children see. Beverly Hills, CA: Sage. Worth, S., 8c Gross, L. L. (1974). Symbolic strategies. Journal of Communication, 24, 27-39. Wright, J. G , Huston, A. C , Ross, R P., Calvert, S. L., Rolandelli, D., Weeks, L. Α., Raeissi, P., 8c Potts, R. (1984). Pace and continuity of television programs: Effects on children's attention and comprehension. Developmental Psychology, 20, 653-666. Wright, J. C , 8c Huston, A. C. (1981). Children's understanding of the forms of television. In H. Kelly 8c H. Gardner (Eds.), Viewing children through television (pp. 73-88). San Francisco: Jossey-Bass. Yamaguchi, K., 8c Kandel, D. B. (1984). Patterns of drug use from adolescence to young adulthood. American Journal of Public Health, 74, 668-681. Young, Β. M. (1990). Television advertising and children. Oxford: Clarendon Press. Zucker, R. A. (1979). Developmental aspects of drinking through the young adult years. In Η. T. Blane 8c Μ. E. Chafetz (Eds.), Youth, alcohol and social policy (pp. 91-140). New York: Plenum.

Preschool

Attitudes still developing

still in flux, know social norms

Parents, significant

Tangible rewa rds from others Avoid punishrnent

Rewards, moral labels Conventional rules

Social norms Need for

Much

Sehex>l, family, ρ>eers

1-800 numbers Everyday role models Peers for present-

: peers, parental luence declining

caregivers

Motivated by

>rs well entrenched . . .

experimentation... Habitual use . . .

parents Parents, peers

Drop out of school

.ts c w

Directly influenced by

Expierimentatior

May experiment Peers, older role

r

More difficult to reach

Low resistance to peers

ε

All are credibl«

Eno rmous uncei

"8

Most credible info sources

Late Adolescence Ion-

C

Attitudes established;

Awareness, Imitation

MidAdolescence 13-16

2

expectations... Substance use

Early

1

Low

achievement... Antisocial behavior...

rign Design and Message: Understanding

iolescence 10

1

Under-

environment Family

-


Middle Childhood 7-10

Deprived

problems... Orientations to health

ts.

them at risk

in

d

Factors placing

Early School

erations in C
deration...

ε

00

teacher traini

c

strategies

Cognitive and

Parent &

Don't overreact, avoid preaching, avoid

Provide alternatives to risk taking

Basic cognitive

Media literacy...

solving skills

Decision-making skills... Informal classroom instruction...

How to get help Game playing,

Tactics

Hands-on activities

and problem-

puppets, songs, stories

Teach tacts, norms, consequences

Involve them in planning

community support Role playing, class presentation, guest speakers Frequency...

Type of rnedia to gain jiccess

Kids'TV Programs

TV, especially

heterosexism... Emphasize

TV, radio

formula shows

Interactive media... Radio & TV Magazines (esp. Seventeen, Teen, Sports Illustrated)...

parents watch

Mass media as catalyst.. Peer workshops... Novelty, drama Guest speakers Radio more than T V . . .

Posters Billboards Street theater Microcable Soaps, MTV

Why thin pro gran broadca

To entertain and inform...

Understanding of adveitising

May confuse ads & programs Separators help Visual & sound

Especiallyf pay arte ntion to

To make money...

Can ID an ad

Understand intent behind ads

To manipulate: skeptical of news, PSAs Skeptical but still respond...

Know ads sell More complexity

effects such as

in production...

Relevance, importance

Production values still important...

Real characters

animation, songs, puppets Immediacy Simplicity nding ises

Labels help Can get short &

143

direct messages Redundancy helps Consistency between visual

Visual presentations help

Understand symbols, metaphors, irony, sarcasm... Can handle longer

Adults levels of comprehension Still interpret lyrics in myriad ways

programs Can handle more

I

ι»

ο υ

144

Appendix

itinued Middle

Early

Childhood 7-10

and audio important

ylescence 10-13

Adolescemze 13-16

Adolescence

&

Age 5-7

•Si

Early School

0-5

1

Preschool

complexity... Order of plot elements matters

ayal is probable or represei itative?

Can do one thing at a time

elements

Can handle a few visual effects

Retain more information Recall more

Betteir at sorting central and inci dental i nformation incidental information Interruptions in plot sequence still hurt understanding

NOTES: Adaj>ted, u]pdated, and extended from Dorr, 1980. nerely estimates—many children will be ahead of or behind these estimates c >n various characteristics. Age differena . . . Indicates (:haract eristics relevant well past the age initially labeled.

c Ü

TV is made up Use more content

More skeptical cues to analyze if familiar

message

Integration oi

Portrayal is possible?

ο

Characters are real, animation is fantasy

connections

motivations Can take another's perspective with help IX,

W>

Skepticism toward mess

more than

c

miss the intended point

Very interested in motives, gooc 1 at understanding perspective and ir infer missing content υ

Learning Understand Interest in motives, conventions surface meaning, internal Respond to may rely on responses; OVERT behavior, stereotypes Make associations, appearances, can Notice consequences may lack logical

Inferential abilities

8

Fishing for Success USING THE PERSUASIVE HEALTH MESSAGE FRAMEWORK TO GENERATE EFFECTIVE CAMPAIGN MESSAGES

KIM WITTE

Give a person a fish, and he will eat supper. Teach a person to fish, and he will eat for a lifetime. —Chinese Proverb

B

r i d g i n g t h e gap b e t w e e n t h e o r y a n d p r a c t i c e is a n increasingly i m p o r t a n t b u t elusive goal. O n e i m p e d i m e n t t o t h e use of t h e o r y b y p r a c t i t i o n e r s is t h a t t h e o r i e s a p p e a r f o r m i d a b l e a n d difficult t o use. I n d e e d , s o m e t h e o r i e s are so c o m p l e x as t o p r e v e n t their use in practical settings. I n a d d i t i o n , t h e sheer n u m b e r of available theories is confusing in a n d of itself. M a n y p r a c t i t i o n e r s see t h e o r i e s as i v o r y - t o w e r c r e a t i o n s w i t h little relevance t o t h e real w o r l d . H o w e v e r , t h e o r i e s h a v e t h e capacity t o simplify a n d s y s t e m a t i z e t h e d e v e l o p m e n t of h e a l t h e d u c a t i o n i n t e r v e n t i o n s . I n fact, t h e y can m a k e t h e d e v e l o p m e n t of a h e a l t h c a m p a i g n easier a n d less t i m e - c o n s u m i n g t h a n a c a m p a i g n t h a t starts from scratch w i t h o u t a n y g u i d i n g p r i n c i p l e s . B u t , h o w d o e s o n e keep all of t h e theories straight? H o w does o n e choose a single t h e o r y from t h e array of available options? W h i c h is t h e m o s t a p p r o p r i a t e t h e o r y for a given health problem? Unfortunately, n o single t h e o r y can explain everything. AUTHOR'S NOTE: Kim Witte (Ph.D., University of California, Irvine) is Assistant Professor at Michigan State University. Kelly Morrison and Steve Robbins are gratefully acknowledged for their helpful comments on an earlier draft of this chapter, and Michael Stephenson and Melissa Becktold are thanked for developing some of the campaign messages presented in this chapter.

145

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APPROACHES

T h e o r i e s p r o v i d e explanations for limited, finite p h e n o m e n a . I n light of t h e s e p e r c e i v e d c o m p l e x i t i e s , it is little w o n d e r t h a t p r a c t i t i o n e r s t h r o w u p t h e i r h a n d s in f r u s t r a t i o n w h e n faced w i t h a m u l t i t u d e of t h e o r i e s , each r e l e v a n t only to limited situations. O n e w a y t o c u t c o n f u s i o n s u r r o u n d i n g t h e selection of a t h e o r y for a c a m p a i g n is t o c o m b i n e parts of successful a n d well-tested t h e o r i e s i n t o a single framework. A framework differs from a t h e o r y in that it d o e s n o t a t t e m p t t o e x p l a i n h u m a n b e h a v i o r , it s i m p l y o u t l i n e s w h a t o n e s h o u l d d o t o d e v e l o p t h e m o s t effective a n d p e r s u a s i v e c a m p a i g n possible. A f r a m e w o r k p o o l s t h e b e s t available k n o w l e d g e a b o u t a m u l t i t u d e of factors i n t o a s i m p l e g u i d e for c a m p a i g n d e v e l o p m e n t . T h a t is w h a t t h e f r a m e w o r k o u t l i n e d h e r e a t t e m p t s t o d o . It takes t h e best of t h r e e p r o m i n e n t p e r s u a s i o n t h e o r i e s , c o m b i n e s t h e m , a n d o u t l i n e s s t e p - b y - s t e p p r o c e d u r e s for d e v e l o p i n g an effective h e a l t h e d u c a t i o n p r o g r a m . This c h a p t e r p r e s e n t s a " c o o k b o o k " for busy practitioners desiring to develop theory-based campaigns that work. First, t h e f r a m e w o r k will b e o u t l i n e d (see W i t t e [1992a] for full r a t i o n a l e a n d e x p l i c a t i o n ) , t h e n t w o e x a m p l e s will b e given t o illustrate h o w t o u s e t h e f r a m e w o r k . T h e goal of o u t l i n i n g this t h e o r e t i c a l f r a m e w o r k is a n a l o g o u s t o t e a c h i n g s o m e o n e t o fish—the f r a m e w o r k can b e u s e d over a n d o v e r as a g u i d e t o d e v e l o p i n g health c a m p a i g n s .

The Persuasive Health Message (PHM) Framework R e s e a r c h e r s a n d p r a c t i t i o n e r s alike h a v e a r g u e d t h a t messages m u s t b e culturally, d e m o g r a p h i c a l l y , a n d geographically a p p r o p r i a t e if t h e y a r e t o i n f l u e n c e t h e a u d i e n c e as i n t e n d e d (Atkin 8c F r e i m u t h , 1989; F i s h b e i n & Ajzen, 1981; Flora 8c T h o r e s o n , 1988). T h e Persuasive Health Message ( P H M ) F r a m e w o r k , c o m p r i s e d of e l e m e n t s from t h e t h e o r y of r e a s o n e d a c t i o n (Fishbein 8c Ajzen, 1975), the elaboration likelihood m o d e l (Petty 8c C a c i o p p o , 1986), a n d p r o t e c t i o n m o t i v a t i o n t h e o r y (Rogers, 1983), offers an i n t e g r a t e d a p p r o a c h t o g e n e r a t i n g effective c a m p a i g n s . In brief, t h e P H M f r a m e w o r k states t h a t t w o s e p a r a t e factors, t h e constant a n d t h e transient factors, m u s t b e a d d r e s s e d p r i o r t o t h e d e v e l o p m e n t of c a m p a i g n messages (see Figure 8.1). T h e c o n t e n t a n d features of a p e r s u a sive m e s s a g e a r e s t r u c t u r e d b y t h e c o n s t a n t c o m p o n e n t s of t h e f r a m e w o r k . F o r e x a m p l e , a persuasive h e a l t h message s h o u l d c o n t a i n a threat m e s s a g e , a n efficacy m e s s a g e , v a r i o u s cues, a n d s h o u l d b e t a r g e t e d t o w a r d a specific a u d i e n c e — r e g a r d l e s s of t h e t o p i c , t y p e of message, o r e n v i r o n m e n t . T h e

The Persuasive Message Framework

147

t h r e a t p o r t i o n of t h e m e s s a g e tries t o m a k e t h e a u d i e n c e feel susceptible t o a severe t h r e a t . T h e efficacy p o r t i o n o f t h e m e s s a g e tries t o c o n v i n c e i n d i v i d u als t h e y a r e able t o p e r f o r m t h e r e c o m m e n d e d r e s p o n s e (i.e., self-efficacy) a n d t h a t t h e r e c o m m e n d e d r e s p o n s e effectively averts t h e t h r e a t (i.e., r e s p o n s e efficacy). T h e available e v i d e n c e f r o m fear a p p e a l r e s e a r c h suggests t h a t w h e n i n d i v i d u a l s perceive h i g h levels of t h r e a t (e.g., " I ' m at risk for d e v e l o p i n g skin c a n c e r a n d c o u l d die from it") and h i g h levels of efficacy (e.g., " B u t if I w e a r s u n s c r e e n a n d get m y d o c t o r t o p e r f o r m s k i n e x a m i n a tions I can prevent serious h a r m and perhaps prevent the disease"), then t h e y a r e m o t i v a t e d t o p r o t e c t t h e m s e l v e s against t h e t h r e a t ( W i t t e , 1992b, 1992c). T h u s , t o m o t i v a t e a u d i e n c e s i n t o a c t i o n , a p e r s u a s i v e h e a l t h m e s s a g e s h o u l d c o n v i n c e i n d i v i d u a l s (a) t h e y are susceptible t o a severe t h r e a t a n d t h a t (b) a d o p t i n g a n easy a n d feasible r e c o m m e n d e d r e s p o n s e w o u l d effectively avert t h e t h r e a t . R e c e n t theoretical a n d e m p i r i c a l w o r k o n fear a p p e a l s offers i m p o r t a n t caveats t o k e e p in m i n d w h e n d e s i g n i n g t h r e a t e n i n g o r f e a r - a r o u s i n g p e r s u a s i v e h e a l t h messages. Specifically, p e r c e p t i o n s of t h r e a t m u s t b e sufficiently b a l a n c e d b y s t r o n g r e s p o n s e a n d self-efficacy p e r c e p t i o n s . T h a t is, t h e r e c o m m e n d e d r e s p o n s e m u s t b e p e r c e i v e d b y t h e a u d i e n c e as efficacious e n o u g h t o e l i m i n a t e o r substantially r e d u c e t h e t h r e a t b e f o r e i n d i v i d u a l s will c h a n g e their b e h a v i o r s (Rogers, 1975, 1983; W i t t e , 1992b, 1992c). If a t h r e a t is p e r c e i v e d as t o o h i g h , s u c h t h a t i n d i v i d u a l s believe n o r e s p o n s e w o u l d effectively d e t e r it, t h e m e s s a g e will backfire. F o r i n s t a n c e , w h e n p e r c e i v e d t h r e a t is h i g h a n d p e r c e i v e d efficacy is low (e.g., "Skin c a n c e r is u n a v o i d a b l e ; I c a n ' t d o a n y t h i n g that'll p r e v e n t i t " ) , p e o p l e b e c o m e f r i g h t e n e d a n d defensive m o t i v a t i o n is elicited, r e s u l t i n g in m a l a d a p t i v e r e s p o n s e s s u c h as d e n i a l o r defensive a v o i d a n c e ( W i t t e , 1992b, 1992c). Fear a p p e a l s c a n t h u s b e effective p e r s u a s i v e messages, b u t o n l y w h e n both t h r e a t a n d efficacy a r e h i g h . T h e cues c o n s t a n t c o m p o n e n t refers t o t h o s e variables t h a t can i n f l u e n c e t h e p e r s u a s i v e p r o c e s s in an i n d i r e c t m a n n e r . F o r e x a m p l e , a p e r s o n m a y a c c e p t a p e r s u a s i v e m e s s a g e s i m p l y b e c a u s e it w a s d e l i v e r e d b y a h i g h credibility p e r s o n , n o t b e c a u s e she o r h e believed t h e a r g u m e n t s . T h u s , p e o p l e c a n b e p e r s u a d e d b y p e r i p h e r a l cues s u c h as credibility o r a t t r a c t i v e ness of t h e s o u r c e o r b y t h e a r g u m e n t s o r c o n t e n t of a m e s s a g e ( P e t t y 8c C a c i o p p o , 1986). W h e n p e o p l e are p e r s u a d e d b y p e r i p h e r a l cues, t h e y a r e said t o h a v e p r o c e s s e d t h e message peripherally. T h a t is, t h e y h a v e n o t t h o u g h t f u l l y c o n s i d e r e d t h e a r g u m e n t s in t h e m e s s a g e a n d h a v e u s e d cues to guide their decisions. People process a message peripherally w h e n they h a v e little interest, ability, a n d / o r m o t i v a t i o n t o evaluate t h e m e s s a g e . F o r e x a m p l e , messages p e r s u a d e p e o p l e via t h e p e r i p h e r a l r o u t e b y p r o v i d i n g

148

"Constants"

THEORY-DRIVEN

APPROACHES

"Transients"

Ti h r e a t Susceptibility Seventy Message Goals Efficacy Response Efficacy Self-Efficacy

Salient Beliefs Salient Referents Arguments Developed

Cues Message Source A u d i e n c e Profile Demographics Psychographics Customs, Values

Persuasive Message

Culture Environment Preferences

Figure 8.1. A Framework for Developing Culturally Specific Persuasive Health Messages

s i m p l e associations o r heuristics (e.g., "If m y d o c t o r uses Bayer a s p i r i n , t h e n I s h o u l d , t o o " ) . In c o n t r a s t , w h e n p e o p l e believe a t o p i c t o b e r e l e v a n t t o t h e m a n d i m p o r t a n t , t h e y p r o c e s s t h e m e s s a g e centrally b y carefully listeni n g t o a n d e v a l u a t i n g t h e c o n t e n t of t h e message ( P e t t y 8c C a c i o p p o , 1986). B e c a u s e p r o c e s s i n g a m e s s a g e via t h e c e n t r a l r o u t e takes m u c h c o g n i t i v e w o r k , h o w e v e r ( o n e has t o t h i n k ! ) , messages are p r o c e s s e d centrally o n l y w h e n t h e y a r e very i m p o r t a n t o r relevant t o a p e r s o n . T w o variables act as c u e s — s o u r c e a n d message variables. Variables r e lated t o t h e s o u r c e of a message, s u c h as credibility, a t t r a c t i v e n e s s , similarity, o r p o w e r , can h a v e s u b t l e b u t significant i m p a c t s o n w h e t h e r t h e a u d i e n c e takes t h e m e s s a g e seriously a n d is m o t i v a t e d t o act ( M c G u i r e , 1984). S i m i larly, t h e m a n n e r in w h i c h a message is o r g a n i z e d , t h e t y p e of a p p e a l given (i.e., e m o t i o n a l o r logical), the n u m b e r of repetitions in a message, t h e vividness of language used, a n d m o r e , can all influence the persuasive process ( M c G u i r e , 1984). A l t h o u g h s o u r c e a n d message variables can b e t h o u g h t f u l l y c o n s i d e r e d in a c e n t r a l r o u t e m a n n e r , t h e y are believed t o act m o r e often as variables t h a t c u e a p e r s o n t o accept a message, a n d t h u s t e n d t o b e p r o c e s s e d peripherally.

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Framework

149

T h e final c o n s t a n t c o m p o n e n t is t h e audience profile. T h e a u d i e n c e profile is a n i m p o r t a n t c o n s t a n t c o m p o n e n t b e c a u s e it m a k e s t h e m e s s a g e "fit" t h e audience. For example, demographic and psychographic information gathered a b o u t t h e audience, as well as cultural beliefs a n d values, m a k e t h e m e s s a g e r e l e v a n t a n d a p p r o p r i a t e for t h e t a r g e t e d a u d i e n c e . If a t a r g e t e d a u d i e n c e speaks V i e t n a m e s e , h a s a l o w literacy level, a n d h o l d s a collectivist w o r l d v i e w (i.e., family c o n c e r n s placed above self-concerns), t h e n a message s h o u l d b e in V i e t n a m e s e , easy t o r e a d o r c o m p r e h e n d , a n d f r a m e t h e r e c o m m e n d e d r e s p o n s e in a m a n n e r t h a t helps t h e family o r g r o u p . T h e p a r t s of a message t h a t c h a n g e given different p o p u l a t i o n s a n d m e s s a g e goals are t h e transien f c o m p o n e n t s of t h e P H M f r a m e w o r k . T r a n sient o r c h a n g e a b l e e l e m e n t s of a c a m p a i g n — s u c h as salient beliefs, salient referents, c u l t u r e , e n v i r o n m e n t , a n d m e s s a g e g o a l s — d e t e r m i n e t h e a c t u a l m e s s a g e c o n t e n t a n d features of t h e c o n s t a n t c o m p o n e n t s . T h e r e a r e t w o categories of t r a n s i e n t i n f o r m a t i o n t o gather. First, i n f o r m a t i o n r e l e v a n t t o t h e t h r e a t a n d efficacy of t h e r e c o m m e n d e d r e s p o n s e m u s t b e d e t e r m i n e d . T h e goals of t h e m e s s a g e m u s t b e clearly stated. W h a t exactly is t h e t h r e a t a n d w h a t exactly is t h e r e c o m m e n d e d r e s p o n s e t o avert o r m i n i m i z e h a r m f r o m t h e threat? As well, salient beliefs a b o u t t h e t h r e a t a n d efficacy of t h e r e c o m m e n d e d r e s p o n s e n e e d t o b e d e t e r m i n e d . Finally, salient referents a n d salient r e f e r e n t s ' beliefs a b o u t t h e t a r g e t e d a u d i e n c e m e m b e r ' s risk o f e x p e r i e n c i n g t h e t h r e a t , t h e severity of t h e t h r e a t , t h e efficacy o f t h e r e c o m m e n d e d r e s p o n s e in a v e r t i n g t h e t h r e a t , a n d t h e t a r g e t e d a u d i e n c e m e m b e r ' s ability t o p e r f o r m the r e c o m m e n d e d response, m u s t b e gathered. ( T h e r a t i o n ale for d e t e r m i n i n g t h e s e beliefs is b a s e d o n t h e t h e o r y of r e a s o n e d a c t i o n a n d is e x p l a i n e d below.) T h e s e c o n d c a t e g o r y of t r a n s i e n t i n f o r m a t i o n — c u l t u r e / e n v i r o n m e n t a n d p r e f e r e n c e s — i s u s e d t o d e v e l o p cues a n d t h e a u d i e n c e profile. S o u r c e a n d m e s s a g e p r e f e r e n c e s will aid in t h e p r o d u c t i o n o f cues (e.g., W h o d o y o u w a n t t o h e a r a b o u t safer sex from?). T h e a u d i e n c e profile is d e v e l o p e d f r o m cultural ( d e m o g r a p h i c s , psychographics) a n d e n v i r o n m e n t a l (potential b a r r i ers, e.g., lack of services, lack of t r a n s p o r t a t i o n ) i n f o r m a t i o n . I n a d d i t i o n , c h a n n e l (e.g., r a d i o , T V , n e w s p a p e r ) preferences s h o u l d b e d e t e r m i n e d t o achieve m a x i m u m r e a c h of t h e m e s s a g e ( t h e s e are n o t cues p e r se, b u t t h e y c a n b e p a r t of t h e a u d i e n c e profile). T o d e t e r m i n e t h e t r a n s i e n t i n f o r m a t i o n n e e d e d for t h e f r a m e w o r k , a n a u d i e n c e analysis n e e d s t o b e c o n d u c t e d w h e r e i n f o r m a t i o n specified b y t h e c o n s t a n t c o m p o n e n t s is d e t e r m i n e d . Fishbein a n d Ajzen ( 1 9 7 5 , 1 9 8 1 ) a r g u e in t h e i r t h e o r y o f r e a s o n e d a c t i o n t h a t t h e o n l y w a y t o effectively i n d u c e b e h a v i o r c h a n g e in a p e r s u a s i v e message is t o c h a n g e t h e u n d e r l y i n g set of

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salient beliefs t h a t are c a u s i n g a specific b e h a v i o r . (Salient beliefs a r e o n e ' s p r i m a r y beliefs o n a t o p i c o r issue.) For i n s t a n c e , if a f a r m e r believes "I a m i n v u l n e r a b l e t o skin c a n c e r , " " o n l y city folk get t h e disease," " w e a r i n g a h a t a n d a long-sleeved shirt m a k e s m e h o t , " "real m e n d o n ' t w e a r s u n s c r e e n , " " t h e r e ' s n o t h i n g y o u can d o t o p r e v e n t skin c a n c e r , " a n d "I d o n ' t h a v e t i m e t o g o see a d o c t o r , " t h e n c h a n g i n g o n l y a single belief is unlikely t o i n f l u e n c e his overall skin cancer risk b e h a v i o r b e c a u s e t h e o t h e r e x t a n t beliefs p r o m o t e t h e s a m e risky b e h a v i o r . In a d d i t i o n to d e t e r m i n i n g t h e target a u d i e n c e ' s salient beliefs a b o u t a health threat, the theory of reasoned action also suggests t h a t salient referents b e d e t e r m i n e d (e.g., i n d i v i d u a l s w h o i n f l u e n c e h o w t h e f a r m e r b e h a v e s ) , a n d beliefs a b o u t w h a t t h e t a r g e t e d a u d i e n c e t h i n k s salient referents t h i n k a b o u t t h e a d v o c a t e d b e h a v i o r c h a n g e b e assessed (e.g., " M y wife t h i n k s I s h o u l d use s u n s c r e e n " ) . For e x a m p l e , t h e t h e o r y of r e a s o n e d a c t i o n ' s subjective n o r m c o m p o n e n t is c o m p r i s e d of (a) w h a t t h e t a r g e t e d i n d i v i d u a l t h i n k s salient referents t h i n k a b o u t t h e t a r g e t e d i n d i v i d u a l p e r f o r m i n g B e h a v i o r X, a n d (b) t h e t a r g e t e d i n d i v i d u a l ' s m o t i v a t i o n t o c o m p l y w i t h t h e salient referent. A p p l y i n g this c o n c e p t of subjective n o r m t o t h e P H M f r a m e w o r k , it is i m p o r t a n t t o d e t e r m i n e w h a t t a r g e t e d i n d i v i d u a l s t h i n k salient referents believe a b o u t t h e h e a l t h t h r e a t a n d r e c o m m e n d e d response (as well as finding o u t h o w motivated the targeted a u d i e n c e m e m b e r is t o c o m p l y w i t h salient referents). For e x a m p l e , if t a r g e t e d a u d i e n c e m e m bers are heavy smokers, salient referents will influence w h e t h e r o r n o t t a r g e t e d a u d i e n c e s d o in fact q u i t s m o k i n g . T h a t is, if a significant o t h e r d o e s n ' t really t h i n k t h e t a r g e t e d a u d i e n c e m e m b e r is at risk for l u n g c a n c e r ( b e c a u s e h e o r s h e c o m e s f r o m g o o d genetic s t o c k ) , d o e s n ' t t h i n k l u n g c a n c e r is severe (after all, w e h a v e t w o l u n g s ) , t h i n k s it's t o o late t o q u i t s m o k i n g a n y w a y ( t h e d a m a g e is d o n e ) , a n d d o e s n ' t believe t h a t t h e t a r g e t e d a u d i e n c e m e m b e r w o u l d actually b e able t o q u i t , t h e n it is unlikely t h a t t h e target a u d i e n c e m e m b e r s will q u i t . I n s u m , t o m a x i m i z e t h e o d d s of achieving b e h a v i o r c h a n g e , (a) t h e whole set o f salient beliefs t o w a r d an a d v o c a t e d b e h a v i o r m u s t b e u n c o v e r e d , a n d (b) salient beliefs t h a t i n h i b i t t h e b e h a v i o r s h o u l d b e c o u n t e r e d w h i l e salient beliefs t h a t e n c o u r a g e t h e b e h a v i o r s h o u l d b e s u p p o r t e d ( F i s h b e i n & Ajzen, 1975, 1981). O n c e this t r a n s i e n t i n f o r m a t i o n (i.e., salient beliefs a n d refere n t s ) for each of t h e c o n s t a n t c o m p o n e n t s is d e t e r m i n e d , t h e n t h e messages can b e d e v e l o p e d . T h e i n t e g r a t i o n of t h e " t r a n s i e n t " i n f o r m a t i o n i n t o t h e " c o n s t a n t " c o m p o n e n t s of t h e f r a m e w o r k serves a n i m p o r t a n t f u n c t i o n . First, t h e t a r g e t i n g of a n a u d i e n c e ' s specific salient beliefs a b o u t t h e t h r e a t a n d efficacy of t h e r e c o m m e n d e d r e s p o n s e increases i n v o l v e m e n t in a n d p e r s o n a l relevancy of

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t h e m e s s a g e . I n c r e a s e d i n v o l v e m e n t in a message leads t o c e n t r a l p r o c e s s i n g of the message, which is desirable because it leads t o lasting a n d stable a t t i t u d e change (Petty & C a c i o p p o , 1986). If salient beliefs are targeted in t h e m e s s a g e t h e n m o t i v a t i o n a n d / o r a b i l i t y of a u d i e n c e m e m b e r s t o p r o c e s s t h e m e s s a g e s h o u l d increase b e c a u s e t h e message is relevant t o t h e m a n d t h e y can u n d e r s t a n d it. S o m e t i m e s , h o w e v e r , a u d i e n c e s are s i m p l y t o o t i r e d o r p r e o c c u p i e d t o p r o c e s s a m e s s a g e centrally, even t h o u g h t h e i n t e g r a t i o n of t h e t r a n s i e n t salient beliefs s h o u l d m o t i v a t e t h e m t o care a n d t o t h i n k a b o u t t h e h e a l t h t h r e a t a n d r e c o m m e n d e d r e s p o n s e . T h u s , cues a r e i m p o r t a n t t o a n effective health campaign. As m a n y of the cues (e.g., source credibility, s o u r c e a t t r a c t i v e n e s s , m e s s a g e f o r m ) as possible s h o u l d b e a d d r e s s e d in t h e p e r s u a sive m a s s m e d i a message, b e c a u s e p e o p l e w h o a r e u n a b l e o r u n m o t i v a t e d t o p r o c e s s t h e h e a l t h c o m m u n i c a t i o n centrally can still b e p e r s u a d e d b y a p p r o p r i a t e cues via t h e p e r i p h e r a l r o u t e . T r a n s i e n t c u l t u r a l , e n v i r o n m e n t a l , a n d d e m o g r a p h i c factors influence t h e selection of w h i c h cues t o e m p h a s i z e . In s h o r t , d e v e l o p i n g a p e r s u a s i v e h e a l t h m e s s a g e a c c o r d i n g t o this f r a m e w o r k s h o u l d e n h a n c e t h e likelihood of d e v e l o p i n g m e s s a g e s t h a t i n f l u e n c e b o t h a u d i e n c e m e m b e r s w h o care a b o u t t h e t o p i c a n d p r o c e s s t h e m e s s a g e centrally, a n d t h o s e w h o c o u l d care less a b o u t t h e t o p i c a n d p r o c e s s t h e m e s s a g e peripherally.

Using the PHM Framework to Develop Campaigns D e v e l o p i n g p e r s u a s i v e messages w i t h t h e f r a m e w o r k r e q u i r e s a t h r e e - s t e p p r o c e s s . T h e first t w o steps involve d e t e r m i n i n g t r a n s i e n t i n f o r m a t i o n . As stated p r e v i o u s l y , first, i n f o r m a t i o n a b o u t t h e t h r e a t a n d efficacy of t h e r e c o m m e n d e d response m u s t be determined. Second, cultural a n d environm e n t a l characteristics a n d preferences m u s t b e assessed to develop the a u d i e n c e profile a n d c u e s . In t h e t h i r d step, this t r a n s i e n t i n f o r m a t i o n for e a c h o f t h e c o n s t a n t c o m p o n e n t s is u s e d t o g e n e r a t e t h e p e r s u a s i v e m e s s a g e . In Step 1, salient beliefs a n d salient referents m u s t b e d e t e r m i n e d a n d t h e precise c a m p a i g n b e h a v i o r a l goal m u s t b e specified (i.e., t h e c a m p a i g n goal is t o p r e v e n t T h r e a t X in T a r g e t A u d i e n c e Y b y p r o m o t i n g r e s p o n s e a n d self-efficacy of r e c o m m e n d e d R e s p o n s e Z ) . T a b l e 8.1 gives an e x a m p l e of h o w t o d e t e r m i n e specific goals w i t h t h e case of A I D S p r e v e n t i o n . N o t e t h a t n o t o n l y m u s t t h e t h r e a t b e specified ( H I V t r a n s m i s s i o n ) b u t m o r e i m p o r tantly, t h e specific behavior (i.e., r e c o m m e n d e d response) t h a t will b e a d v o c a t e d t o p r e v e n t o r avert t h e t h r e a t (e.g., c o n d o m u s e ) . I n a n y c a m p a i g n t h e

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TABLE 8.1 Message "Transients" I. Message Goals Overall Behavior Population

What is the threat to be prevented? -> HIV infection How will this threat be prevented? —» By advocating condom use Define target audience —> Hispanic men, age 15-44

II. Salient Beliefs ("attitudes") Susceptibility "Will you contract the AIDS virus? Why or why not?" Severity "What will happen to you if you get the virus?" Self-efficacy "Can you use condoms to prevent HIV infection? Why or why not? Will you use condoms to prevent HIV infection? Why or why not? What are the advantages or disadvantages of using condoms?" "Do you think condoms prevent HIV infection? Why or Response efficacy why not?" Salient referents ("subjective norms")

Susceptibility Severity Self-efficacy

Response efficacy

"Are there any people or groups important to you who would approve or disapprove of you using condoms to prevent pregnancy or HIV infection? Are there any people or groups important to you who would approve or disapprove of you using condoms to prevent HIV infection? Who are these people or groups?" "Do you think your (specific referent) thinks you are at risk for being infected with the AIDS virus? Why or why not?" "What does (specific referent) think happens to people when they get infected with the AIDS virus?" "Does (specific referent) think you can or should use condoms to prevent HIV infection? Why or why not? Does (specific referent) use condoms to prevent HIV infection? Why or why not? What does (specific referent) think are the advantages or disadvantages of using condoms?" "Does (specific referent) think condoms prevent HIV infection? Why or why not?"

r e c o m m e n d e d r e s p o n s e is t h e i m m e d i a t e goal o r focus of t h e c a m p a i g n (e.g., c o n d o m u s e ) , w i t h t h e belief t h a t t h e u l t i m a t e goal (e.g., A I D S p r e v e n t i o n ) c a n b e a c h i e v e d t h r o u g h a d o p t i o n of t h i s r e c o m m e n d e d r e s p o n s e (i.e., prevent AIDS by advocating c o n d o m use). In addition to determining the c a m p a i g n goals in S t e p 1, t h e t a r g e t a u d i e n c e m u s t b e clearly i d e n t i f i e d . T h e r e a r e t w o w a y s t o d e t e r m i n e salient beliefs a n d s a l i e n t r e f e r e n t s . Either existing research m a y b e used or original research can be c o n d u c t e d . T a b l e 8.1 s h o w s t h e k i n d s of q u e s t i o n s o n e w o u l d a s k in o r i g i n a l r e s e a r c h , a n d T a b l e 8.2 s h o w s h o w e x i s t i n g p u b l i s h e d s u r v e y d a t a c a n b e u s e d t o

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TABLE 8.1 Continued III. Culture/Environment Variables and Preferences Source Who would you believe the most in an HIV/AIDS prevention message? Who do you want to hear talk about HIV/ AIDS prevention? Channel Where do you prefer to get your information about HIV/ AIDS prevention? Message Determine appropriate colloquialisms. Present the message in culturally appropriate manner (e.g., watch for embarrassment, respect privacy). Receiver Define target population according to demographic variables (e.g., socioeconomic status, literacy level, age, employment, residence, primary language, etc.). Survey target population for source, channel, and message type preferences, as well as for values (e.g., what are the key values this population holds), customs (e.g., any particular habits or customs?), and health beliefs (e.g., "Is it possible to carry a virus without being sick?").

d e t e r m i n e salient beliefs w i t h t h e e x a m p l e given of H i s p a n i c m e n ' s salient beliefs t o w a r d A I D S a n d c o n d o m s . Salient beliefs a b o u t t h e t h r e a t , t h e efficacy of t h e r e c o m m e n d e d r e s p o n s e , a n d beliefs a b o u t w h a t t h e a u d i e n c e m e m b e r s t h i n k salient referents t h i n k a b o u t t h e t h r e a t a n d r e c o m m e n d e d r e s p o n s e n e e d t o b e d e t e r m i n e d . First, t h e target a u d i e n c e s h o u l d b e q u e r i e d a b o u t t h e i r p e r c e i v e d susceptibility t o t h e t h r e a t as well as t h e p e r c e i v e d severity of t h e t h r e a t (see T a b l e s 8.1 a n d 8.2). N e x t , t h e t a r g e t a u d i e n c e ' s salient beliefs a b o u t the effectiveness of the r e c o m m e n d e d response in a v e r t i n g t h e t h r e a t (i.e., r e s p o n s e efficacy) a n d their p e r c e i v e d ability t o u s e o r n o t use t h e r e c o m m e n d e d response (i.e., self-efficacy a n d barriers t o self-efficacy) n e e d t o b e d e t e r m i n e d . Barriers t o self-efficacy a r e i m p o r t a n t t o d e t e r m i n e b e c a u s e t h e s e act as obstacles t o a d o p t i o n of t h e r e c o m m e n d e d r e s p o n s e . T h u s , if a t a r g e t e d a u d i e n c e m e m b e r believes t h a t c o n d o m s r e d u c e p l e a s u r e a n d d e c r e a s e virility, this belief acts as a b a r r i e r t o his o r h e r p e r c e i v e d ability t o use c o n d o m s . Barriers t h u s decrease p e r c e p t i o n s of self-efficacy. I n t h e case o f c o n d o m s a n d H i s p a n i c m e n (Table 8.2), it a p p e a r s t h a t H i s p a n i c m e n t h i n k t h a t u s i n g c o n d o m s will r e d u c e their virility a n d p l e a s u r e , as well as m a k e t h e m s u s p e c t for " l o o s e " o r d a n g e r o u s b e h a v i o r . It is t h e r e f o r e i m p o r t a n t t o u n c o v e r t h e s e sensitive beliefs so t h a t t h e p e r s u a s i v e c a m p a i g n c a n a d d r e s s t h e s e issues directly. T h i r d , salient referents m u s t b e solicited. T h e i n d i v i d u a l s o r g r o u p s t h a t h a v e t h e m o s t influence o n t h e t a r g e t e d a u d i e n c e w i t h reference t o t h e specified t h r e a t a n d t h e r e c o m m e n d e d

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r e s p o n s e s h o u l d b e d e t e r m i n e d . For e x a m p l e , t h e a u d i e n c e s h o u l d b e a s k e d w h e t h e r " t h e r e are any people o r g r o u p s i m p o r t a n t t o y o u w h o w o u l d a p p r o v e o r d i s a p p r o v e of y o u u s i n g c o n d o m s t o p r e v e n t A I D S ? " (i.e., salient refere n t s for t h e r e c o m m e n d e d r e s p o n s e ) as well as w h e t h e r " t h e r e a r e a n y p e o p l e o r g r o u p s i m p o r t a n t t o y o u w h o w o u l d a p p r o v e o r d i s a p p r o v e of y o u u s i n g c o n d o m s ? " (i.e., salient referents for t h e t h r e a t ) . N o t i c e t h a t t h e s e q u e s t i o n s m a y p r o m p t different a n s w e r s , so b o t h a r e i m p o r t a n t . T h e t a r g e t e d a u d i e n c e ' s beliefs a b o u t w h a t salient referents t h i n k a r e i m p o r t a n t t o u n c o v e r , t o o . I n o t h e r w o r d s , a practitioner needs t o ascertain w h a t t h e target a u d i e n c e m e m b e r believes his o r h e r salient referent believes a b o u t t h e t h r e a t ( b o t h susceptibility a n d severity) a n d t h e r e c o m m e n d e d r e s p o n s e ( b o t h r e s p o n s e efficacy a n d self-efficacy) w i t h reference t o t h e target a u d i e n c e m e m b e r (e.g., " M y wife t h i n k s I a m at risk for c o n t r a c t i n g H I V " ) . Ideally, Ajzen a n d F i s h b e i n ' s ( 1 9 8 0 , c h a p . 6) t e c h n i q u e s for g a t h e r i n g salient beliefs a n d refere n t s s h o u l d b e used. T h e A p p e n d i x t o this c h a p t e r gives a p r o t o t y p e of a c l o s e d - e n d e d q u e s t i o n n a i r e p r a c t i t i o n e r s can use as well as an e x a m p l e of a q u e s t i o n n a i r e focusing o n diabetes ( t h e t h r e a t ) p r e v e n t i o n t h r o u g h a l o w fat, l o w - s u g a r d i e t ( t h e r e c o m m e n d e d r e s p o n s e ) . A l t h o u g h a f a c e - t o - f a c e o r t e l e p h o n e i n t e r v i e w m a y yield m o r e i n - d e p t h i n f o r m a t i o n ( T a b l e 8.1), a n a n o n y m o u s s u r v e y o r m a i l q u e s t i o n n a i r e (as o u t l i n e d in t h e A p p e n d i x ) m a y b e a m o r e efficient m e a n s t o g a t h e r t h e i n f o r m a t i o n n e e d e d for t h e framework. In Step 2, t h e a u d i e n c e profile is d e v e l o p e d , a n d i n f o r m a t i o n for t h e cues is g a t h e r e d . D e m o g r a p h i c i n f o r m a t i o n available f r o m c e n s u s r e c o r d s a n d d a t a f r o m s u r v e y research can b e u s e d t o create a profile. It is also useful t o g a t h e r i n f o r m a t i o n directly from a s a m p l e of t h e t a r g e t e d a u d i e n c e r e g a r d i n g t h e i r c u l t u r a l values, perceived b a r r i e r s , a n d h e a l t h - r e l a t e d c u s t o m s t o flesh o u t t h e profile. Finally, c h a n n e l , m e s s a g e , a n d s o u r c e p r e f e r e n c e s m u s t b e d e t e r m i n e d from t h e t a r g e t a u d i e n c e (e.g., " W h o w o u l d y o u prefer t o get AIDS prevention information from?"). In Step 3 , t h e p e r s u a s i v e m e s s a g e is c o n s t r u c t e d . T h e r e a r e a t least t h r e e types of a r g u m e n t s t h a t c a n b e m a d e in t h e p e r s u a s i v e m e s s a g e . A m e s s a g e c a n t r y t o c h a n g e beliefs, reinforce existing beliefs, o r i n t r o d u c e n e w beliefs ( B u r g o o n , 1989; M c G u i r e , 1985). It is far easier t o i n t r o d u c e , reinforce, o r b u i l d o n existing beliefs in a c a m p a i g n t h a n it is t o t r y t o c h a n g e existing a n d e n t r e n c h e d a t t i t u d e s (Atkin, 1993). T h e b e s t c a m p a i g n s a r e t h o s e t h a t a r e framed t o fit within acceptable beliefs, attitudes, a n d behaviors (i.e., reinforcem e n t ) . It is t h e r e f o r e helpful t o frame t h e r e c o m m e n d e d r e s p o n s e as a l r e a d y fitting w i t h i n t h e target a u d i e n c e ' s c u r r e n t belief a n d b e h a v i o r a l s y s t e m . T a b l e 8.3 s h o w s h o w t h e salient beliefs g a t h e r e d f r o m existing r e s e a r c h a b o u t

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TABLE 8.2 Message "Transients" for Targeted Population of Hispanic Men I. Message Goals Overall Behavior Population II. Salient Beliefs Susceptibility

Severity

Barriers to self-efficacy

Response efficacy Salient referents

Susceptibility Severity Barriers to self-efficacy

Response efficacy

To Prevent AIDS by Using Condoms Hispanic men, age 15-44 Perceive litde susceptibility to AIDS (Navarro, 1989; Peterson & Marin, 1988). D o not think they engage in risky behaviors—even if they have unprotected anal intercourse with other men (Carrier, 1976; Marin, 1989; Peterson & Marin, 1988). Perceived severity of AIDS is unknown. Hispanics in general know less about AIDS and its prevention than nonHispanics (Marin, 1989). Condoms used infrequently by Hispanics (Marin, 1989). Associate condoms with uncleanliness and prostitution, believe condoms reduce pleasure, virility, and are inconvenient and uncomfortable to use (Carrier, 1989; Marin, 1989; Marin & Marin, 1987). Using condoms maybe seen as an admission that one is at risk for AIDS (Marin, 1989). Instructions typically difficult and in English only (Richwald, Schneider-Munoz, 8c Valdez, 1989). Perceived response efficacy of condoms in preventing AIDS is unknown. Other Hispanic men, significant others, family members, the Roman Catholic church (Carrier, 1976; Navarro, 1989; Thompson, 1987). Undetermined Undetermined Roman Catholic church strongly disapproves of condom use. Other referent groups' beliefs undetermined (Navarro, 1989). Undetermined

III. Culture/Environment Variables and Preferences Undetermined, Peers? Source Radio, television Channel Use appropriate colloquialisms (the "pasivo" sexual role for Message receptive anal intercourse; the "activo" sexual role for anal insertive role; etc.) (Carrier, 1989). Spanish-speaking, low literacy level, lives in the Southwest, Audience profile median age 22.8, retains Hispanic values and customs (e.g., machismo, familialism, respeto, simpatia, personalismo, cooperation), strong cultural and religious taboos against homosexuality (Carrier, 1976; Marin, 1989), economically and medically disadvantaged.

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TABLE 8.3 Salient Beliefs and Cues to Address in the Persuasive Message for Hispanic Men Beliefs to CHANGE Low perceived susceptibility Condoms are admission

Beliefs to REINFORCE Family values important (use these values in prevention message)

Beliefs to INTRODUCE HIV infection is severe (even though AIDS won't appear for years)

of risk Condoms unclean and uncomfortable Condoms decrease virility, desirability, pleasure "Activo" partner not at risk

Condoms prevent HIV infection if used correctly

CUES TO ADDRESS Cultural values Colloquialisms Radio, TV channels best Source preferences Literacy level Customs relating to "sexual discussions"

H i s p a n i c m e n a n d H I V can b e placed i n t o each of t h e s e categories. T h e p e r s u a s i v e m e s s a g e , t h e r e f o r e , s h o u l d f r a m e t h e m e s s a g e as p r o m o t i n g a n d p r o t e c t i n g i m p o r t a n t c u l t u r a l values of H i s p a n i c m e n , as well as i n c r e a s i n g t h e i r p e r c e p t i o n of susceptibility of c o n t r a c t i n g t h e v i r u s . In a d d i t i o n , a s u b s t a n t i a l p o r t i o n of t h e message n e e d s t o focus o n t h e acceptability a n d ease w i t h w h i c h H i s p a n i c m e n can use c o n d o m s (i.e., self-efficacy). B e c a u s e w e d o n o t k n o w w h e t h e r A I D S is p e r c e i v e d as severe o r w h e t h e r c o n d o m s a r e seen as effective b y H i s p a n i c m e n , t h e s e beliefs s h o u l d b e i n t r o d u c e d w i t h H I V infection being presented as a severe a n d serious c o n d i t i o n , a n d c o n d o m s b e i n g p r e s e n t e d as a n effective w a y t o p r e v e n t H I V t r a n s m i s s i o n . I n s u m , for H i s p a n i c m e n , it a p p e a r s t h a t susceptibility a n d self-efficacy beliefs n e e d t o b e t a r g e t e d for c h a n g e , a n d t h a t s e v e r i t y a n d r e s p o n s e efficacy beliefs n e e d t o b e e i t h e r i n t r o d u c e d o r r e i n f o r c e d . T o m a x i m i z e effectiveness, t h e a r g u m e n t s in t h e p e r s u a s i v e m e s s a g e n e e d t o c o r r e s p o n d specifically t o t h e goals of t h e p e r s u a s i v e m e s s a g e . In o t h e r w o r d s , t h e t h r e a t a r g u m e n t s m u s t specifically a d d r e s s t h e a u d i e n c e ' s salient beliefs a b o u t their susceptibility a n d t h e severity of AIDS. Likewise, t h e efficacy a r g u m e n t s m u s t specifically a d d r e s s their salient beliefs a b o u t r e s p o n s e a n d self-efficacy of u s i n g c o n d o m s t o p r e v e n t A I D S . A r g u m e n t s s h o u l d b e s u p p o r t e d b y factual e v i d e n c e . For i n s t a n c e , H i s p a n i c m e n ' s beliefs t h a t t h e y

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a r e n o t at risk for H I V c o n t r a c t i o n m u s t b e c o u n t e r e d w i t h t h e fact t h a t t h e y are at increased risk according to m a n y experts ( M a r i n , 1989; N a v a r r o , 1989). Likewise, b e c a u s e H i s p a n i c m e n believe t h a t c o n d o m s r e d u c e virility, a r g u m e n t s m u s t b e g e n e r a t e d t o c o u n t e r this m i s c o n c e p t i o n . A r g u m e n t s m a y b e d e v e l o p e d u s i n g m e m b e r s of salient referent g r o u p s as a d v o c a t e s of c o n d o m u s e t o p r e v e n t A I D S (if t h e a u d i e n c e analysis s h o w s this is a c c u r a t e ) . Ideally, e a c h salient belief d e s c r i b e d in T a b l e 8.2 s h o u l d b e r e i n f o r c e d (ideally) o r r e f u t e d (if necessary) in t h e persuasive message. If t h e p e r s u a s i v e m e s s a g e is l i m i t e d b y space o r t i m e , h o w e v e r , o n l y t h e m o s t salient beliefs m i g h t b e t a r g e t e d for c h a n g e . As a final caveat, it is i m p o r t a n t t o n o t e t h a t w i t h a n y t o p i c great c u l t u r a l sensitivity m u s t b e u s e d in f o r m u l a t i n g a n d asking q u e s t i o n s — e s p e c i a l l y t h o s e of a sensitive n a t u r e (e.g., sexual b e h a v i o r s , d r u g u s e b e h a v i o r s ) . S u r v e y o r s o r i n t e r v i e w e r s m u s t ask q u e s t i o n s u s i n g a p p r o p r i a t e l a n g u a g e (e.g., a p p r o p r i a t e c o l l o q u i a l i s m s or slang) a n d it is b e s t t o m a t c h t h e g e n d e r , age, a n d e t h n i c i t y of i n t e r v i e w e r s / s u r v e y o r s w i t h m e m b e r s of t h e t a r g e t p o p u l a t i o n . By c o n s i d e r i n g these issues u p front, t h e c h a n c e s for a successful h e a l t h c a m p a i g n are i n c r e a s e d d r a m a t i c a l l y . T h e e x a m p l e discussed h e r e ( p r o m o t i n g c o n d o m use a m o n g H i s p a n i c m e n ) u s e d existing research t o d e t e r m i n e salient beliefs, references, a n d c u e p r e f e r e n c e s . F o l l o w i n g is an e x a m p l e w h e r e o r i g i n a l r e s e a r c h w a s c o n d u c t e d t o u n c o v e r salient beliefs, a n d actual c a m p a i g n messages w e r e d e v e l o p e d according to the framework.

Using Original Research to Develop a Campaign T h e o t h e r m e t h o d of collecting t h e t r a n s i e n t i n f o r m a t i o n n e e d e d for t h e f r a m e w o r k is t o c o n d u c t o r i g i n a l research. T h i s task is far easier t h a n it might seem. T h e Appendix provides a questionnaire that can be used to s u r v e y for salient beliefs a n d T a b l e 8.1 gives e x a m p l e s of q u e s t i o n s t h a t can b e a s k e d of t h e target a u d i e n c e . P r a c t i t i o n e r s s h o u l d s i m p l y p l u g in t h e i r h e a l t h p r o m o t i o n o r disease p r e v e n t i o n t o p i c a n d t h e r e c o m m e n d e d r e s p o n s e i n t o t h e q u e s t i o n s in t h e A p p e n d i x . F o l l o w i n g is a d e s c r i p t i o n o f t h e d e v e l o p m e n t of a c a m p a i g n t o p r e v e n t f a r m - e q u i p m e n t - r e l a t e d injuries a n d fatalities. O r i g i n a l research was c o n d u c t e d w i t h f a r m e r s a n d r a n c h e r s in T e x a s t o d e t e r m i n e t h e i r salient beliefs a b o u t t r a c t o r a c c i d e n t s a n d safety p r o c e d u r e s u s i n g t h e P H M f r a m e w o r k as a g u i d e ( W i t t e et al., 1993).

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A l t h o u g h t h e m o s t d e a d l y a n d d a n g e r o u s o c c u p a t i o n in t h e U n i t e d States is a g r i c u l t u r e ( N a t i o n a l Safety C o u n c i l , 1992), little is k n o w n a b o u t w h a t farmers t h i n k a b o u t f a r m - e q u i p m e n t - r e l a t e d accidents a n d safety practices a n d c u r r e n t safety i n t e r v e n t i o n s are typically a t h e o r e t i c a l ( W i t t e et al., 1993). T h e P H M framework was used to develop a theory-based campaign that addressed farmers' a n d ranchers' salient beliefs a b o u t e q u i p m e n t - r e l a t e d accid e n t s a n d safety practices. First, t h e c a m p a i g n goals a n d target a u d i e n c e w e r e specified. T h e goals of t h e c a m p a i g n w e r e t o p r e v e n t f a r m - e q u i p m e n t r e l a t e d injuries a n d d e a t h s ( t h e t h r e a t ) b y p r o m o t i n g e s t a b l i s h e d safety p r o c e d u r e s ( t h e r e c o m m e n d e d r e s p o n s e ) for East Texas f a r m e r s a n d r a n c h ers ( t h e target a u d i e n c e ) . East Texas f a r m e r s a n d r a n c h e r s w e r e c h o s e n for t h e s t u d y b e c a u s e of t h e high n u m b e r of f a r m - e q u i p m e n t - r e l a t e d fatalities in this a r e a (Frerich 8c Valco, 1991). T o solicit salient beliefs, salient referents, a n d p r e f e r e n c e s , f a r m e r s a n d r a n c h e r s w e r e i n t e r v i e w e d w i t h o n e of t h r e e different m e t h o d s — f a c e - t o face interviews, t e l e p h o n e interviews, a n d m a i l e d q u e s t i o n n a i r e s . T h e r e sults i n d i c a t e d t h a t f a r m e r s believe farm e q u i p m e n t injuries t o b e severe a n d serious, b u t d o n o t believe themselves t o be susceptible to injuries o r a c c i d e n t s . T h e y also believe t h a t safety m e a s u r e s are effective in a v e r t i n g a c c i d e n t s a n d p r e v e n t i n g injuries from farm e q u i p m e n t a c c i d e n t s . Finally, t h e y believe they are able t o carry o u t those safety measures to avert accidents a n d / o r p r e v e n t injuries from accidents. In o t h e r w o r d s , t h e y h a d h i g h levels of p e r c e i v e d severity, response efficacy, a n d self-efficacy, a n d low levels of perceived s u s c e p tibility (see Figure 8.2). In t e r m s of cues (Figure 8.3), t h e m a n u f a c t u r e r ' s safety m a n u a l w a s t h e p r e f e r r e d message f o r m a n d c h a n n e l a n d t h e m a n u facturer was the preferred source for tractor safety information. Similarly, farmers' a n d r a n c h e r s ' m o s t c o m m o n salient referent regarding f a r m - e q u i p m e n t related injuries a n d safety p r o c e d u r e s w a s t h e e q u i p m e n t c o m p a n y ( s p o u s e s also r a n k e d h i g h as a salient r e f e r e n t ) . A n a u d i e n c e profile b a s e d o n d e m o g r a p h i c s a n d self-reported e x p e r i e n c e s revealed t h a t t h e target a u d i e n c e was p r i m a r i l y m a l e ( 9 2 . 1 % ) w i t h s o m e college e d u c a t i o n a n d a v e r a g e d 55 years of age. M o s t of t h e t a r g e t a u d i e n c e was w h i t e ( 8 7 . 3 % ) , w i t h 1.9% African A m e r i c a n s , 0 . 8 % H i s p a n i c s , a n d 1 0 % of diverse e t h n i c b a c k g r o u n d s . R e s p o n d e n t s f a r m e d an average of 592 acres; a n d half ( 4 9 . 8 % ) o w n e d o l d e r t r a c t o r s (built before 1980), w h i c h h a v e fewer safety features. M o s t f a r m e r s h a d n o e m p l o y e e s ( 7 2 . 2 % ) , i n d i c a t i n g t h a t m o s t f a r m s w e r e family o r h o b b y f a r m s ( t h e site of m o s t e q u i p m e n t a c c i d e n t s ) . Sixteen p e r c e n t of t h e f a r m e r s r e p o r t e d injuries o n t h e i r farms r a n g i n g f r o m lost fingers t o severe m u l t i p l e injuries; 7 0 % k n e w of s o m e o n e w h o h a d h a d a severe i n j u r y c a u s e d b y farm e q u i p m e n t ; m o r e t h a n half ( 5 1 . 5 % ) k n e w s o m e o n e w h o h a d d i e d from

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injuries r e s u l t i n g from a farm e q u i p m e n t a c c i d e n t . T h i s i n f o r m a t i o n g a t h e r e d f r o m t h e s a m p l e was u s e d t o d e v e l o p a n a u d i e n c e profile. Step 3 w a s t o take this i n f o r m a t i o n a n d d e v e l o p p e r s u a s i v e m e s s a g e s for t h e c a m p a i g n . First, f a r m e r s ' salient beliefs w e r e p l a c e d in t h e categories o u t l i n e d earlier: beliefs (a) t o c h a n g e , (b) t o reinforce, o r (c) t o i n t r o d u c e . Based o n t h e survey, it is clear t h a t p e r c e i v e d susceptibility is t h e belief in greatest n e e d of change. Farmers n e e d t o b e convinced of their m o r t a l i t y a n d t h a t t h e y a r e at risk for farm e q u i p m e n t a c c i d e n t s . Several of t h e f a r m e r s ' beliefs a r e in t h e d e s i r e d d i r e c t i o n a n d s h o u l d b e r e i n f o r c e d in t h e p e r s u a s i v e m e s s a g e . Specifically, f a r m e r s n e e d t o h e a r t h a t f a r m e q u i p m e n t a c c i d e n t s a r e severe (reinforce this belief)> t h a t p e r s i s t e n t a n d h a b i t u a l u s e of safety m e a s u r e s p r e v e n t s injuries a n d a c c i d e n t s , a n d t h a t t h e h a b i t u a l a n d c o n s i s t e n t use of safety m e a s u r e s is s o m e t h i n g that a n y o n e can easily d o . A n i n t e r e s t ing finding t h a t e m e r g e d from the survey was that a l t h o u g h farmers r e p o r t e d t h e y c o n s i s t e n t l y use safety m e a s u r e s , m o s t of t h e m o r e significant safety measures were n o t being used. For example, the majority of farmers rep o r t e d t h e y d i d n o t use seat belts even t h o u g h m a n y a g r i c u l t u r a l w o r k e r s are killed w h e n their tractor o r attached e q u i p m e n t r u n s over t h e m after t h e y h a v e b e e n j o l t e d off t h e vehicle. F i n d i n g s s u c h as this o n e i n d i c a t e t h a t a p e r s u a s i v e m e s s a g e c a n n o t target safety in g e n e r a l — b e c a u s e f a r m e r s a l r e a d y believe themselves t o b e safe. Instead, persuasive messages m u s t target specific safety b e h a v i o r s , s u c h as t h e use of seat belts, o r h a v i n g a " 1 r i d e r at a t i m e " r u l e for their t r a c t o r . Because f a r m e r s ' a t t i t u d e s w e r e a l r e a d y p o s i t i v e t o w a r d safety, a n d t h e y i n t e n d e d t o b e safe in a general sense, t h e f o c u s i n g of a p e r s u a s i v e m e s s a g e o n specific safety b e h a v i o r s is t h e a p p r o p r i a t e strategy. In addition, because e q u i p m e n t manufacturers and spouses have the m o s t i n f l u e n c e o n f a r m e r s ' safety practices, t h e m o s t effective c a m p a i g n w o u l d b e o n e t h a t u s e d t h e m as t h e sources a n d c h a n n e l s of i n f o r m a t i o n . Finally, as m a n y of t h e cues variables as possible s h o u l d b e a d d r e s s e d in t h e p e r s u a sive m e s s a g e s . F o r e x a m p l e , it is i m p o r t a n t to take f a r m e r s ' average age (55 years), educational level ( s o m e college), a n d size of farm (592 acres o n average) i n t o a c c o u n t w h e n d e v e l o p i n g t h e p e r s u a s i v e c a m p a i g n in o r d e r t o m a k e the message appropriate and understandable. F i g u r e 8.3 gives e x a m p l e s of p e r s u a s i v e messages d e v e l o p e d w i t h inform a t i o n gathered according to the P H M framework. These messages are d e s i g n e d (a) t o increase p e r c e p t i o n s of susceptibility a b o u t f a r m e q u i p m e n t a c c i d e n t s ( f a r m e r s a l r e a d y believe accidents lead t o severe i n j u r i e s ) , as well as ( b ) t o e m p h a s i z e t h e effectiveness of safety m e a s u r e s in a v e r t i n g a c c i d e n t s , a n d h o w easy a n d feasible it is t o use safety measures consistently. I n a d d i t i o n , b e c a u s e significant n u m b e r s of f a r m e r s r e p o r t e d n o t u s i n g t h e i r seat belts

160

THEORY-DRIVEN

Strongly Disagree 1

2

3

4

5

APPROACHES

Strongly Agree 7

6

1 1 1 1 1 1

Perceived Severity

Perceived Susceptibility

Response Efficacy

Self-Efficacy

Farmers' salient referents.

OSHA

"IHHI

Equipment Co.

Η Β Ι

Children

pHH

Siblings

H|

Extension Agent Spouse

PH •HH

Employee

HIHP 0

1 0

1 1

t

1

1 1

1 1

1 1

1 1

20 30 40 50 60 70 Number of Farmers Choosing Category

1 1

80

Figure 8.2. East Texas Farmers' and Ranchers' Salient Beliefs About the Threat of Farm Equipment Accidents and the Efficacy of Safety Procedures in Averting Farm Equipment Accidents, and Salient Referents

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Preferred Channel.

Preferred Source.

Television (6%) Radio (.5%) Newspaper

(3%)

OSHA (1.1%)

- Celebrity

(.4%)

Family Member (2.3%)

Preferred Message Form. Otlw

(6%) Strongly Disagree

Strongly Agree

Scare Tactics are Effective I Read the Safety Stickers Pictures Help Explain Safety

t

Manufactun cturer Videotape (8%)

\ \ N

e

w

s

Story

NOTE:

p

a

p

e

r

(1.5%)

Proportion totals may add up to more than 100% due to rounding error.

Figure 8.3. East Texas Farmers and Ranchers* Preferences for Channel, Source, and Message Form ,

a n d n o t h a v i n g a roll b a r o n t h e i r t r a c t o r , t h e s e specific safety p r a c t i c e s w e r e t h e focus of t h e p e r s u a s i v e messages. Finally, f a r m e r s ' p r e f e r r e d s o u r c e s of i n f o r m a t i o n w e r e u s e d ( m a n u f a c t u r e r , fellow f a r m e r , e x t e n s i o n a g e n t ) in a d d i t i o n t o t h e i r p r e f e r r e d m o d e s ( b r o c h u r e , safety stickers) a n d c h a n n e l s ( m a g a z i n e a d v e r t i s e m e n t s , m a i l i n g s ) of i n f o r m a t i o n d i s s e m i n a t i o n (Figu r e 8.3).

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« S o u n d of tractor r u n n i n g » JACK

Hey Bill.

BILL

Good mornin' Jack, Susan. « T r a c t o r sounds s t o p . »

JACK BILL

We just came by to give you an update on Hank. Oh thanks—isn't it a shame. I guess we're lucky he just lost his arm, he could have died like ol' Ted Rogers down the road.

SUSAN

JACK

Yeah, that was terrible. I always knew an uncovered PTO shaft is dangerous, but so many farmers—including us—don't replace the safety cover each and every time, and now look what's happened, Hank lost his arm and Ted was killed. Well, you can bet that I replace my safety cover on my PTO shaft each and every time I grease it now. It's just plain stupid and lazy not to. It doesn't take but two minutes to put it back on and my and my family's peace-of-mind is worth it.

BILL

You're right. I have to admit that I've been kind of lax about replacing my safety cover too but now I'm going to start doing it.

SUSAN

You know what we did? After hearing about all of these accidents around here and the rest of the state, Jack called John Deere to come and tell us what kinds of safety upgrades our tractor needed. If your tractor was built 1980 or before, it might be missing some important safety features. The John Deere Representative came out and gave us a free safety inspection. He also gave us a special reduced price to install a roll bar and seatbelt.

JACK

The rep said that most farm-equipment injuries happen when you get tangled up in a PTO or when you get bounced off a tractor after hitting a ditch or a bump.

BILL

Hmmm, well, I better give them a call today and have them come out and look at my tractor. You say it's free for them to inspect the equipment?

JACK

Yeah, and they'll make you a good deal if you need to upgrade any safety features.

SUSAN

I bet Emma and Sophie wish Hank and Ted had done the same.

ANNOUNCER

Call 1 -800-123-FARM for your free safety inspection by a local John Deere representative. Your safety and livelihood is important to us. Please call 1-800-123-FARM.

Figure 8.4. Public Service Announcement, Tractor Safety, 45 seconds

Conclusion W i t h limited funds a n d time, public health practitioners need quick a n d easy m e t h o d s t o d e v e l o p c a m p a i g n s t h a t w o r k . T h e P H M f r a m e w o r k o u t -

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l i n e d h e r e a t t e m p t s t o offer a q u i c k a n d easy " c o o k b o o k " a p p r o a c h t o d e v e l o p i n g effective a n d t a r g e t e d p e r s u a s i v e messages t h a t a d d r e s s specific a u d i e n c e beliefs a n d b e h a v i o r s . U s i n g a t h e o r y - b a s e d f r a m e w o r k s u c h as t h e o n e p r e s e n t e d h e r e s h o u l d decrease t h e c h a n c e s for c a m p a i g n failures a n d i n c r e a s e t h e c h a n c e s of c a m p a i g n success.

References Ajzen, I., 8c Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall. Atkin, C. K. (1993, November). Perspectives on health campaign persuasion strategies. Paper presented at the annual meeting of the Speech Communication Association, Miami. Atkin, C. K., 8c Freimuth, V. (1989). Formative evaluation research in campaign design. In R. E. Rice 8c C. K. Atkin (Eds.), Public communication campaigns (2nd ed.) (pp. 131-150). Newbury Park, CA: Sage. Burgoon, M. (1989). Messages and persuasive effects. In J. J. Bradac (Ed.), Message effects in communication science (pp. 129-164). Newbury Park, CA: Sage. Carrier, J. M. (1976). Cultural factors affecting urban Mexican male homosexual behavior. Archives of Sexual Behavior, 5, 103-124. Carrier, J. M. (1989). Sexual behavior and the spread of AIDS in Mexico. Medical Anthropologist, 10, 129-142. Fishbein, M., 8c Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. Fishbein, M., 8c Ajzen, I. (1981). Acceptance, yielding and impact: Cognitive processes in persuasion. In R. E. Petty, Τ. M. Ostrom, 8c T. C. Brock (Eds.), Cognitive responses in persuasion (pp. 339-359). Hillsdale, NJ: Lawrence Erlbaum. Flora, J. Α., 8c Thoreson, C. E. (1988). Reducing the risk of AIDS in adolescents. American Psychologist, 43, 965-970. Frerich, S. J., 8c Valco, T. D. (1991, October). Ten year summary of Texas farm and ranch fatalities for 1980-1989. Paper presented at the annual meeting of the Texas Section of the American Society of Agricultural Engineers, Temple, TX. Marin, G. (1989). AIDS prevention among Hispanics: Needs, risk behaviors, and cultural values. Public Health Reports, 104, 411-415. Marin, Β. V., 8c Marin, G. (1987). Attitudes and expectancies regarding AIDS among Hispanics. In Psychology and AIDS (pp. 46-47). Washington, DC: American Psychological Association. McGuire, W. J. (1984). Public communication as a strategy for inducing health-promoting behavioral change. Preventive Medicine, 13, 299-319. McGuire, W. J. (1985). Attitudes and attitude change. In L. Gardner 8c E. Aronson (Eds.), Handbook of social psychology (3rd ed.) (Vol. 2, pp. 233-346). New York: Random House. National Safety Council. (1992). Accident facts (1992 ed.). Itasca, IL: Author. Navarro, M. (1989, December 29). AIDS in Hispanic community: Threat ignored. The New York Times, pp. B l , BIO. Peterson, J. L., 8c Marin, G. (1988). Issues in the prevention of AIDS among black and Hispanic men. American Psychologist, 43, 871-877.

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Petty, R. E., & Cacioppo, J. T. (1986). Communication and persuasion: Central and peripheral routes to attitude change. New York: Springer. Richwald, G. Α., Schneider-Munoz, M., 8c Valdez, R B. (1989). Are condom instructions in Spanish readable? Implications for AIDS prevention activities for Hispanics. Hispanic Journal of Behavioral Sciences, 11, 70-82. Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change. Journal of Psychology, 91, 93-114. Rogers, R. W. (1983). Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In J. Cacioppo & R. Petty (Eds.), Social psychophysiobgy (pp. 153-176). New York: Guilford. Thompson, L. (1987, August 11). AIDS and minorities. The Washington Post, p. 7. Witte, Κ. (1992a). Preventing AIDS through persuasive communications: A framework for constructing effective, culturally-specific, preventive health messages. International and Intercultural Communication Annual 16, 67-86. Witte, Κ. (1992b). Putting the fear back into fear appeals: Reconciling the literature. Communication Monographs, 59, 329-349. Witte, Κ. (1992c). The role of threat and efficacy in AIDS prevention. International Quarterly of Community Health Education, 12, 225-249. Witte, Κ., Peterson, Τ. R , Vallabhan, S., Stephenson, Μ. T., Plügge, C. D., Givens, V. K., Todd, J. D., Becktold, M. G., Hyde, Μ. K., 8c Jarrett, R. (1993). Preventing tractor-related injuries and deaths in rural populations: Using a persuasive health message (PHM) framework in formative evaluation research. International Quarterly of Community Health Education, 13, 219-251.

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Appendix E x a m p l e of a G e n e r i c a n d Specific Q u e s t i o n n a i r e t o D e t e r m i n e C a m p a i g n G o a l s a n d A u d i e n c e S a l i e n t Beliefs

Questions

for

Practitioner:

1. What is the health threat? 2. What is the recommended response to avert the health threat (the specific goal of the campaign)? 3. W h o is the target audience? (describe in demographic, psychographic, cultural terms)

Questions

for the Target

Audience:

4. How serious is ? 1

2

3

4

5

Not At All Serious

6

7

Extremely Serious

5. How likely is it that will happen to you? 1

2

3

4

Not At All Susceptible

5

6

7

Extremely Susceptible

6. will keep me from getting . 1

2

3

4

5

Strongly Disagree

6

7

Strongly Agree

8. My thinks is a serious disease. 1

2

Strongly Disagree

3

4

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6

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Strongly Agree

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9. My thinks I am at risk for checkups, instead of medication or surgery.

W

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• Medication. Your doctor may prescribe PROSCAR for BPH. See "What PROSCAR does" below. • Surgery Some patients may need surgery. Your doctor can describe several different surgical procedures for BPH. Which procedure is best depends on your symptoms and medical condition. What PROSCAR does PROSCAR lowers levels of a key hormone called DHT (dihydrotestosterone), which is a major cause of prostate growth. Lowering DHT leads to shrinkage of the enlarged prostate gland in most men. This can lead to gradual improvement in urine flow and symptoms over the next several months. However, since each case of BPH is different, you should know that: • Even though the prostate shrinks, you may NOT see an improvement in urine flow or symptoms. • You may need to take PROSCAR for six (6) months or more to see whether it helps you. • Even though you take PROSCAR and it may help you, it is not known whether PROSCAR reduces the need for surgery. What you need to know while taking PROSCAR - You must see your doctor regularly. While taking PROSCAR, you must have regular checkups. Follow your doctor's advice about when to have these checkups. • About side effects. Like all prescription drugs, PROSCAR may cause side effects. Side effects due to PROSCAR may include impotence (or inability to have an erection) and less desire for sex. Each of these side effects occurred in less than 4% of patients in clinical studies. In some cases side effects went away while the patient continued to take PROSCAR.

Some men taking PROSCAR may have a decrease in the amount of semen released during sex. This decrease does not appear to interfere with normal sexual function. You should discuss side effects with your doctor before taking PROSCAR and anytime you think you are having a side effect. • Checking for prostate cancer. Your doctor has prescribed PROSCAR for symptomatic BPH and not for cancer — but a man can have BPH and prostate cancer at the same time. Doctors usually recommend that men be checked for prostate cancer once a year when they turn 50 (or 40 if a family member has had prostate cancer). These checks should continue while you take PROSCAR. PROSCAR is not a treatment for prostate cancer. • About Prostate Specific Antigen (PSA). Your doctor may have done a blood test called PSA. PROSCAR can alter PSA values. For more information, talk to your doctor. • A warning about PROSCAR and pregnancy. PROSCAR is for use by MEN only. PROSCAR is generally well tolerated in men. However, women who are pregnant, or women who could become pregnant, should avoid the active ingredient in PROSCAR. If the active ingredient is absorbed by a woman who is pregnant with a male baby, it may cause the male baby to be born with abnormalities of the sex organs. Therefore, any woman who is pregnant or who could become pregnant must not come into direct contact with the active ingredient in PROSCAR.

Two of the ways in which a woman might absorb the active ingredient in PROSCAR are: Sexual Contact. Your semen may contain a small amount of the active ingredient of the drug. If your partner is pregnant, or if you and your partner decide to have a baby, you must stop taking PROSCAR and talk to your doctor. If your partner could become pregnant, proper use of a condom can reduce the risk of exposing her to your semen (discuss this further with your doctor). Handling broken tablets. Women who are pregnant or who could become pregnant must not handle broken tablets of PROSCAR. PROSCAR tablets are coated to prevent contact with the active ingredient during normal handling. If this coating is broken, the tablets should not be handled by women who are pregnant or who could become pregnant. If a woman who is pregnant comes into contact with the active ingredient in PROSCAR, a doctor should be consulted. Remember, these warnings apply only if the woman exposed to PROSCAR is pregnant or could become pregnant. How to take PROSCAR Follow your doctor's advice about how to take PROSCAR. You must take it every day. You may take it with or between meals. To avoid forgetting to take PROSCAR, it may be helpful to take it the same time every day. Do not share PROSCAR with anyone else; it was prescribed only for you. Keep PROSCAR and all medicines out of the reach of children.

FOR MORE INFORMATION ABOUT PROSCAR AND BPH, TALK WITH YOUR DOCTOR. IN ADDITION, TALK TO YOUR PHARMACIST OR OTHER HEALTH CARE PROVIDER.

MERCK & CO., INC. West Point, PA 19486

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materials have been p r o d u c e d in b o t h English a n d Spanish a n d , except for t h e flip c h a r t s , a r e i n t e n d e d t o b e given t o t h e p a t i e n t b y t h e h e a l t h care p r o v i d e r .

PROSCAR PATIENT SUPPORT PROGRAM P r o s c a r is a relatively n e w d r u g i n d i c a t e d for t h e t r e a t m e n t of s y m p t o matic benign prostatic hyperplasia ( B P H ) — o r enlarged prostate. C o m p l i a n c e w i t h P r o s c a r is a p a r t i c u l a r p r o b l e m b e c a u s e a m i n i m u m o f 6 m o n t h s of t r e a t m e n t m a y b e necessary t o d e t e r m i n e w h e t h e r a n i n d i v i d u a l will r e s p o n d t o t h e d r u g (i.e., s y m p t o m s will d e c r e a s e ) . It is often difficult for p a t i e n t s t o c o n t i n u e to take a d r u g in t h e face of p e r s i s t e n t u n c o m f o r t a b l e or painful s y m p t o m s . T h e P r o s c a r P a t i e n t S u p p o r t P r o g r a m has a p h y s i c i a n - i n i t i a t e d c o m p o n e n t as well as a pharmacist c o m p o n e n t . W h e n a patient is started o n P r o s c a r , his p h y s i c i a n will give h i m a p a t i e n t starter kit t h a t c o n t a i n s disease a w a r e ness i n f o r m a t i o n a n d a p a t i e n t starter certificate for a 3 0 - d a y c o m p l e m e n t a r y s u p p l y o f P r o s c a r . I n o r d e r t o e n r o l l in t h e p r o g r a m , t h e p a t i e n t m u s t r e d e e m his certificate at t h e p h a r m a c y . At t h e p h a r m a c y , t h e p a t i e n t is given a free s u p p l y of Proscar; t h e p h a r m a c i s t is t h e n r e i m b u r s e d b y t h e p h a r m a ceutical c o m p a n y for a $4.00 h a n d l i n g c h a r g e a n d is sent a r e p l a c e m e n t b o t t l e of 30 tablets. W h e n t h e p h a r m a c y s u b m i t s t h e c o m p l e t e d certificate t o t h e c o m p a n y for r e i m b u r s e m e n t , t h e p a t i e n t is a u t o m a t i c a l l y e n r o l l e d in t h e p r o g r a m a n d will begin receiving t h e s u p p o r t p r o g r a m m a i l i n g s . P a t i e n t s receive six m a i l i n g s t h e first year t h e y are t a k i n g P r o s c a r . T h e first m a i l i n g includes: (a) a patient information sheet explaining the materials in t h e p a c k age, (b) a wellness newsletter of interest to m e n o v e r 50, a n d (c) p u n c h - o u t c a l e n d a r c a r d s t o h e l p t h e p a t i e n t r e m e m b e r t h a t h e has t a k e n his pill for t h e day. T h e m a t e r i a l s from this m a i l i n g are also i n c l u d e d in all s u b s e q u e n t p a c k a g e s , w i t h t h e a d d i t i o n of: ( d ) a c o m p l i a n c e e d u c a t i o n b r o c h u r e , (e) a n o t h e r certificate for a c o m p l e m e n t a r y 3 0 - d a y s u p p l y of P r o s c a r , (f) a 7 - d a y pillbox, a n d (g) a b r o c h u r e entitled 7 Tips to Help You Remember to Take Your Medicine. T h e p h a r m a c e u t i c a l c o m p a n y also m a i n t a i n s toll-free telep h o n e a n d fax n u m b e r s for p a t i e n t s u p p o r t .

INSOMNIA: PATIENT E D U C A T I O N MATERIALS T h e d r u g H a l c i o n is often p r e s c r i b e d b y physicians for their p a t i e n t s w h o h a v e difficulty sleeping. It is o n e of several b e n z o d i a z e p i n e sleeping pills t h a t

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261

h a v e several i m p o r t a n t risks a n d l i m i t a t i o n s , i n c l u d i n g d i m i n i s h i n g effectiveness w i t h c o n t i n u e d u s e a n d possible d e v e l o p m e n t o f d e p e n d e n c e a n d m e n t a l c h a n g e s w h e n t h e d r u g is u s e d for m o r e t h a n a few d a y s . I n fact, in t h e past few years t h e news m e d i a has r e p o r t e d o n several criminals w h o h a v e used H a l c i o n as an excuse for their illegal actions; h e n c e , the " H a l c i o n d e f e n s e . " P a t i e n t e d u c a t i o n m a t e r i a l s a r e p r o v i d e d t o p h y s i c i a n s for d i s t r i b u t i o n t o t h e i r p a t i e n t s w h o h a v e q u e s t i o n s a b o u t i n s o m n i a a n d sleep d i s o r d e r s . T h e f o l d e r - t y p e p a c k e t i n c l u d e s : (a) a 1 7 - m i n u t e PBS e d u c a t i o n a l v i d e o titled " J o u r n e y I n t o Sleep," (b) a 12-page b o o k l e t o n " W h a t Y o u S h o u l d K n o w A b o u t I n s o m n i a , " (c) a p a c k e t of tear-off sheets listing " T i p s for a G o o d N i g h t ' s Sleep . . . " a n d "If Y o u r D o c t o r H a s P r e s c r i b e d a Sleep M e d i c a t i o n . . .", a n d ( d ) a p a c k e t of tear-off sheets listing b u l l e t e d s u g g e s t i o n s for p r o m o t i n g b e t t e r sleep. All of these m a t e r i a l s are e d u c a t i o n a l in n a t u r e , n o t a p r o m o t i o n of H a l c i o n .

ROGAINE: CLINICAL EXPERIENCE PROGRAM R o g a i n e w a s recently a p p r o v e d as a topical s o l u t i o n for s t i m u l a t i o n of h a i r g r o w t h . T h e c h e m i c a l in R o g a i n e , m i n o x i d i l , h a s b e e n u s e d in t a b l e t f o r m s i n c e 1980 t o lower severe h i g h b l o o d p r e s s u r e . T h e p r o d u c t t h e r e f o r e p o s e s a p a r t i c u l a r risk t o p a t i e n t s w h o h a v e u n d e r l y i n g c o r o n a r y a r t e r y disease. R o g a i n e r e q u i r e s t h a t p a t i e n t s a p p l y t h e s o l u t i o n twice a d a y for at least 4 m o n t h s before a n y h a i r r e g r o w t h m a y b e o b s e r v e d . T h e a p p l i c a t i o n p r o c e d u r e is s o m e w h a t c o m p l i c a t e d a n d t h e p h a r m a c e u t i c a l c o m p a n y h a s a s s e m b l e d a b o x of m a t e r i a l s t o b e given t o p a t i e n t s b y t h e i r p h y s i c i a n w h e n p r e s c r i b e d R o g a i n e . T h e 1 3 " χ 10" b o x a n d its inserts a r e p r o d u c e d in t w o c o l o r s : m a u v e for female p a t i e n t s a n d gray for m a l e p a t i e n t s . T h e b o x c o n t a i n s : (a) a 1 0 - m i n u t e v i d e o t a p e featuring t h r e e p a t i e n t s w h o h a v e h a d p e r s o n a l e x p e r i e n c e w i t h R o g a i n e (female p a t i e n t s in t h e v i d e o for w o m e n , m a l e p a t i e n t s in t h e v i d e o for m e n ) , ( b ) a 2 7 - p a g e b o o k l e t c o n t a i n i n g a c o u p o n for p a t i e n t s t o s e n d in t o receive a $ 1 0 certificate a n d m o n e y - s a v i n g r e b a t e c o u p o n s , (c) a 7 - i n c h c o m b t o use d u r i n g a p p l i c a t i o n , a n d ( d ) a n i l l u s t r a t e d g u i d e for a p p l y i n g t h e p r o d u c t . T h e b o x also c o n t a i n s a p a c k a g e w i t h t h r e e a p p l i c a t o r s for d e m o n s t r a t i o n p u r p o s e s o n l y ; n o m i n o x i d i l is i n c l u d e d i n t h e p a c k a g e . T h e p h a r m a c e u t i c a l c o m p a n y also m a i n t a i n s a 1-800 n u m b e r for p a t i e n t s u p p o r t .

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PREGNANCY PREVENTION P R O G R A M FOR W O M E N ON A C C U T A N E A c c u t a n e is p r e s c r i b e d for p a t i e n t s w i t h severe r e c a l c i t r a n t a c n e w h o are u n r e s p o n s i v e t o c o n v e n t i o n a l t h e r a p y . H o w e v e r , severe b i r t h defects a r e k n o w n t o o c c u r in babies of w o m e n t a k i n g A c c u t a n e in a n y a m o u n t , even for s h o r t p e r i o d s of t i m e , d u r i n g p r e g n a n c y . As a result, female p a t i e n t s m u s t be counseled to avoid pregnancy while undergoing t r e a t m e n t with Accutane a n d s h o u l d u n d e r g o a s e r u m p r e g n a n c y test b e f o r e s t a r t i n g t h e r a p y . T h e m a k e r s of A c c u t a n e h a v e a s s e m b l e d a c o m p r e h e n s i v e p a c k a g e t o h e l p h e a l t h care p r o v i d e r s c o n d u c t this c o u n s e l i n g . T h e p a c k a g e is set u p as a n a r r o w fde b o x with eight tabular sections. T h e sections include: (a) a tear-off p a c k a g e of p a t i e n t qualification checklists for t h e p h y s i c i a n t o use t o d e t e r m i n e suitability for A c c u t a n e t r e a t m e n t , (b) a n 11-page i n f o r m a t i o n a l b r o c h u r e titled Important Information Concerning Your Treatment With Accutane, (c) a p a c k e t of tear-off sheets w i t h a toll-free n u m b e r t o call t o h e a r i m p o r t a n t i n f o r m a t i o n a b o u t A c c u t a n e in 13 l a n g u a g e s , ( d ) a n inform a t i o n a l b o o k l e t o n b i r t h c o n t r o l , (e) a p a c k e t of tear-off r e i m b u r s e m e n t i n f o r m a t i o n sheets for t h e initial visit t o a c o n s u l t i n g p h y s i c i a n [if t h e p a t i e n t h a s b e e n referred for e x p e r t c o u n s e l i n g o n c o n t r a c e p t i o n a n d s e r u m p r e g n a n c y t e s t i n g , t h e m a k e r s of A c c u t a n e p a y for t h e c o n s u l t a t i o n a n d p r e g n a n c y t e s t ] , (f) a health care p r o v i d e r ' s g u i d e t o qualifying a n d c o u n s e l i n g c a n d i d a t e s for A c c u t a n e t h e r a p y , (g) copies of a true/false test for p a t i e n t s t o take after s p e a k i n g w i t h their physician a n d r e a d i n g t h e i n f o r m a t i o n a l b r o c h u r e s , a n d (h) a p a c k e t of tear-off i n f o r m e d c o n s e n t sheets t o b e s i g n e d b y t h e p a t i e n t o r h e r g u a r d i a n a n d t h e physician [also c o n t a i n s a n e n r o l l m e n t f o r m for a f o l l o w - u p survey c o n d u c t e d b y t h e School of P u b l i c H e a l t h at B o s t o n U n i v e r s i t y to g a t h e r i n f o r m a t i o n o n h o w A c c u t a n e is u s e d b y w o m e n of c h i l d - b e a r i n g p o t e n t i a l ] . ALTACE ALLIANCE PROGRAM AGAINST HYPERTENSION Altace is p r e s c r i b e d for p a t i e n t s w i t h h y p e r t e n s i o n a n d is o n e of several " A C E i n h i b i t o r " d r u g s (ACE s t a n d s for a n g i o t e n s i n - c o n v e r t i n g e n z y m e ) . As w i t h a n y d r u g for w h a t is basically a " s y m p t o m l e s s " disease, n o n c o m p l i a n c e w i t h t h e m e d i c a t i o n r e g i m e n is a w i d e s p r e a d p r o b l e m . I n fact, n o n c o m p l i a n c e w i t h t h e e n t i r e l o n g - t e r m t h e r a p e u t i c r e g i m e n for h y p e r t e n s i o n , w h i c h m a y include diet, exercise, a n d s o d i u m c o m p o n e n t s , is a severe p r o b l e m . T h e m a k e r s of Altace h a v e a s s e m b l e d a professional s a m p l e kit i n t e n d e d t o aid p a t i e n t s in c o m p l y i n g w i t h their r e g i m e n . T h e kit is t o b e given b y t h e

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p h y s i c i a n t o p a t i e n t s b e g i n n i n g a r e g i m e n of Altace. It i n c l u d e s : (a) a free 1-week s u p p l y of Altace capsules; (b) a n e m e r g e n c y identification c a r d ; (c) a n i n f o r m a t i o n a l b o o k l e t titled Hypertension: What It Is, and What YOU Can Do About It [discusses h o w Altace a n d o t h e r n o n d r u g r e g i m e n s , s u c h as d i e t a n d exercise, c o n t r i b u t e t o h y p e r t e n s i o n c o n t r o l ] ; a n d ( d ) a p o c k e t - s i z e d p a t i e n t r e c o r d b o o k t o h e l p p a t i e n t s k e e p t r a c k of t h e i r m e d i c a t i o n - t a k i n g , diet, a n d exercise p r o g r a m . T h e kit also c o n t a i n s V o l u m e 1, N u m b e r 1 of a n e w s l e t t e r p r o d u c e d b y t h e m a k e r s of Altace titled Lowering Your Blood Pressure—It's Up to You. A p o s t a g e - p a i d c a r d is i n c l u d e d for p a t i e n t s t o e n r o l l in t h e Altace Alliance P r o g r a m in o r d e r t o receive f u t u r e issues o f t h e newsletter.

T E N O R M I N W E L L S P R I N G SERVICE T e n o r m i n , like Altace, is i n d i c a t e d for t h e m a n a g e m e n t of h y p e r t e n s i o n a n d , a g a i n , c o m p l i a n c e w i t h t h e t h e r a p e u t i c r e g i m e n is t r o u b l e s o m e . T h e W e l l s p r i n g Service for T e n o r m i n p a t i e n t s is a l o n g - t e r m s u p p o r t service p u r p o r t i n g to enhance the physician/patient relationship by reinforcing the p h y s i c i a n ' s advice a b o u t c a r d i o v a s c u l a r disease, its t r e a t m e n t , exercise, diet, a n d a h e a l t h i e r lifestyle in general. T h e W e l l s p r i n g Service p a r t i c u l a r l y a p p e a l s t o p h a r m a c i s t s w h o a r e c o n c e r n e d a b o u t l o w refill rates of a n t i h y p e r t e n s i v e d r u g s . In fact, p r o m o t i o n a l m a t e r i a l s for t h e Service d i r e c t e d at p h a r m a c i s t s p o i n t o u t r e s e a r c h t h a t h a s f o u n d t h a t t h e m a j o r i t y of p a t i e n t s delay r e n e w i n g a n t i h y p e r t e n s i v e m e d i c a t i o n a n average o f 15 d a y s (Jackson 8c H u f f m a n , 1990). E n r o l l m e n t in t h e p r o g r a m i n c l u d e s m o n t h l y m a i l i n g s c o n s i s t i n g of n e w s l e t t e r s , m o n e y - s a v i n g c o u p o n s , a n d s a m p l e s of h e a l t h p r o d u c t s s u c h as " n o salt" m a r i n a d e s . M o s t i m p o r t a n t , a c u s t o m e r r e p r e s e n t a t i v e of t h e W e l l s p r i n g Service telep h o n e s p a t i e n t s o n c e a m o n t h for t h e first few m o n t h s t o r e m i n d t h e m t o refill t h e i r p r e s c r i p t i o n . In this way, t h e m a k e r s of T e n o r m i n c l a i m a n i n c r e a s e in refill c o m p l i a n c e as a result of e n r o l l m e n t in t h e Service. A d d i t i o n a l benefits of t h e Service i n c l u d e a $3.00 s t o r e c r e d i t w h e n a proof-ofp u r c h a s e c a r d for a T e n o r m i n refill is s e n t t o t h e c o m p a n y a n d a 1-800 patient support number.

HANDS-ON-HEALTH T h e m a k e r s of a n o t h e r a n t i h y p e r t e n s i v e m e d i c a t i o n , V e r e l a n , h a v e also d e v e l o p e d a p a t i e n t s u p p o r t p r o g r a m for t h e i r p r o d u c t . T h e H a n d s - o n H e a l t h p r o g r a m b e g i n s w h e n a physician gives t h e p a t i e n t a s a m p l e p a c k of

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V e r e l a n t h a t c o n t a i n s a m a i l - i n registration card. O n c e t h e e n r o l l m e n t c a r d h a s b e e n received a n d p r o c e s s e d , t h e p a t i e n t receives t h e i n t r o d u c t o r y p a c k a g e , w h i c h i n c l u d e s a v i d e o t a p e a n d n e w s l e t t e r d e v e l o p e d in c o o p e r a tion with the Philadelphia Heart Institute a n d an i m p o r t a n t enrollment c a r d . T h e u n i q u e feature of this p a t i e n t s u p p o r t p r o g r a m is t h a t o n c e t h e p a t i e n t fills o u t a n d mails t h e e n r o l l m e n t c a r d a n d it is received a n d v a l i d a t e d b y t h e firm, h e o r she receives b y m a i l a free digital h o m e b l o o d - p r e s s u r e m o n i t o r a n d diary. T h e m a n u f a c t u r e r claims t h a t t h e m o n i t o r a n d d i a r y motivate patients to chart their o w n progress and points to published research that shows that a h o m e blood pressure m o n i t o r improves medicat i o n c o m p l i a n c e a n d is helpful in e v a l u a t i n g t h e effectiveness of t h e t h e r a p y . After 3 m o n t h s the p a t i e n t receives a s e c o n d newsletter. P r o m o t i o n a l m a terials for t h e H a n d s - o n - H e a l t h p r o g r a m state t h a t as of 1993, m o r e t h a n 30,000 V e r e l a n p a t i e n t s h a v e e n r o l l e d in t h e p r o g r a m . THE PRAVACHOL PARTNERS PROGRAM P r a v a c h o l , like L o p i d , is a c h o l e s t e r o l - r e g u l a t i n g agent. T h e P r a v a c h o l P a r t n e r s P r o g r a m was d e s i g n e d " w i t h t h e h e l p of over 250 p h y s i c i a n s a c r o s s the c o u n t r y w h o routinely prescribe lipid-lowering therapy" to s u p p o r t p h y s i c i a n s ' efforts t o c o m m u n i c a t e t o t h e i r p a t i e n t s t h e necessity of a l o n g - t e r m c o m m i t m e n t t o t r e a t i n g t h e i r cholesterol p r o b l e m . T h e m a k e r s of P r a v a c h o l cite t h e results of an i n t e r n a l , n o n p u b l i c s t u d y of 300 p a t i e n t s receiving l i p i d - l o w e r i n g d r u g t h e r a p y t h a t s h o w e d t h a t m o r e t h a n 4 5 % c o u l d n o t r e m e m b e r a n y of t h e i n f o r m a t i o n s h a r e d at t h e t i m e t h e y w e r e given t h e i r p r e s c r i p t i o n . T h e m a k e r s h a v e t h e r e f o r e d e v e l o p e d a p r o g r a m t h a t includes an informational videotape, hosted b y Regis Philbin a n d K a t h i e Lee Gifford, w i t h a n a c c o m p a n y i n g b r o c h u r e t o h e l p p a t i e n t s k e e p t r a c k of t h e i r c h o l e s t e r o l levels. P a t i e n t s also receive t h r e e s u b s e q u e n t n e w s l e t t e r s d e s i g n e d t o " r e m i n d t h e m of t h e i r c o m m i t m e n t t o c h o l e s t e r o l m a n a g e m e n t . " T h e newsletters i n c l u d e articles t o k e e p p a t i e n t s u p t o d a t e a b o u t issues in c h o l e s t e r o l m a n a g e m e n t , advice for d e v e l o p i n g a low-fat, l o w c h o l e s t e r o l n u t r i t i o n p l a n , a n d special d i s c o u n t offers o n h e a l t h y p r o d u c t s . T h e p r o g r a m is available free of charge t o Pravachol patients, with an e n r o l l m e n t f o r m a n d a p h a r m a c y receipt for t h e i r first P r a v a c h o l p r e s c r i p t i o n . HEALTHQUEST PATIENT SUPPORT PROGRAM T h e m a k e r s of Q u e s t r a n , a n o t h e r cholesterol-lowering d r u g , have also d e veloped a patient support p r o g r a m to help patients comply with their

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t h e r a p e u t i c r e g i m e n . U n l i k e L o p i d a n d P r a v a c h o l , o n e factor i n f l u e n c i n g c o m p l i a n c e w i t h Q u e s t r a n is t h a t t h e d r u g c o m e s o n l y in p o w d e r f o r m a n d m u s t b e m i x e d w i t h w a t e r , juice, s o u p , o r p u l p y fruits w i t h a h i g h m o i s t u r e c o n t e n t — l i k e a p p l e s a u c e o r c r u s h e d p i n e a p p l e — a n d t a k e n twice a d a y . T h i s p r o c e d u r e r e q u i r e s c o n s i d e r a b l y m o r e t i m e a n d effort o n t h e p a r t o f t h e p a t i e n t , t h e r e b y possibly affecting c o m p l i a n c e w i t h t h e r e g i m e n . T o c o m b a t this p r o b l e m , t h e H e a l t h Q u e s t p a t i e n t s u p p o r t p r o g r a m is d e s i g n e d t o reinforce p h y s i c i a n s ' i n s t r u c t i o n s t o p a t i e n t s a b o u t l o w e r i n g their cholesterol a n d to motivate patients to continue their prescribed t h e r a p y . P h y s i c i a n s are a s k e d t o e n c o u r a g e their Q u e s t r a n p a t i e n t s t o call a 1-800 n u m b e r t o e n r o l l in t h e p r o g r a m . M a n y i n n o v a t i v e r e m i n d e r devices a r e p r o v i d e d t o p h y s i c i a n s t o h e l p t h e m r e m e m b e r a b o u t t h e availability of t h e H e a l t h Q u e s t p r o g r a m , s u c h as silver adhesive stickers w i t h t h e 1-800 n u m b e r i m p r i n t e d o n t h e m for p l a c i n g o n p h o n e s , c l i p b o a r d s , p a t i e n t folders, a n d m o r e ; a plastic s t e t h o s c o p e identification tag w i t h t h e 1-800 n u m b e r ; a p h o n e i n d e x card; a n d a t a b l e t o p t e n t c a r d a d v e r t i s i n g t h e p r o g r a m w i t h tear-off 3 " x 5 " sheets w i t h t h e 1-800 n u m b e r . P a t i e n t s calling t h e toll-free n u m b e r h e a r a c o m p u t e r i z e d script t h a t briefly discusses c h o lesterol, its m a n a g e m e n t , a n d t h e H e a l t h Q u e s t p r o g r a m . T h e y a r e t h e n asked to press any key o n the p h o n e keypad a n d another c o m p u t e r i z e d voice asks t h e m t o state clearly t h e i r n a m e , a d d r e s s , a n d t e l e p h o n e n u m b e r . Enrollees a r e t h e n s e n t a series of four newsletters " d e s i g n e d t o s u p p o r t , entertain, a n d inform people taking Questran." T h e newsletters contain articles o n c h o l e s t e r o l a n d w h a t it d o e s , suggest c h a n g e s in diet a n d lifestyle, offer stories a n d tips from p e o p l e w h o use Q u e s t r a n , a n d i n c l u d e low-fat, l o w - c h o l e s t e r o l recipes. If t h e y h a v e n o t a l r e a d y received o n e , p a t i e n t s a r e also s e n t t h e Start S m a r t P a t i e n t I n f o r m a t i o n Kits for users o f Q u e s t r a n . T h e kit i n c l u d e s an i n f o r m a t i o n a l b o o k l e t e n t i t l e d Cholesterol Questran and You, a m i x i n g g u i d e for Q u e s t r a n w i t h tips a n d recipe ideas, a n a u d i o t a p e titled A Patient's Guide to Questran, a r e c i p e c a r d for m i x i n g a o n e - q u a r t q u a n t i t y o f Q u e s t r a n , a n d a folder titled " S h o r t C u t s t o S u c c e s s " c o n t a i n i n g t h r e e helpful guides t o u s i n g Q u e s t r a n .

Conclusion If t h e goal of m e d i c a t i o n c o m m u n i c a t i o n is t o p r o v i d e i n f o r m a t i o n t h e p a t i e n t is able t o u n d e r s t a n d a n d utilize, n o o n e c o m m u n i c a t i o n s t r a t e g y is likely t o b e effective w h e n u s e d a l o n e . T h e r e s e a r c h suggests t h a t a c o m b i n a t i o n o f i n t e r v e n t i o n s , b o t h e d u c a t i o n a l a n d b e h a v i o r a l , are n e c e s s a r y t o

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i m p r o v e c o m p l i a n c e w i t h t h e r a p i e s . O r g a n i z a t i o n s t h a t e n g a g e in c o m m u n i c a t i n g a b o u t m e d i c a t i o n w i t h p a t i e n t s h a v e t a k e n this a d v i c e a n d d e v e l o p e d m u l t i p l e strategies t o help p a t i e n t s c o m p l y w i t h t h e i r r e g i m e n s . In m a n y instances, these p r o g r a m s are a direct application of traditional c o m m u n i c a t i o n t h e o r y . In fact, a n April 1993 article in a n i n d u s t r y t r a d e press bulletin cited a 1985 article by Marshall Becker that r e c o m m e n d e d several goals for p h a r m a c e u t i c a l c o m p a n i e s ' p a t i e n t s u p p o r t p r o g r a m s , i n c l u d i n g : • increasing patients' specific knowledge of the disease and the restoration of health • influencing patients' health beliefs • helping patients adopt lifestyle changes if necessary • increasing provider-patient communication • extending care beyond the d o c t o r s office and pharmacy, using reminder strategies and techniques • showing the importance of family and social support as a means for enhancing adherence to therapies. ("Drug Companies' Patient Support," 1993) A t this t i m e , o n l y t w o p u b l i s h e d studies specifically evaluate a n y of t h e i n d u s t r y p r o g r a m s d e s c r i b e d in this c h a p t e r t o d e t e r m i n e t h e i r success vis-ä-vis t h e i r stated goals, b o t h of w h i c h are e v a l u a t i o n s of t h e T e n o r m i n W e l l s p r i n g Service. O n e , a 1-year, c o m p a n y - f u n d e d s t u d y o f 9 8 5 m e m b e r s o f H M O s in seven states, f o u n d t h a t h y p e r t e n s i v e p a t i e n t s w h o received t h e W e l l s p r i n g service refilled their p r e s c r i p t i o n s 1 6 % m o r e often t h a n t h o s e o n t h e d r u g w h o w e r e n o t e n r o l l e d in t h e p r o g r a m . In a d d i t i o n , d u r i n g t h e s t u d y p e r i o d , W e l l s p r i n g enrollees s p e n t a n average of $ 127 less in p h y s i c i a n fees a n d hospital bills t h a n did those n o t in t h e p r o g r a m (Podolsky 8c N e w m a n , 1993). T h e s e c o n d , a n e x p e r i m e n t a l s t u d y o f 4 5 3 o u t p a t i e n t H M O enrollees in t h r e e states, f o u n d t h a t existing h y p e r t e n s i v e p a t i e n t s w h o received t h e W e l l s p r i n g kit a n d r e m i n d e r t e l e p h o n e calls o r d e r e d a n average of 2 7 days m o r e medication than the control group; and new hypertensive patients o r d e r e d 4 0 days m o r e m e d i c a t i o n t h a n t h e c o n t r o l g r o u p (Sclar et al., 1991). It m u s t b e n o t e d t h a t refill rates are at best an i n d i r e c t m e a s u r e of a c t u a l daily c o m p l i a n c e w i t h a m e d i c a t i o n r e g i m e n . I n s u m , this c h a p t e r illustrates t h a t w r i t t e n p a t i e n t i n f o r m a t i o n m a y b e u s e d t o h e l p p a t i e n t s u n d e r s t a n d a n d use t h e i r m e d i c a t i o n s a p p r o p r i a t e l y , a l t h o u g h n o single i n f o r m a t i o n strategy is effective for all p a t i e n t s u n d e r all c i r c u m s t a n c e s . D e s i g n e r s of m e d i c a t i o n messages s h o u l d t a k e i n t o a c c o u n t t h e objectives t o b e achieved b y t h e d r u g i n f o r m a t i o n , t h e characteristics of t h e p a t i e n t p o p u l a t i o n , t h e n a t u r e of t h e m e s s a g e t o b e c o m m u n i c a t e d , a n d

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t h e c i r c u m s t a n c e s u n d e r w h i c h t h e s t r a t e g y is t o b e u s e d ( M u l l e n 8c G r e e n , 1 9 8 4 ) . F o r m a t i v e a n d p r o c e s s e v a l u a t i o n s of p r o g r a m s ' effectiveness s h o u l d b e u n d e r t a k e n t o g u i d e o n g o i n g a n d f u t u r e efforts t o c o m m u n i c a t e a b o u t m e d i c a t i o n s . In this way, individuals w h o r e s p o n d to c a m p a i g n messages t o s e e k s c r e e n i n g a n d t r e a t m e n t , a n d receive (as is s o o f t e n t h e case) p r e s c r i p t i o n s for m e d i c a t i o n s , will b e p r o v i d e d w i t h m e s s a g e s t h a t facilitate r a t h e r t h a n i n h i b i t s o c i e t a l h e a l t h p r o m o t i o n efforts.

References Ascione, F., James, M., Austin, S., & Shimp, L. (1980). Seniors & pharmacists: Improving the dialogue. American Pharmacy, 5, 30-32. Becker, M. (1985). Patient adherence to prescribed therapies. Medical Care, 23(5), 539-555. Brown, C. S., Wright, R G., & Christensen, D. B. (1987). Association between type of medication instruction and patients' knowledge, side effects, and compliance. Hospital and Community Psychiatry, 37, 55-60. Coccia, B. (1992, June). Creative marketers help physicians communicate with a diverse U.S. patient population. Product Management Today, pp. 10-13. Culbertson, V. L., Arthur, T. G., Rhodes, P. J., 8c Rhodes, R S. (1988). Consumer preferences for verbal and written medication information. Drug Intelligence and Clinical Pharmacy, 22, 390-396. Dodds, L. J. (1986). Effects of information leaflets on compliance with antibiotic therapy. The Pharmaceutical Journal, 11, 48-51. Drug companies' patient support programs on the rise. (1993, April). FDA Advertising and Promotion Manual Monthly Bulletin, 1, pp. 1-7. George, C. F., Waters, W. E., 8c Nicholas, J. A. (1983). Prescription information leaflets: A pilot study in general practice. British Medical Journal, 287, 1193-1196. Gibbs, S. (1992). Prescription information leaflets for patients. European Respiratory Journal, 5, 140-143. Gibbs, S., Waters, W. E., 8c George, C. F. (1989). The benefits of prescription information leaflets (1). British Journal of Clinical Pharmacology, 27, 723-739. Green, L. W., Mullen, P. D., 8c Stainbrook, G. L. (1986). Programs to reduce drug errors in the elderly: Direct and indirect evidence from patient education. Journal of Geriatric Drug Therapy, 1, 59-70. Harvey, J. L., 8c Plumridge, R. J. (1991). Comparative attitudes of verbal and written medication information among hospital outpatients. DICP, The Annals of Pharmacology, 25, 925-928. Isaacman, D. J., Purvis, K., Gyuro, J., Anderson, Y., 8c Smith, D. (1992). Standardized instructions: D o they improve communication of discharge information from the emergency department? Pediatrics, 89, 1204-1208. Haynes, R. B., Wang, E., 8c Da Mota Gomes, M. (1987). A critical review of interventions to improve compliance with prescribed medications. Patient Education and Counseling 10, 155-166. Jackson, R. Α., 8c Huffman, D. C. (1990, July). Patient compliance: The financial impact on your practice. NARD Journal, pp. 67-71.

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Janz, N., & Becker, M. (1984). The health belief model: A decade later. Health Education Quarterly, 11, 1-47. Johnston, M., Clarke, Α., Mundy, K., Cromarty E., & Ridout, K. (1986). Facilitating comprehension of discharge medication in elderly patients. Age and Aging, 15, 304-306. Kessler, D. A. (1991). Communicating with patients about their medications. The New England Journal of Medicine, 325, 1650-1652. Lamy, P. P. (1990). Adverse drug effects. Clinical Pharmacology, 6, 293-307. Meichenbaum, D., 8c Turk, D. C. (1987). Facilitating treatment adherence: A practitioner's guidebook. New York: Plenum. Morris, L. Α., Grossman, K., Barkdoll, G., & Gordon, E. (1987). A segmentational analysis of prescription drug information seeking. Medical Care, 25, 953-964. Morris, L. S., 8c Schulz, R. M. (1992). Patient compliance—An overview. Journal of Clinical Pharmacy and Therapeutics, 17, 283-295. Mullen, P. D., 8c Green, L. W. (1984). Measuring patient drug information transfer: An assessment of the literature. Houston: University of Texas Health Science Center, Center for Health Promotion Research and Development. Myers, E. D., 8c Calvert, E. J. (1984). Information, compliance and side-effects: A study of patients on antidepressant medication. British Journal of Clinical Pharmacology, 17, 21-25. O'Connell, Μ. B., 8c Johnson, J. F. (1992). Evaluation of medication knowledge in elderly patients. The Annals of Pharmacotherapy, 26, 919-921. Office of Inspector General. (1990). Medication regimens: Causes of noncompliance (DHHS Publication No. OEI-04-89-89121). Washington, DC: Government Printing Office. Opdycke, R.A.C., Ascione, F. J., Shimp, L. Α., 8c Rosen, R. I. (1992). A systematic approach to educating elderly patients about their medications. Patient Education and Counseling, 19, 43-60. Podolsky, D., 8c Newman, R. J. (1993, March 29). Prescription prizes: Drug makers hope giveaways and discounts will snag customers. U.S. News & World Report, pp. 56-60. Quaid, Κ. Α., Faden, R. R., Vining, E. P., 8c Freeman, J. M. (1990). Informed consent for a prescription drug: Impact of disclosed information on patient understanding and medical outcomes. Patient Education and Counseling, 15, 249-259. Robinson, G. L., Gilbertson, A. D., 8c Litwack, L. (1986). The effects of a psychiatric patient education to medication program on post-discharge compliance. Psychiatric Quarterly, 58, 113-118. Schwartz-Lookinland, S., McKeever, L. C , 8c Saputo, M. (1989). Compliance with antibiotic regimens in Hispanic mothers. Patient Education and Counseling, 13, 171-182. Sclar, D., Chin, Α., Skaer, T., Okamoto, M., Nakahiro, R., 8c Gill, M. (1991). Effect of health education in promoting prescription refill compliance among patients with hypertension. Clinical Therapeutics, 13, 489-495. Shapiro, A. K., 8c Morris, L. A. (1978). Placebo effects in medical and psychological therapies. In A. E. Bergin 8c S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change: Empirical analysis (pp. 213-222). New York: John Wiley. Smith, D. L. (1989). Compliance packaging: A patient education tool. American Pharmacy, NS29{2), 126-134. U.S. Department of Health and Human Services. (1990). Healthy people 2000: National health promotion and disease prevention objectives (Conference ed.). Washington, DC: U.S. Department of Health and Human Services.

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Van Haecht, C.H.M., Vander Stichele, R., & Bogaert, M. G. (1990). Package inserts for antihypertensive drugs: Use by the patients and impact on adverse drug reactions. European Journal of Clinical Pharmacology, 39, 551-554. Weiderholt, J., Clarridge, B. R , Sc Svarstad, B. L. (1992). Verbal consultation regarding prescription drugs. Medical Care, 30, 159-173. Weinman, J. (1990). Providing written information for patients: Psychological considerations. Journal of the Royal Society of Medicine, 83, 303-305.

14 Enabling Health POLICY A N D ADMINISTRATIVE PRACTICES AT A CROSSROADS

ROXANNE LOUISELLE PARROTT MARY LOUISE KAHL EDWARD W. MAIBACH

Since the ethical laws, which concern the individual duty of each man in himself, are so hard to frame... it is no wonder if those that govern so many individuals are more so. (Frame, 1973, pp. 112-113) —Montaigne, 16th century philosopher

s u b s t a n t i a l k n o w l e d g e base h a s a c c u m u l a t e d in r e l a t i o n t o u n d e r jLjLstanding h u m a n behavior and health. W h e n c o m b i n e d with c o m m u n i c a t i o n t h e o r y a n d p u b l i c h e a l t h practice, this k n o w l e d g e h i g h l i g h t s t h e m e a n s a n d m e t h o d s t o design messages t h a t p r o m o t e i n d i v i d u a l r e s p o n s i bility in relation to health. T h e o u t c o m e s associated with such efforts, h o w e v e r , d e p e n d u p o n t h e e n v i r o n m e n t in w h i c h a n i n d i v i d u a l lives, as c o n s t r u c t e d b y state a n d local, n a t i o n a l , a n d even i n t e r n a t i o n a l h e a l t h policy a n d a d m i n istrative practices. Before c o n s t r u c t i n g h e a l t h messages a i m e d at t h e i n d i vidual, therefore, o n e should carefully evaluate the larger social scene, e x a m i n ing the administrative health policies a n d practices that p r o v i d e t h e b a c k d r o p for h e a l t h p r o m o t i o n p r o g r a m s . Such e x a m i n a t i o n fulfills a n ethical obligat i o n t o u n d e r s t a n d t h e e x t e r n a l b a r r i e r s t h a t m a y i n h i b i t t h e success of h e a l t h e n a b l e m e n t activities.

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Health Message Designers' Ethical Obligations T h e first t w o d e c a d e s of t h e 2 0 t h c e n t u r y saw t h e U . S . m i d d l e class evolve t o w a r d greater social awareness. A n u r b a n p o p u l a t i o n increasingly dealt w i t h i n d i g e n t s in a c o n c e r n e d a n d p u b l i c m a n n e r , a d o p t i n g c o n s u m e r p r o t e c t i o n laws a n d public regulatory c o m m i s s i o n s . Individual free choice, a n d t h e belief t h a t a h u m a n b e i n g ' s m a t e r i a l f o r t u n e d e p e n d s o n c h a r a c t e r traits a n d m o r a l i t y , b e c a m e u n r e a l i s t i c t o t h e early 2 0 t h - c e n t u r y p r o g r e s s i v e . T h e n e w A m e r i c a n i n d u s t r i a l society's w o r k i n g - c l a s s citizens suffered ill h e a l t h a n d injury, often t h r o u g h n o fault of their o w n . As a result, middle-class p r o g r e s sives c o n s i d e r e d social i n s u r a n c e , a m e a n s t o f u r n i s h p a r t o f t h e p o p u l a t i o n w i t h p r o t e c t i o n t h a t o t h e r s m a y n e e d less o r afford for t h e m s e l v e s , u s i n g society's r e s o u r c e s t o m a i n t a i n t h e l a b o r e r ' s t r a d i t i o n a l self-reliance (Hirshfield, 1970). O n e specific area t h a t A m e r i c a n s felt w a r r a n t e d g o v e r n m e n t a c t i o n a n d social i n s u r a n c e was h e a l t h a n d m e d i c a l care. S u p p o r t e r s s t r u c t u r e d d i s c o n n e c t e d ideologies i n t o t h e b e g i n n i n g s of a political m y t h , a n d in 1906, t h e A m e r i c a n Association for Labor Legislation (AALL), a n e d u c a t i o n a l p r e s s u r e g r o u p c o n c e r n e d w i t h h e a l t h r e f o r m s in i n d u s t r y , s o u g h t c o m p u l s o r y health insurance as a solution t o indigent medical care ( H i r s h f i e l d , 1970). T h e AALL, w i t h leaders v e r s e d in E u r o p e a n social i n s u r a n c e e x p e r i m e n t s , c o n c e n t r a t e d initially o n a c a m p a i g n t o i m p l e m e n t w o r k m e n ' s c o m p e n s a t i o n laws, t h e first successful social i n s u r a n c e in t h e U n i t e d States. W i t h t h a t a c h i e v e m e n t , t h e AALL's m e m b e r s h i p g r e w t o i n c l u d e p r o g r e s s i v e p o l i t i cians a n d university professors, W o o d r o w Wilson a m o n g t h e m . T h e g r o u p ' s e x e c u t i v e secretary, J o h n B. A n d r e w s , w o r k e d w i t h o t h e r influential AALL m e m b e r s t o i n s e r t t h e social i n s u r a n c e p l a n k i n t o t h e 1912 P r o g r e s s i v e P a r t y ' s p l a t f o r m ( A n d r e w s , 1938). T h e AALL's efforts s p a n n e d t h e d e c a d e o f l 9 1 0 t o l 9 2 0 , a p r e d e c e s s o r t o m o d e r n efforts t o r e f o r m h e a l t h p o l i c y a n d t h e vision t h a t i n s p i r e s t h e s e activities. T h e AALL's efforts w e r e i n h i b i t e d b y failure t o a d d r e s s l a b o r leaders, w h o felt t h a t t h e e n a c t m e n t of social i n s u r a n c e w o u l d w e a k e n l a b o r u n i o n s ; e m p l o y e r s , w h o felt t h e y w o u l d p a y a n unfair portion; a n d commercial insurance companies, w h o viewed national h e a l t h i n s u r a n c e as a t h r e a t t o b u s i n e s s (Hirshfield, 1970). T h e s e s a m e issues will always challenge h e a l t h policy m a k e r s a n d a d m i n i s t r a t o r s , f o r m i n g t h e c o n t e x t w i t h i n w h i c h efforts t o e m p o w e r a n d e n a b l e i n d i v i d u a l s t o b e h e a l t h y m u s t b e f r a m e d . T h e s e issues suggest several b r o a d q u e s t i o n s t h a t h e a l t h c a m p a i g n e r s s h o u l d a d d r e s s d u r i n g t h e p r o c e s s of p l a n n i n g , i m p l e m e n t i n g , a n d e v a l u a t i n g t h e i r messages:

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THEORY AND

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1. To what degree are there clear statements of national standards applicable to health? 2. To what degree have domestic laws been created to observe the national standards? 3. To what degree do federal administrative domestic laws?

goals and institutions support the

4. To what degree do state and local rules and actions exist to facilitate or inhibit the attainment of federal administrative goals and institutions? 5. To what degree do cultural norms allocate legal responsibility and support for health policies and practices?

mobilize

NATIONAL HEALTH STANDARDS T h e identification of n a t i o n a l health s t a n d a r d s is a t e n u o u s p r o p o s i t i o n at best. O n e p r o b l e m w i t h f o r m i n g s t a t e m e n t s of n a t i o n a l h e a l t h s t a n d a r d s is t h a t a n y i n d i v i d u a l m i g h t c o n s i d e r a l m o s t a n y t h i n g t o b e w i t h i n t h e r e a l m of j u s t claims. For e x a m p l e , is clean air a b i r t h r i g h t ? D o e s every h u m a n b e i n g h a v e a j u s t claim to b r e a t h e air t h a t is n o n i n j u r i o u s t o h e r or his health? If s o , d o e s an i n d i v i d u a l have t h e right t o b r i n g suit against a state t h a t d o e s n o t g u a r a n t e e t h a t t h e air she or h e b r e a t h e s is n o n i n j u r i o u s t o health? In t h e U n i t e d States, a Bill of Rights g u a r a n t e e s citizens certain i n a l i e n a b l e r i g h t s , a n d o n e i n d i v i d u a l ' s rights s t o p w h e r e a n o t h e r i n d i v i d u a l ' s b e g i n . T h e difficulty in establishing n a t i o n a l h e a l t h s t a n d a r d s , t h e n , is t o d e t e r m i n e w h e r e t o d r a w t h a t line, p a r t i c u l a r l y if o n e c o n s i d e r s life in t e r m s of m e n t a l a n d physical h e a l t h , a n d w o r k - r e l a t e d activities h a r m o n e ' s m e n t a l a n d / o r physical h e a l t h . T h e s e are issues t h a t n a t i o n s h a v e w r e s t e d w i t h b o t h i n t e r nally a m o n g states a n d externally at t h e level of i n t e r n a t i o n a l law. T h e r e l a t i o n s h i p t h a t exists b e t w e e n an i n d i v i d u a l a n d t h e state f o r m s an u n d e r l y i n g n o t i o n of h u m a n rights a n d p r o v i d e s a w a y t o f r a m e d i s c u s s i o n a b o u t n a t i o n a l h e a l t h s t a n d a r d s . In p a r t i c u l a r , t w o U n i t e d N a t i o n s ' d o c u m e n t s t h a t a d d r e s s h u m a n rights illustrate t h e t e n s i o n a r o u n d t h e t o p i c of n a t i o n a l h e a l t h s t a n d a r d s . T h e C o v e n a n t of Civil a n d Political Rights was d e s i g n e d t o a c k n o w l e d g e an i n d i v i d u a l ' s f r e e d o m of religious e x p r e s s i o n , peaceful a s s e m b l a g e , a n d m o v e m e n t , in a d d i t i o n t o t h e i n h e r e n t r i g h t t o life ( v o n G l a h n , 1981). T h e C o v e n a n t o n E c o n o m i c , Social, a n d C u l t u r a l R i g h t s , o n t h e o t h e r h a n d , directly a d d r e s s e s issues relating t o e c o n o m i c a n d social areas, s u c h as: t h e right to w o r k , m e d i c a l care, e d u c a t i o n , a n d m e n t a l or physical h e a l t h ( v o n G l a h n , 1981). T h e U n i t e d States h a d reservations a b o u t b e i n g a s i g n a t u r e p a r t y t o b o t h U . N . c o v e n a n t s , r e c o g n i z i n g t h e p o t e n t i a l for conflict b e t w e e n w h a t o n e citizen d o e s to satisfy t h e right to w o r k a n d a n o t h e r citizen's i n h e r e n t r i g h t

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t o life. U n d e r l y i n g this issue, as a r t i c u l a t e d b y t h e AALL d e c a d e s earlier, is t h e struggle t o a d d r e s s w h e t h e r o r n o t a n i n d i v i d u a l m a y b e h e l d r e s p o n s i b l e for his o r h e r o w n ill h e a l t h . I n o t h e r w o r d s , if s o m e o n e willingly w o r k s , a n d t h e w o r k h a r m s p h y s i c a l / m e n t a l h e a l t h , is t h e w o r k e r o r t h e e m p l o y e r responsible? In r e l a t i o n t o s o m e t h i n g s u c h as t h e air w e b r e a t h e o r t h e w a t e r w e d r i n k , n a t i o n a l h e a l t h s t a n d a r d s a p p e a r t o b e clearly necessary. W i t h o u t s u c h s t a n d a r d s , o n e state o r a n a r e a w i t h i n a state m a y a d o p t policy t h a t u n d e r m i n e s t h e efforts a n d policy of a n e i g h b o r i n g state o r r e g i o n . F e w w o u l d d i s a g r e e w i t h t h e s t a t e m e n t t h a t n a t i o n a l h e a l t h s t a n d a r d s a p p e a r t o b e of vital i m p o r t a n c e t o safeguard t h e food s u p p l y , t o o . T h e u s e o f s o m e f o r m s of pesticides, h o w e v e r , m a y t h r e a t e n t h e q u a l i t y of t h e air o r w a t e r w e use, w h i l e p r o m o t i n g t h e q u a l i t y of t h e food w e c o n s u m e . S u c h conflicts m u s t b e a d d r e s s e d , a n d h e a l t h m e s s a g e d e s i g n e r s s h o u l d start w i t h a n analysis of t h e n a t i o n a l h e a l t h s t a n d a r d s w i t h i n w h i c h t h e i r efforts a r e t o b e f r a m e d . T w o q u e s t i o n s s h o u l d g u i d e this u n d e r t a k i n g , w h i c h leads t o t h e ability t o e x a m i n e p o t e n t i a l conflicts: 1. What is the relationship between the health activity being planned and the right to life; a n d 2. What is the relationship between the health activity being planned and the right to work? T o e x t e n d t h e d i s c u s s i o n of pesticide use as a n e x a m p l e , m e s s a g e d e s i g n ers w h o seek t o evaluate n a t i o n a l h e a l t h s t a n d a r d s relating t o pesticides s h o u l d e x a m i n e t h e r e l a t i o n s h i p of use t o t h e r i g h t t o life a n d t h e r i g h t t o w o r k . In r e l a t i o n t o t h e r i g h t t o life, h e a l t h p r o m o t e r s m i g h t list t h e fact t h a t p e s t i c i d e use is r e l a t e d t o r e s p i r a t o r y a n d skin a i l m e n t s t h a t negatively affect q u a l i t y of life a n d m a y even t h r e a t e n o n e ' s survival. O n t h e o t h e r h a n d , pesticides p r o t e c t t h e food s u p p l y f r o m spoilage d u e t o insect i n f e s t a t i o n , a n d f o o d is necessary t o s u s t a i n life. A n e v a l u a t i o n o f t h e r e l a t i o n s h i p b e t w e e n pesticide u s e a n d t h e right t o w o r k m i g h t d e m o n s t r a t e t h a t u s e is r e l a t e d t o f a r m e r s ' ability t o m a k e a profit a n d stay in b u s i n e s s . P r o d u c t i o n of pesticides also creates j o b s . H a v i n g r e a c h e d these c o n c l u s i o n s , m e s s a g e d e s i g n e r s s h o u l d r e c o g n i z e t h e clear p o t e n t i a l for conflict t o o c c u r in t h e face of a t t e m p t i n g to restrict pesticide use. T h e evidence of conflict o r p o t e n t i a l for conflict signifies t h e n e e d to i n c l u d e messages for m u l t i p l e a u d i e n c e s , w i t h a r g u m e n t s a n d c o u n t e r a r g u m e n t s d e s i g n e d t o a d d r e s s different sides of t h e issue.

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E v a l u a t i o n of t h e n a t i o n a l i n f l u e n c e t o p i c is t h e first step frames t h e m e s s a g e d e s i g n e r ' s is a n e x a m i n a t i o n of w h e t h e r health standards.

PRACTICE

h e a l t h s t a n d a r d s t h a t relate t o a p a r t i c u l a r in efforts t o e x a m i n e t h e societal system t h a t efforts. T h e n e x t u n d e r t a k i n g in this analysis d o m e s t i c laws exist t o o b s e r v e t h e n a t i o n a l

D O M E S T I C LAWS T O OBSERVE T H E NATIONAL STANDARDS T o m a k e c o m p a r i s o n s a b o u t h e a l t h s t a n d a r d s from o n e n a t i o n to a n o t h e r , i n d i c a t o r s s u c h as infant m o r t a l i t y r a t e a r e u s e d . T h e s e p r o v i d e a gross s u m m a t i v e m e a s u r e of a n u m b e r of n a t i o n a l h e a l t h s t a n d a r d s , i n c l u d i n g s a n i t a t i o n a n d n u t r i t i o n levels, as well as available m e d i c a l care. T h e U n i t e d States h a s a relatively h i g h infant m o r t a l i t y rate in c o m p a r i s o n t o o t h e r developed n a t i o n s (Willis 8c Fullerton, 1991), suggesting t h a t n a t i o n a l h e a l t h s t a n d a r d s in s u p p o r t of a l o w e r infant m o r t a l i t y r a t e h a v e n o t b e e n clearly a r t i c u l a t e d , are in conflict, a n d / o r are u n s u p p o r t e d b y d o m e s t i c laws. Legislation t o s u p p o r t a n a t i o n a l h e a l t h s t a n d a r d often o c c u r s in r e a c t i o n t o a n event that costs lives a n d / o r captures m e d i a attention. In relation t o air quality, for e x a m p l e , early in this c e n t u r y , Trail Smelter e m i s s i o n s in British C o l u m b i a c a u s e d d a m a g e to t h e state of W a s h i n g t o n a n d i n j u r y t o p e r s o n s a n d p r o p e r t y . U n d e r a 1935 treaty, t h e d i s p u t e was a r b i t r a t e d in favor o f t h e U n i t e d States, a n d t h e assertion was m a d e t h a t n o State h a d t h e r i g h t t o use its t e r r i t o r y t o t h e injury of a n o t h e r State's p e r s o n s o r p r o p e r t y ( v o n G l a h n , 1981). D e t e r m i n i n g responsibility for fallout a n d o t h e r b y - p r o d u c t s of n u c l e a r t e s t i n g also illustrates issues t h a t r e q u i r e d o m e s t i c law t o s u p p o r t n a t i o n a l air q u a l i t y s t a n d a r d s . N a t i o n a l h e a l t h s t a n d a r d s are b r o a d guidelines t h a t a r t i c u l a t e p h i l o s o p h y a n d p r i n c i p l e s t o direct h e a l t h - r e l a t e d activities u n d e r t a k e n w i t h i n a n a t i o n . F o r e v e r y s t a n d a r d , m u l t i p l e d o m e s t i c laws a r e likely t o b e n e c e s s a r y t o evolve t h e p r i n c i p l e t o w a r d practice. T o assess w h e t h e r d o m e s t i c laws exist w h i c h o b s e r v e t h e n a t i o n a l h e a l t h s t a n d a r d s , m e s s a g e d e s i g n e r s ask: 1. What domestic

laws exist to support

2. What domestic

laws exist to oppose the

the standards;

and

standards?

I n r e l a t i o n t o t h e discussion of pesticide use, m e s s a g e d e s i g n e r s m a y d e t e r m i n e t h a t d o m e s t i c laws exist t h a t s u p p o r t use t o safeguard t h e food s u p p l y . Laws m a y also exist t h a t o p p o s e use in areas t h a t h a v e a certain p o p u l a t i o n d e n s i t y . N o law m a y actually exist t o s u p p o r t use to p r o t e c t f a r m e r s ' profits,

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b u t u s e for t h e p u r p o s e of s a f e g u a r d i n g t h e f o o d s u p p l y m a y at t h e s a m e t i m e p r o m o t e f a r m e r s ' profits. N o law m a y exist t o o p p o s e use t h a t e n d a n gers f a r m w o r k e r s ' h e a l t h , b u t u s e for t h e p u r p o s e o f s a f e g u a r d i n g t h e f o o d supply m a y at the same time endanger farmworkers' health. As in t h e case of n a t i o n a l h e a l t h s t a n d a r d s , m e s s a g e d e s i g n e r s s h o u l d identify s i t u a t i o n s in w h i c h d o m e s t i c laws create conflict o r p o t e n t i a l for conflict, t h e r e b y g a i n i n g a b e t t e r u n d e r s t a n d i n g of t h e a u d i e n c e s t o b e a d d r e s s e d a n d t h e a p p r o p r i a t e c o n t e n t for messages. A m e r i c a n f a r m i n g is o n e a r e n a t h a t clearly illustrates t h e c o m p e t i n g d e m a n d s b e t w e e n d o m e s t i c laws d e s i g n e d t o s u p p o r t t h e right t o life v e r s u s t h e r i g h t t o w o r k . F a r m e r s often d e p e n d u p o n workers w h o w o r k for low wages a n d d e m a n d few benefits. T h e a g r i c u l t u r a l l a b o r force is " t h e o n l y sector o f t h e U . S . e c o n o m y t o b e given p r e f e r e n t i a l t r e a t m e n t in t h e I m m i g r a t i o n R e f o r m a n d C o n t r o l A c t ( I R C A ) of 1 9 8 6 " ( T h o m p s o n 8c M a r t i n , 1 9 9 1 , p . 5 2 7 ) . M i g r a n t a n d s e a s o n a l f a r m w o r k e r s reside in very p o o r c o n d i t i o n s a n d often h a v e ill h e a l t h w i t h n o o n e e n f o r c i n g l a b o r p r o t e c t i o n laws o n t h e i r b e h a l f ( L i n d e r , 1990). T o e n f o r c e laws o n b e h a l f of seasonal f a r m w o r k e r s , h o w e v e r , j e o p a r d i z e s t h e a l r e a d y s m a l l profit m a r g i n of f a r m e r s . In o t h e r w o r d s , t o p r o t e c t t h e h e a l t h of o n e g r o u p p u t s at risk t h e right t o w o r k a n d m a k e a living of a n o t h e r g r o u p . B o t h g r o u p s a n d b o t h goals m u s t b e a d d r e s s e d in m e s s a g e d e s i g n e r s ' p l a n s to enable health. T h e m a j o r w e a k n e s s of d o m e s t i c laws a i m e d at s u p p o r t i n g n a t i o n a l h e a l t h s t a n d a r d s is in t h e a r e a of i m p l e m e n t a t i o n . H a v i n g identified d o m e s t i c laws t h a t relate t o o b s e r v i n g p a r t i c u l a r n a t i o n a l h e a l t h s t a n d a r d s , a n e x a m i n a t i o n o f federal a d m i n i s t r a t i v e goals a n d i n s t i t u t i o n s d e s i g n e d t o i m p l e m e n t t h e s e laws is a n a p p r o p r i a t e n e x t step t o fulfill t h e m e s s a g e d e s i g n e r ' s ethical obligation.

F E D E R A L A D M I N I S T R A T I V E GOALS A N D I N S T I T U T I O N S T O I M P L E M E N T D O M E S T I C LAWS T h e d e s i g n a n d passage o f d o m e s t i c laws t o s u p p o r t n a t i o n a l h e a l t h s t a n d a r d s is a necessary b u t n o t sufficient c o n d i t i o n t o e n a b l e h e a l t h . T o i m p l e m e n t t h e laws, t h e s u p p o r t of federal a d m i n i s t r a t i v e goals a n d i n s t i t u tions are frequently required. At a n y p o i n t in t i m e , t h e c u r r e n t federal a d m i n i s t r a t i o n ' s goals h a v e a s u b s t a n t i a l i m p a c t o n w h e t h e r o r n o t t h e n e c e s s a r y institutions exist to s u p p o r t laws created to u p h o l d a national health s t a n d a r d . T h e basic p u r p o s e of n a t i o n a l h e a l t h care policy a n d r e f o r m is t o p r o v i d e l e a d e r s h i p a n d d i r e c t i o n for efforts t o i m p r o v e t h e h e a l t h a n d w e l l - b e i n g of a n a t i o n ' s citizens. T h i s i n c l u d e s t h e design a n d i m p l e m e n t a t i o n o f t h e

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m e a n s t o g r a n t access, b o t h g e o g r a p h i c a l l y a n d financially, t o h e a l t h a n d m e d i c a l care. As p a r t of t h e effort b o t h t o create j o b s a n d t o p r o t e c t i n d i v i d u a l h e a l t h a n d safety, s t a t e m e n t s of policy t o reflect federal a d m i n i s t r a t i v e goals a r e w r i t t e n a n d p r e s e n t e d t o t h e p u b l i c . T h e s e policy s t a t e m e n t s c o m p r i s e w h a t has b e e n t e r m e d b u r e a u c r a t i c d i s c o u r s e , w h i c h is, " a n y r e p o r t p r o d u c e d b y a n o r g a n i z a t i o n for e v a l u a t i o n a n d o t h e r practical p u r p o s e s t h a t is t a r g e t e d for i n d i v i d u a l s , c o m m i t t e e s , o r publics w h o are u n a w a r e of its p r o m o t i v e c h a r a c t e r a n d t h e e d i t i n g processes u s e d to s h a p e it" (Altheide 8c J o h n s o n , 1980, p . 5 ) . Federal g o v e r n m e n t agencies a n d d e p a r t m e n t s e m p l o y b u r e a u cratic d i s c o u r s e frequently w h e n t h e y a d d r e s s b o t h i n t e r n a l a n d e x t e r n a l a u d i e n c e s "in t h e exercise of p o w e r " ( C o m b s 8c N i m m o , 1993, p . 122). T h e p u r p o s e of b u r e a u c r a t i c d i s c o u r s e is t o create, m o b i l i z e , a n d c o n t i n u e s u p p o r t for a d m i n i s t r a t i v e goals, while c o n c o m i t a n t l y l i m i t i n g a n d restricting any opposition to them. T h i s n a t i o n ' s p u b l i c s t a t e m e n t s of a d m i n i s t r a t i v e goals a b o u t h e a l t h care e m a n a t e largely from the D e p a r t m e n t of Health a n d H u m a n Services, a d d r e s s m u l t i p l e a u d i e n c e s , p r o m o t e t h e p a r t i c u l a r v i e w p o i n t of t h e P r e s i d e n t a n d advisers, a n d e n d o r s e specific c o u r s e s of a c t i o n , often in t h e face of o p p o s i t i o n . T h e very p r o c e s s of a r t i c u l a t i n g h e a l t h care p r i o r i t i e s , of " s e t t i n g t h e a g e n d a , " d e m o n s t r a t e s significant political p o w e r s . H e a l t h m e s s a g e d e s i g n ers s h o u l d assess: 1. What administrative goals underlie bureauaatic discourse; and 2. What institutions exist to create, mobilize, and continue support for these goals? Analysis of b o t h these issues is critical t o u n d e r s t a n d t h e likely success o r failure of h e a l t h e n a b l e m e n t activities. If a d m i n i s t r a t i v e d i s c o u r s e p r o m o t e s p r e n a t a l care as a p r a c t i c e for all p r e g n a n t w o m e n , for e x a m p l e , this m a y b e a m e a n s t o articulate t h e goal of r e d u c i n g t h e infant m o r t a l i t y rate. Such a goal m a y b e t h e result of efforts t o i m p l e m e n t t h e H e a l t h y Birth Act, w h i c h was passed as o n e d o m e s t i c law in s u p p o r t of a n a t i o n a l health s t a n d a r d . C a m p a i g n p l a n n e r s assigned t h e t a s k of p r o m o t i n g p r e n a t a l care, h o w e v e r , o u g h t t o ask t h e m s e l v e s w h e t h e r t h e r e are an a d e q u a t e n u m b e r of accessible p r o v i d e r s a n d clinics t o give t h e care. P r o m o t i n g t h e desire for p r e n a t a l care w i t h o u t a s s u r i n g access t o s u c h care p e r p e t u a t e s a n d exacerbates t h e u n d e r l y i n g i n e q u i t i e s in t h e h e a l t h care system (see P a r r o t t 8c Daniels, in press).

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H e a l t h p r o b l e m s of t h e p o o r a n d m i n o r i t i e s have often b e e n f o u n d t o b e e x a c e r b a t e d b y t h e i n a d e q u a c i e s of i n s t i t u t i o n s t h a t p r o v i d e services. T h i s is particularly t r u e for p r e g n a n t w o m e n a n d y o u n g children. T h e r e p o r t of t h e N a t i o n a l C o m m i s s i o n o n C h i l d r e n (1990) c o n c l u d e d : fragmented, narrowly defined policies and programs often create financial, administrative, and geographical barriers to early and regular care. The result is a disjointed tangle of services that reach some but not all of those who need them. As in other areas of h u m a n services, it is typically those women who need prenatal care most who are least likely to receive it. (p. 124) In a n o t h e r area of t h e n a t i o n ' s h e a l t h policy, n a m i n g t h e p r e v e n t i o n a n d detection of H I V as a priority alerts health planners a n d campaigners t h a t t h e r e will b e s u p p o r t for activities in relation t o H I V . W h a t varies w i t h different a d m i n i s t r a t i o n s is t h e specific vision t h a t f o r m s t h e a p p r o a c h t o b e t a k e n . T h e R e a g a n , B u s h , a n d C l i n t o n a d m i n i s t r a t i o n s h a v e all b e e n criticized for m a k i n g H I V p r e v e n t i o n a p r i o r i t y in n a m e only. F o r m e r P r e s i d e n t B u s h ' s a p p o i n t m e n t o f Earvin " M a g i c " J o h n s o n t o t h e N a t i o n a l C o m m i s s i o n o n A I D S illustrates action t a k e n t o s u p p o r t a h e a l t h goal. T h i s a d m i n i s t r a t i v e a c t i o n c a p t u r e d w i d e s p r e a d a t t e n t i o n a n d a p p r o v a l , as t h e B u s h a d m i n i s t r a t i o n heralded J o h n s o n ' s affiliation with t h e C o m m i s s i o n as p r o o f of its c o m m i t m e n t t o o u t r e a c h o n t h e issue of A I D S a n d e v i d e n c e of o n g o i n g a t t e m p t s t o publicize m e a s u r e s c o n t r i b u t i n g t o p r e v e n t i o n of t h e disease. W h e n B u s h refused, h o w e v e r , t o a d o p t t h e suggestions of this very C o m m i s s i o n , n o t a b l y w i t h r e g a r d t o t h e d i s t r i b u t i o n of c o n d o m s in p u b l i c s c h o o l s , t h e s o m e t i m e s inevitable clash t h a t o c c u r s b e t w e e n health care p r i o r i t i e s a n d electoral politics b e c a m e a p p a r e n t . C u r b i n g alcohol a n d d r u g use has also long been n a m e d as a n a d m i n i s t r a t i v e h e a l t h care p r i o r i t y in t h e U n i t e d States, suggesting yet a n o t h e r s a n c t i o n e d focus for c a m p a i g n e r s ' messages. Millions of A m e r i c a n s r e q u i r e t r e a t m e n t for a l c o h o l a n d d r u g a b u s e , b u t t h e cost of p r o g r a m s t o r e d u c e d r u g d e m a n d is excessively h i g h . Because t h e federal g o v e r n m e n t ' s willingness t o f u n d d r u g t r e a t m e n t h a s n o t k e p t p a c e w i t h t h e d e m a n d for d r u g t r e a t m e n t a m o n g l o w - i n c o m e p e o p l e , t h e r e is a large t r e a t m e n t availability g a p . T h e a p p r o v a l o f a d d i t i o n a l f u n d i n g for facilities t o t r e a t d r u g a b u s e is n e c e s s a r y to p r o v i d e institutional s u p p o r t for a n administrative health goal a n d reflects s u p p o r t for d o m e s t i c laws t h a t m a k e d r u g use illegal. H a v i n g e v a l u a t e d w h e t h e r o r n o t federal a d m i n i s t r a t i v e goals a n d instit u t i o n s exist to s u p p o r t t h e i m p l e m e n t a t i o n of d o m e s t i c laws, message d e s i g n -

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ers s h o u l d next consider state a n d local rules a n d actions. These m a y c o m p l e m e n t , d e n i g r a t e , or b e u n r e l a t e d to federal policies.

S T A T E A N D LOCAL RULES AND ACTIONS TO SUPPORT A D M I N I S T R A T I V E GOALS A N D I N S T I T U T I O N S State a n d local rules a n d a c t i o n s t o s u p p o r t a d m i n i s t r a t i v e goals a n d i n s t i t u t i o n s a r e frequently necessary t o e m p o w e r i n d i v i d u a l s t o b e h e a l t h y . If clinics a n d p r o v i d e r s are available for p r e g n a n t w o m e n t o u s e t o receive p r e n a t a l care, for e x a m p l e , b u t eligible w o m e n h a v e n o m o d e of t r a n s p o r t a t i o n t o get t o t h e clinics, or h a v e t o w a i t for h o u r s t o receive c a r e , t h e existence o f t h e i n s t i t u t i o n s d o e s little t o e n s u r e p r o p e r care. A n e x a m i n a t i o n o f t h e c o m m u n i t y e n v i r o n m e n t in w h i c h a t a r g e t a u d i e n c e lives often reveals b a r r i e r s t o t h e use of i n s t i t u t i o n s d e s i g n e d t o p r o v i d e h e a l t h services. M o r e o v e r , state a n d local rules a n d actions are often n e e d e d to enforce federal laws p a s s e d to p r o m o t e well-being. A n analysis of state a n d local rules a n d a c t i o n s m a y t h u s highlight necessary r e f o r m s t o m o v e p r o m i s e f o r w a r d i n t o the realm of performance. H e a l t h m e s s a g e designers s h o u l d assess: 1. What state and local rules/ordinances exist to supportfederal adm inistrative goals and institutions, and domestic laws created to observe national health standards; and 2. What state and local actions have been taken to support federal administrative goals and institutions, and the domestic laws created to observe national health standards? In r e c o g n i t i o n of t h e significant role of state a n d local o r d i n a n c e s a n d a c t i o n s , c o n s i d e r t h e c o n s u m p t i o n of alcohol, w h i c h has often b e e n l i m i t e d b y state laws t h a t assign age limits t o p u r c h a s e r s . If local c o n v e n i e n c e s t o r e w o r k e r s sell b e e r t o m i n o r s , h o w e v e r , t h e law p r o v e s t o b e a n i n a d e q u a t e m e a n s t o e n a b l e h e a l t h . Similarly, laws h a v e b e e n p a s s e d t o c o n s t r a i n t h e sale of t o b a c c o p r o d u c t s , b u t stores a n d v e n d i n g m a c h i n e s allow u n d e r a g e c o n s u m e r s t o p u r c h a s e a n d use t o b a c c o p r o d u c t s . T h e s e p r a c t i c e s , o n c e identified, p r o v i d e an i m p o r t a n t avenue for message designers to target efforts to enable health. M a n y state a n d local o r d i n a n c e s illustrate t h e s y m b i o t i c r e l a t i o n s h i p t h a t exists b e t w e e n federal a n d state laws, as o n e state m a y a d o p t a m o r e liberal policy t h a n a n o t h e r state, so individuals cross state b o r d e r s t o i m b i b e . In t h e

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a b s e n c e of a federal r e g u l a t i o n , these state activities a r e s a n c t i o n e d . State a n d local rules also i m p o r t a n t l y affect w h e t h e r o r n o t federal i n s t i t u t i o n a l s u p p o r t will b e g r a n t e d t o a p a r t i c u l a r state o r locale. A state m u s t s a n c t i o n a n d s u p p o r t t h e r e p o r t i n g o f injuries, illness, a n d / o r disease, for e x a m p l e , t o p r o v i d e e v i d e n c e of a n e e d for federal i n s t i t u t i o n a l s u p p o r t . H e a l t h m e s s a g e d e s i g n e r s increase t h e l i k e l i h o o d t h a t t h e i r messages will s u c c e e d b y e v a l u a t i n g w h e t h e r o r n o t a s i t u a t i o n lacks i n s t i t u t i o n a l s u p p o r t b e c a u s e of a n a b s e n c e of n e e d o r a n a b s e n c e of state a n d / o r local a c t i o n t o d e m o n s t r a t e t h e n e e d . I n t h e e v e n t of t h e latter, m e s s a g e d e s i g n e r s m a y c o n c l u d e t h a t a p r e c u r s o r t o e n a b l i n g h e a l t h is t o p r o m o t e r e c o g n i t i o n at t h e s t a t e a n d local level t h a t a n e e d exists. In r e c o g n i t i o n o f t h e vital role t h a t state a n d local c o m m u n i t i e s p l a y in h e a l t h e n a b l e m e n t efforts, c a m p a i g n e r s h a v e m o v e d t o w a r d e m p h a s i z i n g c o m m u n i t y - b a s e d p r o g r a m s . H e a l t h p l a n n e r s seek t o identify t h e local opinion-leaders a n d to work with t h e m toward enabling health. At the same t i m e , t h e vital n e e d t o gain insights a b o u t t h e c u l t u r a l n o r m s t h a t g u i d e health behavior becomes apparent.

CULTURAL N O R M S T O ALLOCATE RESPONSIBILITY AND MOBILIZE SUPPORT F O R S T A T E A N D LOCAL RULES A N D A C T I O N S T h e i n f o r m a t i o n t h a t individuals h a v e a b o u t h e a l t h d e p e n d s u p o n c o m m u n i c a t i o n w i t h friends, family, physicians, a n d o t h e r s , as well as e x p o s u r e t o m e d i a t e d m e s s a g e s a b o u t h e a l t h . W h e n a n i n d i v i d u a l ' s family o r friends fail t o s u p p o r t a h e a l t h r e c o m m e n d a t i o n , t h e l i k e l i h o o d of following t h e advice is r e d u c e d (e.g., Alcalay 8c T a p l i n , 1989). Past i n v e s t i g a t i o n s d e m o n s t r a t e t h a t social s u p p o r t systems are as likely t o lead t o n e g a t i v e as t o p o s i t i v e h e a l t h h a b i t s (e.g., Pearlin 8c A n e s c h e n s e l , 1986). H e a l t h m e s s a g e d e s i g n e r s m u s t t h e r e f o r e seek t o u n d e r s t a n d c u l t u r a l n o r m s t h a t affect t h e i n t e r p r e t a t i o n of a n d b e h a v i o r associated w i t h state a n d local rules a n d a c t i o n s t a k e n t o s u p p o r t a d m i n i s t r a t i v e goals a n d i n s t i t u t i o n s , a n d d o m e s t i c laws d e signed t o attain national health standards. Health message designers should assess: 1. What cultural norms exist to allocate responsibility for behaviors affecting health; and

2. What cultural norms mobilize support for state and local rules and actions?

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In relation t o alcohol a n d d r u g a b u s e , an analysis of t h e h e a l t h objectives attained b y the e n d of 1990 as specified by the Surgeon General's R e p o r t in 1979, " H e a l t h y People," revealed that 19 goals h a d been set, a n d only a p p r o x i m a t e l y half w e r e m e t , w i t h a n o t h e r o n e - f o u r t h viewed as unlikely t o b e m e t ( M c G i n n i s , 1991). T h e objectives t h a t t h e n a t i o n h a d m a d e p r o g r e s s o n i n c l u d e d e d u c a t i n g t h e p u b l i c a b o u t t h e effects of alcohol a n d d r u g use, a n d c h a n g i n g societal a t t i t u d e s t h a t glorify a l c o h o l u s e . A m o n g t h e objectives yet t o b e a t t a i n e d a r e t h o s e t h a t focus a t t e n t i o n o n issues t h a t result f r o m d r u g a n d alcohol abuse, including the spread of H I V a n d child a n d spouse abuse ( S t o t o , B e h r e n s , 8c R o s e m o n t , 1990). T o attain these goals necessitates t h a t t h e cultural n o r m s that allocate responsibility in relation to d r u g use a n d s u p p o r t for d r u g u s e m u s t b e e x a m i n e d . In s o m e c u l t u r e s , n o r m s associated w i t h d r u g - a n d a l c o h o l - r e l a t e d child a n d s p o u s e a b u s e i n c l u d e " l o o k i n g t h e o t h e r w a y " o r " b l a m i n g t h e v i c t i m , " exemplifying t h e failure of state a n d local o r d i n a n c e s t o b e carried o u t b e c a u s e of c u l t u r a l n o r m s . W h e n an i n d i v i d u a l ' s cultural g r o u p eschews care in an o r g a n i z e d setting, t h e i n d i v i d u a l is less likely t o o b t a i n s u c h care, even w h e n i n s t i t u t i o n s exist to p r o v i d e t h e care (e.g., Flay 8c B u r t o n , 1990). H e a l t h m e s s a g e d e s i g n e r s m a y e n t e r c a m p a i g n s with the a s s u m p t i o n t h a t t h e a p p r o p r i a t e s t a r t i n g place for t h e i r efforts is t o c h a n g e t h e n o r m s t h a t fail t o s u p p o r t t h e b e h a v i o r t h a t c a m p a i g n e r s seek t o c h a n g e . G a r n e r i n g s u p p o r t for d e s i r e d b e h a v i o r f r o m t h e i n d i v i d u a l s for w h o m t h e b e h a v i o r is r e q u e s t e d is an i m p o r t a n t c o m p o n e n t of d e s i g n i n g health messages. It is b y n o m e a n s t h e b e s t o r t h e o n l y s t a r t i n g place, h o w e v e r , n o r t h e o n e t h a t is m o s t likely t o e n a b l e h e a l t h , as suggested t h r o u g h o u t this d i s c u s s i o n of h e a l t h message d e s i g n e r s ' ethical o b l i g a t i o n s . T h e analysis t h a t h a s b e e n a d v o c a t e d leads t o several c o n c l u s i o n s w i t h s u b s e q u e n t i m p l i c a t i o n s for fulfilling t h e m e s s a g e d e s i g n e r ' s goal to enable health.

Implications and Conclusion Incidents that unnecessarily cost h u m a n life appear to h a p p e n all t o o freq u e n t l y a n d are t h e b a n e of t h e existence of h e a l t h m e s s a g e d e s i g n e r s , w h o a i m t o p r o m o t e i n d i v i d u a l s ' well-being. For e x a m p l e , t h e s e events o c c u r in p l a n t s w h e r e c h i c k e n s are b e i n g p r o c e s s e d a n d fire exits a r e locked, a n d o n f a r m s w h e r e pesticides are u s e d t o p r o t e c t c r o p s b u t p e r s o n a l safety e q u i p m e n t is d e e m e d t o b e t o o expensive t o p u r c h a s e t o p r o t e c t h u m a n s d u r i n g p e s t i c i d e u s e . H e a l t h message designers o u g h t t o w e i g h s u c h issues d u r i n g

Policy and Practice at a Crossroads

281

t h e p r o c e s s of c o n s t r u c t i n g a c a m p a i g n . T h e s e b a r r i e r s h a v e little t o d o w i t h w h e t h e r o r n o t i n d i v i d u a l s u n d e r s t a n d p a r t i c u l a r h e a l t h m e s s a g e s a n d far m o r e t o d o w i t h t h e activities of t h o s e w h o m a k e a n d e n f o r c e policies. T h u s , t h e issue for t h e m e s s a g e d e s i g n e r b e c o m e s : W h o s h o u l d b e t h e t a r g e t of messages? For e x a m p l e , if w e a r e c o n c e r n e d a b o u t t h e toxic effect of p e s ticides, s h o u l d w e b e t a r g e t i n g : • individuals with the message "don't eat pesticide-laden foods" • farmers with the messages "don't use particular types of pesticides" and "don't use any pesticides without wearing personal protective equipment" • manufacturers with the messages "don't manufacture toxic substances" and "educate farmers about personal safety when using pesticides and risk of failure to practice personal safety" • lawmakers with the message "don't license manufacturers who fail to provide safety measures for using pesticides" • the general public with the message "support the enactment of laws to safeguard personal health and safety" As a result of r e c o g n i z i n g t h e m u l t i p l e a u d i e n c e s i n v o l v e d in t h e effort t o e n a b l e h e a l t h , m e s s a g e designers will r e c o g n i z e t h e n e e d t o c o n s t r u c t m e s sage c o n t e n t a i m e d at a t t a i n i n g t h e goal m o s t a p p r o p r i a t e for t h a t target. T o assist m e s s a g e designers d u r i n g t h e p r o c e s s of p l a n n i n g a c a m p a i g n a n d selecting target a u d i e n c e s a n d goals t o b e associated w i t h m e s s a g e s , t h e following q u e s t i o n s can b e u s e d t o g u i d e a n ethical analysis: 1. Does the absence of domestic laws to support a national health standard reduce the likelihood that a message will enable health? If yes, an appropriate starting place and audience for health messages is the lawmakers rather than the general public. 2. Is there a conflict among present domestic laws that reduces the likelihood that a health message will enable health? Ifyes, once more, the appropriate starting place and audience for health messages is the lawmakers rather than the general public. 3. Do federal administrative practices inhibit the design of appropriate messages? If yes, proceed if the health of most audience members could still potentially be improved within the constraints of message design; otherwise, do not proceed. 4. Do institutions exist to provide the services recommended to enable health? If not, the appropriate starting place and audience will be the group(s) responsible for allocating support for the institutions.

282

COMBINING THEORY AND

PRACTICE

5. Do state and local rules and actions support the use of institutions designed to provide services to enable health? If not, an appropriate starting place and audience will be the group(s) responsible for enforcing federal policy. 6. Do cultural norms support the actions advocated by state and local health promotion efforts? If not, revise the practices and aims to acknowledge cultural traditions. T h i s analysis a i m s to e n c o m p a s s a p p r o a c h e s t o m o b i l i z e social s u p p o r t t o c h a n g e a d m i n i s t r a t i v e policy a n d practices, a n d m a y involve m e d i a a d v o cacy a p p r o a c h e s t o c h a n g e a d m i n i s t r a t i v e policy a n d practices. R e c o g n i t i o n is given t o t h e fact t h a t w h e n a d m i n i s t r a t i v e c o n d i t i o n s d o n o t w a r r a n t an e m p h a s i s o n i n d i v i d u a l e n a b l e m e n t , h e a l t h m e s s a g e d e s i g n e r s are ethically o b l i g a t e d t o cease s u c h p r o m o t i o n s . In s u m , a n analysis of a d m i n i s t r a t i v e policies a n d practices e x t e n d s t h e health message designer's formative evaluation i n t o a realm t o o often forgott e n , neglected, o r relegated t o p o s t h o c e x p l a n a t i o n s for failure. U l t i m a t e l y , t h e goal is t o g a r n e r o p p o r t u n i t i e s for i n d i v i d u a l s t o elect b e h a v i o r t h a t fosters well-being. I n d i v i d u a l s j u d g e political p r o g r a m s a n d d e c i s i o n m a k i n g a b o u t h e a l t h in t e r m s of p e r s o n a l access t o care a n d t h e q u a l i t y of t h a t care, a n elusive a n d m u l t i d i m e n s i o n a l p h e n o m e n o n ( P a r a s u r a m a n , Z e i t h a m l , 8c Berry, 1985). Such analysis is t h u s u p t o message d e s i g n e r s , w h o m u s t exercise an ethical f r a m e w o r k , c o n c e r n i n g t h e i n d i v i d u a l d u t y of e a c h o n e u n t o h i m - o r herself, a n d e v e r y o n e t h e y p u r p o r t t o e n a b l e t o b e h e a l t h y .

References Alcalay, R., & Taplin, S. (1989). Community health campaigns: From theory to action. In R. E. Rice 8c C. K. Atkin (Eds.), Public communication campaigns (pp. 105-130). Newbury Park, CA: Sage. Altheide, D. L., 8c Johnson, J. (1980). Bureaucratic propaganda. Boston: Allyn 8c Bacon. Andrews, J. B. (1938). N o time to falter. American Labor Legislation Review, 29, 147-148. Combs, J. E., 8c Nimmo, D. (1993). The new propaganda: The dictatorship of palaver in contemporary politics. New York: Longman. Flay, Β. R., 8c Burton, D. (1990). Effective mass communication strategies for health campaigns. In C. Atkin 8c L. Wallack (Eds.), Mass communication and public health: Complexities and conflicts (pp. 129-146). Newbury Park, CA: Sage. Frame, D. M. (1973). Selections from the messages of Montaigne. Columbus, OH: Columbus University Press. Hirshfield, D. S. (1970). The lost reform. Cambridge, MA: Harvard University Press. Linder, Μ. (1990). Crewleaders and agricultural sweatshops: The lawful and unlawful exploitation of migrant farmworkers. Creighton Law Review, 23, 213-233.

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McGinnis, J. M. (1991). Health objectives for the nation. American Psychologist, 46, 520-524. National Commission on Children. (1991). Beyond rhetoric: A new American agenda for children and families. Washington, DC: Government Printing Office. Parasuraman, Α., Zeithami, V. Α., & Berry, L. L. (1985). A conceptual model of service quality and its implications for future research. Journal of Marketing, 49,41-50. Parrott, R. L., 8c Daniels, M. (in press). Promoting prenatal care to women: Promises, pitfalls, and pratfalls. In R. L. Parrott 8c C. M. Condit (Eds.), Women*s health care campaigns: The rhetoric of reproduction. Urbana-Champaign: University of Illinois Press. Pearlin, L. I., 8c Aneschensel, C. S. (1986). Coping and social supports: Their functions and applications. In L. H. Aiken 8c D. Mechanic (Eds.), Applications of social science to clinical mediane and health policy (pp. 417-437). New Brunswick, NJ: Rutgers University Press. Stoto, Μ. Α., Behrens, R , 8c Rosemont, C. (1990). Healthy people 2000. Washington, DC: National Academy Press. Thompson, G. D., 8c Martin, P. L. (1991). Immigration reform and the agricultural labor force. Labor Law Journal, 42, 528-536. von Glahn, G. (1981). Law among nations: An introduction to public international law. New York: Macmillan. Willis, W. O., 8c Fullerton, J. T. (1991). Prevention of infant mortality: An agenda for nurse-midwifery. Journal of Nurse-Midwifery, 36, 343-354.

Index

Abramson, P. R., 33 Accidents, farm equipment and, 158-161 Acting out, 117 Action: belief in capability to execute, 47 committing to course of, 32 fear appeals and, 72-73 positive affective appeals and, 92-94 preparation for, 55-58 probability of taking, 26 reasoned, 146 Action stage of change, 26, 42, 47, 55-60, 225 Active information processing, 8-20 Adams, N., 49 Adler, R P., 117 Administrative practices, 270-282 Adolescence/adolescents: behavioral inoculation and, 99-100, 102110 decision making and, 25 early, 119, 122-123 fear appeals and, 77 mid- to late, 119-120, 123-124 peer pressure and, 103, 104 risk perceptions of, 29 smoking and, 4, 102-110 Advertising/advertisers: children misunderstanding, 122 5 A Day campaign and, 241 humor and, 84 support for health promotion and, 209 Advertising model, 220 284

Affective appeals, 81-96 Affective efficacy information, 49 Age: fear appeals and, 77 microtargeting and, 118-124 See also Adolescence/adolescents; Elderly Agricultural industry, 5 A Day campaign and, 239-240 Agriculture, equipment-related accidents and, 158-161 AIDS messages/prevention, 13 "America Responds to AIDS" campaign and, 169-183 fear appeals and, 65, 68, 69, 71-73, 78 goals, 151-154 pictorial information and, 74 positive affect and, 87 Aitken, P., 131 Ajzen, I., 146, 149, 150, 154, 183, 189 Alcalay, R., 279 Alcohol use messages: fear appeals, 65, 77 youth and, 115-116, 122-123 Aldenderfer, M. S., 193 Alexander, J., 45 Altheide, D. L., 276 American Association for Labor Legislation, 271 "America Responds to AIDS," 169-183 Anderson, D., 125, 126 Anderson, L. R., 101 Anderson, P. Α., 16 Andrews, J. B., 271

Index Aneschensel, C. S., 279 Anxiety: attitudinal challenges and, 106-107 fear appeals and, 66, 77-78 Apertures, 223 Approach behaviors, 84, 87 Arguments: in persuasive messages, 156 quality of, 90 Arkin, E. B.,81 Armstrong, Β. K., 109 Arousal, fear appeals and, 66 Arthur, T. G., 251 Ascione, F., 251 Atkin, C.,92, 122 Atkin, C. K., 146, 154, 170, 171, 186, 187 At-risk children, 122, 123, 128 Attention: active, 8-20 external versus internal requests for, 1520 linguistic considerations and, 7-21 positive affect and, 84 selective, 84-85 voluntary, 76-77 young audiences and, 125 Attitudes: challenges to, 102, 106-107 children's, 102 established, 103-104 positive affect and, 89-92 vulnerability of, 101 Audience, 167-168 age of, 77 attention levels, 7-8 attitudes of, 89-92 belief system, 154-156 commitment of, 90 database and, 229-233 identifying, 221-222 idiosyncracies of, 186 level of exposure, 178-179 lifestyle profile and, 231-232 linguistic approaches and, 7-21 low-involvement, 88-89 minority, 174-175 needs and interests of, 218 news and, 202

285 nonvolunteers, 76 persuasive health message framework and, 146-147 precampaign research and, 171-174 public service announcements, 204 segmentation strategies, 186-197 sources of influence, 124-130 targeting, 114-132 youth, 4 Audience profile, 149-150, 154 Auld, G., 192 Austin, E. W., 114-132 Austin, S., 251 Authority, media gatekeepers and, 203 Avard, J., 47 Avoidance, 77-78, 85, 147 Awareness: 5 A Day program, 243 mass media campaigns and, 207-208

Bachman, J. G., 116 Backer, Τ. E., 66, 208 Baggeley, J., 181 Baker, T. G., 170 Balch, G. I., 217-245 Ball, S., 126 Ballard-Reisch, D. S., 36 Ball-Rokeach, S., 127 Bandura, A , 3, 44, 46, 47, 48, 49, 117, 118, 125,189 Bandy, C., 8 Baranowski, T., 26, 43, 50, 128 Barenboim, D., 119 Barie, L., 117 Barkdoil, G., 249 Barnea, Z., 128 Barnett, L., 100 Barnett, W. S., 120 Baron, J., 25, 36 Basil, M.,84, 126 Bates, R, 170 Batra, R, 82, 90 Baumrind, D., 115, 119, 120, 122, 128 Beasley, D., 19 Beauvais, K. L., 129 Beck, Κ. H., 69 Becker, M., 44, 251,266

286

DESIGNING

Becker. M . H . , 189 Behavior(s): appeal in forbiddance of, 114-115 approach, 84, 87 automatic, 13 avoidance, 85 benefits in changing, 222 children controlling, 130 dominant influence on, 189-190 objectives for, 174 predicting later, 117 salient beliefs toward, 150 short-term goals for, 51, 57, 58-59 social cognitive theory and, 43-61 substituting, 56 variables, 189,192-193,196 Behavioral decision-making, 3, 24-37 Behavioral inoculation, 99-110 Behavioral modeling, 46, 48-49, 53 Behavioral theories, role of, 1-2 Behavior change: moving people to, 41-61 obstacles, 58 personal factors, 44-51 personality of, 224-225, 232 social support for, 58 stages of, 26-36,41-61, 225 Behrens, R., 280 Behrman, M., 9 Beliefs: changing, 154 reinforcing existing, 154-156 resistance and, 100,101 Benefits, short- versus long-term, 24 Benthin, A. C , 29 Bernier, M., 47 Berrueta-Clement, J. R., 120 Berry, L. L., 282 Best, J. Α., 109 Bicycle helmet messages, comic books and, 11 Billings, J. Α., 121, 123, 130 Blank, Α., 13 Blashfield, R. K., 193 Blatt, Μ. Α., 29 Bless, Η., 90 Block, G., 220 Block, M., 122

HEALTH

MESSAGES

Blosser, B. J., 122 Bogaert, M. G., 252 Bogatz, G., 126 Bohner, G., 90 Booster message, 109 Borgida, E., 8 Boster, F. J., 67,68, 69, 70, 71, 76, 77 Bostrom, Α., 25, 29 Botvin, G. J., 121 Branch, L. G., 100 Breast cancer, gain-framed messages and, 75 Broadcast Advertisers Reports, 179 Broadcast Data Systems, 179 Brouwers, M. C., 73 Brown, A. L., 117, 119, 121 Brown, Β. B., 129 Brown, I., 47 Brown, K. S., 109 Brown, R. V., 25, 36 Brown, S., 117 Bruce, P., 128 Bryant, G. D., 31 Bryant, J., 118 Buchanan, D. R., 8 Bukosi, W., 122 Bunton, R.,217 Burgoon, M., 99, 101, 105, 109, 110, 154 Burke, R. J., 129 Burnkrant, R. E., 17 Burton, D., 104, 280 Burton, W., 121 Bush, P. J., 120

Cacioppo, J. T., 8, 9, 11, 86, 87, 146, 147, 148, 151 Cafferata, P., 217 Calvert, E. J., 252 Calvert, S., 125, 126 Camerer, C. F., 25 Campbell, T., 125 Cancer: gain-framed messages and, 75 risk perception and, 91 Capability, perception of, 56 Cardiovascular disease: audience segmentation and, 193 fear appeals and, 73, 78

Index Carroll, J. S., 35 Catalano, R. F. J., 120 Catania, J. Α., 26 Catastrophic potential, 29 Cause and effect, predictions about, 126 Celebrity role models, 123-124 Cervone, D., 47 Chaffee, S. H., 124,128, 189 Chaiken, S., 9, 7 2 , 7 4 , 75 Chambliss, C. Α., 49 Chan, G., 76 Chandler, M. J., 119 Chandler, P., 19 Chanowitz, B., 9 , 1 3 Chassin, L., 103 Child development, 118-124 Children: at-risk, 122, 123,128 attitudinal patterns of, 102 decision making and, 25 targeting, 114-132 Chipman, H., 192 Christiansen, B., 117 Christenson, P., 120, 121, 123, 124, 125, 128 Cigarettes, See Smoking Clark, A. W., 121 Clark, M. S., 85, 88 Clarke, Α., 250 Clarke, J. J., 109 Clarridge, B. R , 249 Clasen, D. R , 129 Classroom-based instruction, 121 Cluster analyses, 193 -196 Coates, T. J., 26 Coccia, B., 256 Cochrane, K., 100 Cognitive processes: affect and, 83 behavioral decision-making and, 25 efficacy beliefs and, 47-48 youth and, 115 Cohrssen, J. J., 27-28 Cole, G. E., 171,173, 183 Collier C. B., 171 Collins, P., 125 Collins, W. Α., 126, 127 Collins-Jarvis, L. Α., 87 Combs, J. E., 276

287 Comic books, messages in, 11-12 Commands, attending to messages and, 15 Communication: audience segmentation and, 186-197 bureaucratic, 276 children's skills, 129 consumer-based, 217-245 effective, 221-222 gatekeeping process and, 199-215 objectives, 174 prescription drugs and, 249-267 youth and, 125 Communication tools, 223 Community: media gatekeepers and, 212 national health goals and, 279 Community affairs directors, 208-215 Compassion, 87 Compliance, positive affective appeals and, 92-94 Condom use, 13 decision-making perspective and, 33 fear appeals and, 78 multi-attribute utility theory and, 35 preparation stage and, 59 role model story and, 54-55 Conroy, M , 117 Consciousness raising, 27 Consumer-based health communication, 217-245 Consumer research, 227-233 Consumer tracking data, 242-244 Contemplative stage of change, 26, 27-32, 42, 53,54-57, 225 Contraception, probability of risk judgments and, 30 Converse, P. E., 66 Cook, G. M., 76 Cooper, M., 19 Coping, 77,120 Corbett, K., 102, 104, 115 Corder-Bolz, C R , 127, 129 Cost/benefit analysis, 56 Cotton, D., 41-61 Counter-messages, 121 Covello, V. T., 27-28, 29 Cramond, J., 118 Cresweil, W., Jr., 109

288

DESIGNING

Crockett, W. H., 88 Cromarty, E., 250 Cross-cultural panels, 174 Cues, 146, 147-148, 154 Culbertson, V. L., 251 Cullingsford, C , 126 Cultural norms, health policy and, 279-280 Cultural stereotypes, 122,126

Da Mota Gomes, M., 252 Danger control, 68 Daniels, M., 276 Database marketing, 217, 218, 229-233 Davis, D., 170 Death, threat of, 71 DeBenedittis, P., 121 DeBusk, R. F., 47 Decision analysis, 32-36 Decision making, youth and, 115 Decision-making approach to message design, 24-37 de Klerk, Ν. H., 109 Defense mechanisms, 84,147 DeFleur, M. L., 127 DeMarsh, J. P., 120 Demographics: audience profiles and, 154 audience segmentation and, 188-190, 196 database information and, 218 Denial, 147 Denotatively specific speech, 17-18 Dental hygiene: fear appeals and, 67 pictorial information and, 74 positive affective appeals and, 92-94 Department of Health and Human Services, 276 Description, 1 Desmond, R J., 129 DeVellis, B., 44, 189 Dewey, J., 1 DiClemente, C. C , 25, 26, 27, 41, 42, 43, 47, 183, 225 Diet, "5 A Day for Better Health" campaign and, 217-245 DiFranza,J. R., 115

HEALTH

MESSAGES

Dillard, J. P., 65-79 Discrepant messages, 13-15 Doherty, M. L , 35 Doner, L., 217-245 Donohew, L., 124, 201 Donohue, G. Α., 201 Donovan, R. J., 177 Dorr, Α., 125, 127 Drive explanations, fear appeals and, 66-67 Drug use messages: adolescents and, 122-123, 124 comic book and, 11 fear appeals and, 65, 76, 77 Drug store displays, 14 Dryfoos, J. F., 117, 122

Eagly, Α., 9, 74 Edgar, T , 9, 6 5 , 7 1 , 7 2 , 8 1 Edwards, W., 35 Efficacy evaluations, 178, 207 Efficacy judgments, 47-49 Efficacy message, 146-147 Effort expenditure, 47 Einsiedel, Ε. F., 100 Eiser, J. R., 69 Elaboration likelihood model, 146 Elderly, prescription drug information and, 250,251 Elstein, A. S., 31, 32 Emotional benefit appeals, 82-83 Emotions: efficacy beliefs and, 47-48 positive, 82 Empathy, 87 Environment, 44 changing youth behavior and, 115 disadvantaged, 122 gatekeepers', 208-212 health communication campaign and, 204-205 support for behavior change and, 58 youth and, 117-118, 122 Eron, L. D., 128 Ethics, 270-280 Evaluation, postcampaign, 178-180, 207, 240-244 Evans, R. I., 92, 102

Index Ewart, C K., 47 Experts: campaign contributions, 205-206 interviews, 171-173 review panels, 174 Explanation, theory and, 2 Exploratory research, 181 External reinforcers, 60 External requests to attend, 15-20 Ezekoye, S., 122

Factual evidence, arguments supported by, 156-157 Faden, R. R , 256 Fagin, J., 123 Failure, patterns of, 121 Falco, M., 116, 117, 122, 123, 131, 132 Family: parental control and, 128 parental support and, 117 parent training and, 120 Farmers, equipment-related accidents of, 158-161 Fast food restaurants, 14 Fear appeals, 65-79, 82-83 self-efficacy and, 147 youth and, 115 Fear control, 68 Federal administrative goals, national health standards, 275-278 Feelings, positive, 82 Feshbach, S., 66-67, 74 Field, D., 125, 126 Fischer, C , 117, 126 Fischer, P., 128 Fischhoff, B., 25, 28, 29, 30, 32, 33,123 Fishbein, M., 146, 149, 150, 154, 183, 189 Fisher, D. Α., 109 "5 A Day for Better Health" campaign, 217245 Flavell, J. H., 119 Flay, B. R , 104, 175, 280 Flora, J. A , 46, 89, 146, 188, 189, 193, 207 Focus groups, 173-174, 190-192, 195, 196, 218,228-229 Food and Drug Administration, 250, 253256

289 Foon, A. E., 104 Ford, J. K., 35 Forest, D., 85, 93 Fox, D. T., 122 Frames of reference, 186 Framing, 31-32, 87 fear appeal and, 75 persuasive messages, 156 Frankel, Α., 69 Frankle.RT., 173 Fredriksen, S., 126 Free, C , 116 Freeman, E. R , 205 Freeman, J. M , 256 Freimuth, V. S., 9, 6 5 , 7 1 , 72, 81, 146, 170, 171, 186, 187,203-204 Frerich, S. J., 158 Friestad, M., 82 Fruin, D. J., 73, 78 Fruit, "5 A Day for Better Health" campaign and, 217-245 Fullerton, J. T., 274 Furse, D. H., 83 Future orientation, 129

Gain frame, 75 Garramone, G., 127 Gatekeeping process, 199-215 Gelman,R, 117, 119,121 Gentry, E., 170, 179, 180 George, C. F., 252 Gerbner, G., 127 Gersh, T. L., 125 Gibbons, J., 126 Gibbs, D. A , 177 Gibbs, S., 252 Gibson, W. A , 128 Gieber, W., 200-201 Gilbertini, Μ., 47 Gidin, Τ., 125 Glanz, Κ., 20 Glynn, Κ., 117 Glynn, Τ. J., 124, 125, 128 Goal setting, short-term, 51, 57, 58-59 Goldberg, Μ. E., 128 Goldman, M. S., 117 Goldman, R , 8

290

DESIGNING

Goodstadt, M. S., 76,114 Gordon, E., 249 Gordon, N., 117 Gossctt, D., 17 Grau, J., 8 Gray, L. Α., 72 Green, L., 220 Green, L. W., 250, 267 Green, S. K., 8 Greenberg, B. S., 125 Greenberg, Μ. T., 129 Greene, K., 9,71 Greenspan, S., 119 Gross, L., 119,127 Grossman, K., 249 Grube, J. W., 122 Grunig, J. E., 186, 187,188, 189, 213

Hale, J. L., 65-79 Hallett, R., 69 Hamburg, D. Α., 102 Hammond, S. L., 9 , 6 5 , 7 1 , 72, 81, 203-204, 214, 249-267 Harvey, J. L., 251 Havas, S., 240 Hawkins, J. D., 120 Hawkins, R., 127 Haynes, R. B., 252 Health communication, consumer-based, 217-245 Health message(s): active processing of, 8-20 booster, 109 efficacy of, 177-178 motivation to attend to, 7-21 one- versus two-sided, 100 supplementing, 249-267 variety of sources for, 124-130 Health message design: audience-centered strategies, 167-168 audience segmentation and, 186-197 behavior inoculation and, 99-110 decision-making approach to, 24-37 fear appeals and, 65-79 "5 A Day for Better Health" campaign, 217-245 media gatekeepers and, 199-215

HEALTH

MESSAGES

persuasion and, 145-162 positive affect and, 81-96 prescription drugs and, 249 staged social cognitive approach to, 4161 theory-driven approaches to, 1-5 transtheoretical model and, 41-43 young audiences and, 114-132 Hearold, S., 125 Heath, R L . , 118 Hess, A. K., 17 Heuristic appeals, 82-83, 85, 86, 87, 89, 93 Higgins, Ε. T., 119 Higgins, M. C , 29 Hirsch, P. M., 201 Hirschman, R., 117 Hirshfield, D. S., 271 HIV messages: decision-making perspective and, 33 national policy, 277 probability of risk judgments and, 30 risk comparisons and, 28-29 role model stories and, 53, 57 staged social cognitive approach, 41-61 stages of change approach, 52-53 time horizons and, 34 HIV-positive persons, discrimination against, 176 Hocking, J., 122 Hoffman, H. R., 121 Hogarth, R M., 29 Hollenbeck, Α., 117 Holmes, D. R , 109 Holtgräve, D. R , 24-37, 171,183 Hope, C., 28 Horowitz, I. Α., 76 Hot lines, 124, 181 Hovland, C. I., 66 Howard-Pitney, B., 8 Huesman, L. R., 128 Hurts, Β. M., 35 Humor, 84 Hunt, T., 189 Hunt, W., 100 Hunter, F. T., 129 Hurst-Palermo, K., 122 Huston, Α., 125 Huston-Stein, Α., 126

Index Ianotti, R., 120 Immediate language, 16-17 In-depth interviews, 190,195 Information: core, 218 framing effects, 31-32 preparation for behavior change and, 55 selective attention and, 84-85 transient, 149-154, 157 vivid, 74-75 Information processing: active, 8-20 age and, 118,127 audience attention and, 7-8 central, 151 depth of, 86-88 linguistic approaches and, 7-21 peripheral, 147-148 Information service phone numbers, 181 Injection drug-users, probability judgments and, 31 Inouye, D. K., 47 Internal personal factors, behavior change and, 52,115 Internal reinforcers, 60-61 Internal requests to attend, 15-20 Intervention, 116 Involvement, affective messages and, 88-89 Irwin, C. E., 77 Irwin, R P., 109 Isen, A. M., 85,88, 93,96

Jahoda, G., 118 James, M., 251 Janis, I. L., 66-67, 74, 84, 100 Janz, N., 251 Jason, J., 169, 175, 177, 178, 180, 181, 183 Jeffrey, D. B., 122 Jessor, R , 116,121 Johnson, C. A , 123 Johnson, E. J., 35 Johnson, J., 276 Johnson, J. D., 8 Johnson, L. D., 116 Johnson, S., 8 Johnston, C., 217-245 Johnston, J. F., 251

291 Johnston, M., 250 Jones, R., 109 Jorgensen, C., 170,179,181

Kahl, Μ. L., 270-282 Kahneman, D., 25, 29, 32 Kandel, D. B., 117,122, 124 Kang, J. G., 101 Kassebaum, P., 114, 115,118, 120,122, 123 Kay, D., 84 Kay, L. S., 24-37 Keefe, T., 192 Kegeles, S. M , 26 Keiser, Ν. H., 170 Kelley, Η. H., 66 Kendall, P. A , 192 Kenski, H. C., 101 Keren, G., 34 Kessler, D. A , 254 Kessler, R G , 124 Killen, J. D., 102 Kirsch, G., 34 Kirschner, P., 84 Kirscht, J. P., 20 Klein, R„ 128 Knowledge: behavior change and, 44-46 mass media campaigns and, 207-208 prescription drugs and, 252 Knowledge-only approaches, 115 Kohlberg, L., 118,119, 120 Kohn, P. M., 76 Kraus, Ν., 28, 29 Kreuter, Μ., 220 Kroger, F., 169,177,183 Kuiken, D., 17 Kumpfer, L., 122 Kumpfre, K. L., 120 Kutner, L., 115

Lamy,P. P., 251 Landers, A , 99, 100 Langer, E. J., 7 , 9 , 1 3 Language, 16 denotatively specific, 17-18 framing effects and, 31-32

292

DESIGNING

qualifiers and, 19 spatial immediacy and, 18 temporal immediacy and, 18-19 vividness of, 148 young audiences and, 125 Larson, M. S., 9, 12 Latham, G. P., 50 Lave, L., 29 Laws, S., 191 Leathar, D., 131 Lefebvre, R. C , 217-245 Legislation, national health standards, 274275 Leitch, C J., 129 Lemieux, R , 71 Leventhal, H., 67-68,117 Levin, S., 125 Levy, M. R , 7 Lewin, Κ., 200 Lichtenstein, S., 28, 29, 30 Lightfoot, Μ. Α., 8 Lindeman, Μ. L., 19 Lindloff, Τ., 121 Linguistic theories, 2, 7, 15-20 Lisella, L. W., 170 Lishner, D., 120 Liss, Μ. B., 126 Literature reviews, 171, 196 Local rules, national health goals and, 278279 Locke, Ε. Α., 50 Logan, J. Α., 117 Lopes, L. L., 25 Lorch, Ε., 124, 125 Loss frame, 75 Loughrey, K., 217-245 Louis, M. R , 9-11, 13, 15-16 Lull, J., 124, 129 Lumsdaine, Α. Α., 100 Lyle, J., 121

Macaulay, J. R , 109 Maccoby, N., 45, 103 Macdonald, G , 217 MacPherson.B., 109 Madden, T. J., 84 Magazines, 121, 238

HEALTH

MESSAGES

Maibach, E. W„ 9, 41-61, 84, 89, 270-282 Maiman, L. Α., 189 Maintenance stage of change, 26-27, 42, 53, 59-61,225 Male aggressiveness, 117 Mall intercept interviews, 176, 227-228 Manipulation, 28 behavioral inoculation and, 101 threat, 107 Marchman, F., 169 Marchman, K. L., 175 Margulies, R. Z., 124 Marin, G , 157 Martin, P. L., 275 Marton, Κ. I., 29 Mass media: adolescents and, 123-128 children and, 121-122 5 A Day campaign and, 233-239, 241 McAfee, T., 115 McAlister, Α., 103, 117, 118 McCombs, Μ. E., 201 McDuffie, D., 11 McGinnis, J. M., 280 McGrath, J., 34, 199-215 McGuire, W. J., 7, 89, 100, 101, 104, 109, 114, 115, 148, 154,217 McKeever, L. C , 252 McLeUarn, R. W., 122 McLeod, J. M., 128 McNeil, B. J., 31 "Meat-out" campaign, 14 Media: gatekeepers, 199-215 press conference and, 235-236 See also Mass media Media newsletter, 236-238 Media tracking, 240-241 Mehrabian, Α., 16-17, 18, 19 Meichenbaum, D., 250 Meili, Η. K., 122 Meischke,H.,8 Mendelsohn, H., 7, 21 Mertens, B., 121 Meyerowitz, Β. E., 72, 75 Middlestadt, S. E., 176 Miller, G. R., 67, 99, 110 Miller, Μ. M., 127

Index Miller, P. Μ., 117, 119, 125 Miller, S. Α., 119 Mills, J., 85 Mülstein, S. G., 77 Minority audiences, 174-175 Mitchell, Α., 193 Mitchell, Ε., 114 Modeling, 46, 48-49,53, 121 Moderation, 116 Monahan, J. L., 9, 65, 71, 81-96 Mongeau, P. A , 67, 68, 69, 70, 71, 76, 77 Mooser, L., 128 Moralizing, youth and, 115 Morgan, Μ., 29, 127 Morris, L. Α., 193,249, 251 Morrison, 203-204 Moscovitch, M., 9 Mostellor, F., 31 Motivation, to attend to health messages, 721 Mozer, Μ. C., 9 Mullen, P. D., 250, 267 Multi-attribute utility theory, 35 Multivariate classification, audience segmentation and, 192-194 Mundy, K., 250 Murdoch, P., 177 Murphy, P. E., 170 Murphy, S. T., 84, 86 Murray, D. M., 121 Murray, E. J., 49 Music videos, 124 Myers, E. D., 252

Nach-Ferguson, B., 122, 129 Nader, P. R., 128 Nass, C. I., 127 National AIDS Information and Education Program, 169 National Cancer Institute, 219, 239 National Commission on Children, 277 National Council on Patient Information and Education, 255 National health standards, 272-275 National press conference, 235-236 Navarro, M., 157 Negative affect, in health message design, 3

293 Negative consequences, 75 Negative effects, short-term, 115 Negative messages, processing strategies and, 86 Negative outcomes, 54, 69, 78 Newcomb, Α., 126 Newcombe, Τ. M., 66 Newhagen, J., 84 Newman, R J., 266 Newspapers, 5 A Day campaign and, 241 News wire services, 200, 201 Nicholas, J. Α., 252 Nijkamp, P., 34 Nimmo, D., 276 Nitz, Μ., 101 Norcross, J. C , 25, 26, 27, 4 1 , 4 2 Norman, G. R, 31 Norris, E. L., 109 Novel presentation, 10-12 Novel risk, 29 Nowak, G. J., 169-183

Observational learning, 46 O'Connell, Μ. B., 251 Oetting, E. R , 129 Office of Cancer Communication, 217-245 Ogilvy, D., 85 O'Keefe, G., 170 Olien, C. N., 201 Olins, N. J., 193 Olsen, J., 201 O'Malley, P. O., 116 Outcome expectancies, 49-50, 54 Outcomes: campaign effectiveness and, 179 multiple variables and, 69 prediction of, 1 Owen, A. Y., 173 Owen, N., 73

Palincsar, A. S., 121 Palmer, E., 171 Palmgreen, P., 124 Papageorgis, D., 101, 104 Parallel response models, fear appeals and, 67-68

294

DESIGNING

Parasuraman, Α., 282 Parental control, 128 Parental support, 117 Parent training, 120 Park, C. W., 8, 9, 89-90 Parker, R , 9 Parrott, R. L., 7-21,270-282 Parsons, J. E., 119 Passive information processing, 8-9 Patterson, B., 220 Pauker, S. G., 31 Pearlin, L. I., 279 Pechman, C , 83 Pechmann, C., 8 Peer influences, 103,117, 121, 124, 129 Peer network role model, 53 Pentz, Μ. Α., 123 Performance mastery experiences, 48 Perry, C., 103,121 Persistence, behavior change and, 47 Personal efficacy, fear appeals and, 69, 72-73 Personal factors: behavior change and, 44-51, 115 moving through stages of change and, 54-61 youths and, 115 Personal goals, behavior change and, 50-51 Personal responsibility, 11, 17, 232 Persuasion: adolescent smoking prevention and, 103 counter-, 100 efficacy information and, 49 fear appeals, 65-79 health message design and, 145-162 pictorial information and, 74 positive affect and, 89 Persuasive health message framework, 145162 Peterson, A. J., 121 Petty, R. E., 8, 9, 11, 86, 87, 90, 146, 147, 148,151 Pfau, Μ., 8, 11, 14, 99-110, 120 Pharmaceutical industry, 256-257 Phoenix, V. G., 19 Physician recommendations, 9 Physiological efficacy information, 49 Pictorial information, persuasiveness of, 74 Pingree, S., 127

HEALTH

MESSAGES

Pinkerton, S. D., 33 Plumridge,R J.,251 Podolsky, D., 266 Pogostin, C. L., 171 Policy practices, 270-282 Positive affect, health message design and, 3, 11,81-96 Positive consequences of behavior change, 56 Positive messages, processing strategies and, 86 Positive outcome expectations, 50, 54 Posters, 227-228 Potter, J. D., 220 Practice, theory and, 247 Pratt, C., 73 Precontemplation stage of change, 26, 2732, 42, 54-55, 225 Preparation stage of change, 26, 32-36, 42, 55-58 Preschoolers, 118-119, 120, 125, 126 Prescription drugs, 249-267 Prescriptive theories, 2 Presentation: discrepant, 13-15 novel, 10-12 Prevention: "American Responds to AIDS" campaign and, 169-183 parents and, 129 youth and, 116-118 Pride, 56 Print messages: effort to process, 9 5 A Day campaign and, 241 positive affective appeals and, 11 role model stories, 53 Probabilistic information, processing, 29-31 Problem, acknowledging, 56 Prochaska, J. O., 25, 26, 27, 41, 42, 43, 47, 183,225 Produce for Better Health Foundation, 219, 239 Protection motivation theory, 146 Pryzbeck, T. R., 117 Public service announcements, 14, 202 adolescents and, 123 AIDS messages, 175, 177-178, 181

Index media gatekeepers and, 203-204 target audience, 204 young audiences and, 114-115

Quadrel, M. J., 25 Quaid, Κ. Α., 256 Qualifiers, 19 Qualitative probability expressions, 30-31 Qualitative research, 171-172,174, 190, 196,218 Quantitative research, 190-192, 218 Question, external requests to attend in form of, 16 Quinley, H., 72

Radio, 124 children and, 121 community affairs directors and, 208 5 A Day campaign and, 239 gatekeepers and, 208 media gatekeepers and, 203 Rahav, G., 128 Raines, Β. E., 102 Randomized surveys, 196, 218 Raphaelson, J., 85 Rational appeals, 82-83 Ray, M. L., 82, 84 Reardon, Κ. K., 100 Reasoned action, 146 Recall of campaigns, 88-89 Recycling, decision-making factors and, 3536 Recycling stage of change, 225 Redundant messages, 126 Reese, L. B., 47 Reese, S. D., 127 Reeves, B., 17, 84, 127 Reinforcement for change, 59, 60-61 Reinhardt, L. C., 126 Relapse, 42, 59, 60 Repetitious messages, 148 Research, informing campaign development, 169-183 Resistance: belief, 100, 101 fear appeals and, 67

295 teaching adolescents, 123 Response costs, 78 Response efficacy, fear appeals and, 69, 73 Response research, 177-178 Rewards, 61, 120 Rhodes, P. J., 251 Rhodes, R. S., 251 Richman, S. Α., 90 Ridesharing, positive affective appeals and, 93 Ridout, K., 250 Rios,M. N., 171, 183 Ripper, F., 213 Risk: comparisons of, 27-29 knowledge about, 44 perception of, 27-29, 91 personalization of, 71-72 Risky behaviors, experimenting with, 122 Roberts, D. F., 119, 120, 122, 123, 124, 125, 127, 128 Robins, L.N., 117 Rodin, J., 17 Roe, K., 130 Rogers, Ε. M., 66, 186, 202, 207-208 Rogers, R , 124 Rogers, R. W., 6 9 , 1 4 6 , 1 4 7 Rokeach, M., 102 Role models, 53, 54, 57, 123 Romano, R M., 91 Rosemont, C., 280 Rosenberg, M., 102 Rosengren, Κ. E., 127 Rosenstock, I. M., 2 0 , 4 4 Roser, C., 189 Ross, D., 125 Ross, S., 125 Roth, E., 29 Rubin, D., 71 Ryan, P.B., 31

Sadowski, R P., 126 Saisslin, R., 20 Salient beliefs, 149-155 Salient referents, 149-155 Salmon, C. T., 169, 175, 178, 180, 181, 183 Salomon, G., 127

296

DESIGNING

Sampling bias, 191 Sanders, J., 125 Sandman, P. M., 26, 27 Santi, S. M., 109 Saputo, M., 252 Saracino, M., 72 Sauer, R., 123 Schechtman, S. L. 35 Schiffenbauer, Α., 91 Schmitt, Ν., 35 }

School, health messages in, 122 Schramm, W., 119 Schulz, R. M., 252 Schumann, D., 8 Schumann, D. W., 90 Schunk, D. H., 49 Schwartz-Lookinland, S., 252 Schwarz, Ν., 90 Schweinhart, L. J., 120 Sclar, D . , 2 6 6 Scott, Α., 131 Seat belt use, 30, 159 Selective attention, 84-85 Self-efficacy: behavior change and, 47-49 enhancement of, 56 fear appeals and, 147 strong sense of, 59 Self-evaluation, 5 6 , 6 1 , 9 3 Self-examination, messages that encourage, 54 Self-image, children and, 120 Self-management skills, 59-60 Sensory stimulation, 16-17 Severson, H., 29 Sexual abstinence, 124 Sexually transmitted diseases messages, risk comparisons and, 28-29 Shapiro, A. K., 251 Shaw, D. L., 201 Sheppard, M., 76 Shimp, L., 251 Shoemaker, P., 199-200, 201 Shure,M. B., 120 Shyness, 117 Siegel, J. M., 129 Siegel, Κ., 16 Signitzer, Β., 201

HEALTH

MESSAGES

Signorielli, Ν., 127 Silverberg, S., 130 Silverman, L. T., 126 Singer, D. G , 128, 129 Singer, J. L., 126, 128, 129 Singhal, Α., 124 Sinnock, P., 170 Siska,M., 177 Siska, M. J., 169-183 Situational theory, media gatekeepers and, 213-214 Skills, behavior change and, 46, 58 Skin cancer, 10-14, 17-18 fear appeals and, 72, 78, 147 Slaby, R., 117 Slater, M. D., 186-197 Slovic, P., 25, 28, 29, 30 Smith, D. C , 8, 9 Smith, D. L., 256 Smith, Ε. Α., 109 Smith, G. T., 117 Smith, R., 126 Smoking: behavioral inoculation and, 102-110 decision-making perspective and, 32-33 fear appeals and, 73 peer discussion and, 121 prevention, 118 short-term goal setting and, 51 youth and, 4, 102-110, 115 Sneath, P. Η. Α., 193 Snider, P., 201 Soap opera, message on, 12 Social cognitive theory, 3, 41-61 Social consequences, 56 Social influences, youth and, 115 Social inoculation, 102, 104, 108-109 Social insurance, 271 Social network, support for behavior change and, 58 Social norms, 116, 130, 189 Social perceptions, affect and, 83 Social rewards, 120 Social support, 120, 128 Social threats, 120 Sokal, R. R, 193 Sopory, P., 66, 208 Sorenson, J., 101

Index Sorrentino, R. M., 73 Sox,H. C., 29,31 Spedden, S. E., 31 Spiegler, D., 118 Spivak, G., 120 Sports heroes, 123-124 Sprafkin, J. N., 126 Stages of behavior change, 26-36, 41-61, 225 Stainbrook, G. L., 250 Stakeholders, campaign goals and, 205-208 STAR (Students Taught Awareness and Resistance), 116,123 State anxiety, 77 State rules, national health goals and, 278279 Stauffer, D. J., 109 Stayman, D. M., 90 Steele, C., 117 Steinberg, L., 130 Steinmetz, Κ. Α., 220 Stewart, D. W., 8 , 8 3 Stimuli, affective responses and, 83-84 Stinchcombe, A„ 192 Stone, E. R , 28 Storey, J. D., 186, 202, 207-208 Stoto, Μ. Α., 280 Strack, F., 90 Strathman, Α., 90 Strecher, V . , 4 4 , 189 Strong, C. R , 121 Subar, Α., 220 Subjective expected utility models, fear appeals and, 69 Success, patterns of, 121 Summative evaluation, 207 Surveys, 171, 190 Sutton, R I., 9-11, 13, 15-16 Sutton, S. M., 217-245 Sutton, S. R , 69, 70, 73 Svarstad, B. L., 249 Svenson, O., 33, 34 Sweller, J., 19

Tabak, Ε. R , 193 Talkington, D. R , 20 Tannenbaum, P. Η., 109 Taplin, S., 279

297 Taylor, C, B„ 47 Taylor, S. E., 74 Teacher training, 120 Teichman, M., 128 Television, 9, 124, 125 AIDS messages on, 175, 177-178, 180, 181 children and, 121 community affairs directors and, 208 critical viewing skills and, 128 familial communication about, 128-129 fear appeals and, 76-77 5 A Day campaign and, 239, 241 gatekeepers and, 208, 210 market competition and, 210 media gatekeepers and, 203 preschoolers and, 127 Temporally immediate language, 18-19 Theory, practice and, 247 Theory-driven approaches, 1-5 Thompson, G. D., 275 Thompson, S. C., 74 Thompson, S. J., 109 Thoreson, C. E., 146 Thorson, E., 17, 82, 89-90 Threats, 69,71-72 averting, 151 personalized, 76 salient beliefs about, 153 social, 120 Threat component, of behavioral inoculation, 101 Threat manipulation, 107 Threat message, 146 Tichenor, P. J., 201 Tierney, P., 19 Time horizon, decision making and, 34 Tinsley, B. J., 24-37 Tobler, N., 122, 124, 130 Top-down information processing, 8 Tortu, S., 132 Trait anxiety, 77-78 Transient information, 149-154, 157 Transtheoretical model, 41-43, 51-53, 225 Turk, D. C., 250 Turner, R H., 66 Tversky, Α., 25, 2 9 , 3 1 , 3 2 Tybout, A , 217

298

DESIGNING

Uncertainty: qualitative expression of, 31 words expressing, 19 Underachievement, 117 United Nations, health standards, 272 Unnava, H. R., 17

Valco, T. D., 158 VALS typology, 194 Van Bockern, S., 101,102, 103, 105, 107, 109, 120 Van derVoort, Τ. Η. Α., 121 Van Haecht, C. Η. M., 252 Vander Stichele, R., 252 Vegetables, "5 A Day for Better Health" campaign and, 217-245 Verb tense, 18-19 Verbal immediacy, 16-19. See also Language Vicarious efficacy information, 48-49 Vining, E. P., 256 Vivid information, 74-75 Vivid language, 148 Vlek, C , 34 Voluntarism, fear appeals and, 76-77 von Glahn, G., 272, 274 von Winterfeldt, D., 35 Vulnerability, feelings of, 71-72

Wackman, D., 122, 129 Wallack, L., 44, 102, 104, 115, 182 Waller, R.R., 170 Wang, E., 252 Ward, S., 122, 129 Wartella, Ε., 129 Waters, W. E., 252 Watkins,B., 126 Watson, S. R , 28 Webb, P. Α., 20

HEALTH

MESSAGES

Weber, E. U., 28, 29 Weiderholt, J., 249 Weikhard, D. P., 120 Weinberger, M. G., 84 Weinman, J., 252 Weinstein, Ν. D., 25, 26, 27 Weir, T., 129 Wellman, H., 126 Wellness, young children and, 120 Wells, W. W., 220, 222 Westover, Β. J., 170 White, D., 200 Wiener, M., 16-17, 18,19 Willis, W. O., 274 Windahl, S., 7,127, 201 Wire services, 200, 201 Witte, Κ., 66, 68, 73, 78, 145-162 Wood, R., 48 Woods, D. R , 170 Wooten, K., 180 Worth, S., 119 Wright, J., 125,126

Yamaguchi, K., 117, 122 Yang, W. S., 177 Yates, J. F., 24, 25, 28 Young, Β. Μ., 127 Youth audiences, developmental theory and,4,114-132 Youtz, C , 31

Zajonc, R. B., 83-84, 8 6 , 9 4 Zeithami, V. Α., 282 Ziegler, R G , 220 Zifferblatt, S. M., 20 Zimmermann, Κ., 34 Zucker, R A . , 118 Zuckerman, D. M., 128

About the Contributors

Erica W e i n t r a u b Austin, Ph.D., is Assistant Professor o f C o m m u n i c a t i o n a n d H e a d o f the Public Relations sequence at W a s h i n g t o n State University in Pullman. H e r research focuses o n the d e v e l o p m e n t o f d e c i s i o n - m a k i n g skills through uses o f mass media and interpersonal sources, particularly in the realms o f substance abuse and public affairs. She is also interested in h o w parents can affect their children's interpretations o f m e d i a messages, thereb y affecting the decisions children make about a variety of important issues. Recent w o r k includes publications in Communication Research, Journal of Broadcasting & Electronic Media, Journalism Quarterly, and a contribution to Relational Communication and Health Outcomes (edited b y G. Kreps a n d D a n O'Hair, in the SCA Applied C o m m u n i c a t i o n Series). She recently w o r k e d w i t h the state o f W a s h i n g t o n to d e v e l o p a statewide alcohol abuse p r e v e n t i o n campaign aimed at the parents o f 3 - t o 10-year-olds. George I. Balch, P h . D . , is Visiting Associate Professor in the D e p a r t m e n t o f Marketing at the University o f Illinois at Chicago. H e is currently c o n d u c t ing social marketing research at the Prevention Research Center o f the U n i v e r sity o f Illinois and consulting with the National Cancer Institute and the U.S. Agency for International Development to develop and monitor the effectiveness o f c o m m u n i c a t i o n interventions. H e was formerly Vice President, Associate Director o f Strategy and Research at D D B N e e d h a m W o r l d w i d e , o n e o f the world's largest advertising agencies. D a v i d C o t t o n , Ph.D., M.P.H., is Research Psychologist in the Behavioral and Prevention Research Branch, Division o f S T D / H I V Prevention at the Centers for Disease Control and Prevention. H e received his doctoral degree in Clinical Psychology from the University of Alabama while concurrently pursuing his public health degree at the University o f Alabama at Birmingham. 299

300

DESIGNING

HEALTH

MESSAGES

H i s c u r r e n t research interests are in t h e d e v e l o p m e n t of social s c i e n c e - b a s e d interventions modifying S T D - a n d HIV-related risk behaviors in c o m m u n i t y level, small g r o u p , a n d o n e - o n - o n e settings. J a m e s P r i c e D i l l a r d , P h . D . , is Associate Professor at t h e U n i v e r s i t y of W i s c o n s i n in t h e D e p a r t m e n t of C o m m u n i c a t i o n A r t s . His research exa m i n e s c o m p l i a n c e - g a i n i n g in i n t e r p e r s o n a l r e l a t i o n s h i p s a n d h a s b e e n p u b l i s h e d in s u c h outlets as Communication munication

Monographs

a n d Human

Com-

Research.

L y n n e D o n e r , M.A., is Vice P r e s i d e n t a n d D i r e c t o r of R e s e a r c h at t h e W a s h i n g t o n , D . C . , office of P o r t e r / N o v e l l i . H e r research interests i n c l u d e applying c o m m e r c i a l m a r k e t research techniques a n d data t o target a u d i e n c e d e v e l o p m e n t in social m a r k e t i n g p r o g r a m s , a n d d e v e l o p i n g useful p r o c e s s e v a l u a t i o n m e t h o d o l o g i e s for m a s s m e d i a c o m p o n e n t s of h e a l t h p r o m o t i o n a n d disease p r e v e n t i o n p r o g r a m s . J e r o l d L. H a l e , P h . D . , is Associate Professor in t h e D e p a r t m e n t of S p e e c h C o m m u n i c a t i o n at t h e U n i v e r s i t y of Georgia. His research interests i n c l u d e social i n f l u e n c e a n d relational c o m m u n i c a t i o n . H i s research e x a m i n e s p e r s u a s i o n a n d influence in i n t e r p e r s o n a l r e l a t i o n s h i p s . H i s w o r k h a s b e e n p u b l i s h e d in Communication Monographs a n d Human Communication Research, as well as o t h e r n a t i o n a l a n d regional o u t l e t s . S h a r o n Lee H a m m o n d , P h . D . , is A d j u n c t Assistant Professor at t h e U n i v e r sity of M a r y l a n d ' s G r a d u a t e School of M a n a g e m e n t a n d T e c h n o l o g y , w h e r e s h e teaches t h e graduate-level q u a n t i t a t i v e research m e t h o d s a n d m a r k e t i n g r e s e a r c h m e t h o d s c o u r s e s . She received h e r P h . D . from t h e U n i v e r s i t y of M a r y l a n d ' s H e a l t h C o m m u n i c a t i o n P r o g r a m in 1990. She h a s c o n d u c t e d s u r v e y a n d e x p e r i m e n t a l research in t h e areas of c a n c e r , A I D S , e n v i r o n m e n tal h e a l t h risks, a n d m e d i c a t i o n c o m m u n i c a t i o n , r e s u l t i n g in p u b l i c a t i o n s in a variety of j o u r n a l s a n d e d i t e d b o o k s , i n c l u d i n g Science, Technology & Human Values, Communication Research, Health Communication, Health Education Quarterly, Communication Yearbook, a n d Health Education Research. She is also t h e e d i t o r of a special issue of Health Communication on t h e t o p i c of c o m m u n i c a t i n g w i t h p a t i e n t s a b o u t t h e i r m e d i c a t i o n s . D a v i d R. H o l t g r ä v e , P h . D . , is t h e Acting Assistant D i r e c t o r for B e h a v i o r a l Science, Office of H I V / A I D S , C e n t e r s for Disease C o n t r o l a n d P r e v e n t i o n ,

About the

Contributors

301

a n d is a n a d j u n c t faculty m e m b e r in t h e E m o r y U n i v e r s i t y S c h o o l o f P u b l i c H e a l t h , D i v i s i o n of Behavioral Science a n d H e a l t h E d u c a t i o n . H e received his P h . D . in Q u a n t i t a t i v e P s y c h o l o g y f r o m t h e U n i v e r s i t y of Illinois a n d d i d p o s t d o c t o r a l w o r k a t t h e H a r v a r d School of P u b l i c H e a l t h , I n t e r d i s c i p l i n a r y P r o g r a m s in H e a l t h . H i s w o r k o n decision analysis a n d t h e p s y c h o l o g y of d e c i s i o n m a k i n g h a s b e e n p u b l i s h e d in s u c h o u t l e t s as Risk Analysis, Medical Decision Making, Journal of Behavioral Decision Making, Journal of Family Practice, a n d Archives of Internal Medicine. H i s research interests i n c l u d e behavioral decision m a k i n g , risk c o m m u n i c a t i o n , a n d t h e evaluation of p r e vention programs. Cecile J o h n s t o n , P h . D . , is t h e D i r e c t o r of C o m m u n i c a t i o n s R e s e a r c h at Prospect Associates. In this capacity, she is responsible for t h e design, i m p l e m e n t a t i o n , a n d analysis of research projects d e v o t e d t o t h e p r o m o t i o n of social p r o g r a m s , p a r t i c u l a r l y t h o s e involving h e a l t h c o m m u n i c a t i o n s . As p r o j e c t d i r e c t o r , she designs a n d oversees i m p l e m e n t a t i o n o f f o r m a t i v e , p r o c e s s , o u t c o m e , a n d i m p a c t studies of h e a l t h p r o g r a m s for t h e Office of Cancer Communications, National Cancer Institute. M a r y L o u i s e K a h l , P h . D . , is Assistant Professor in t h e D e p a r t m e n t of C o m m u n i c a t i o n at t h e State U n i v e r s i t y of N e w Y o r k in N e w Paltz. H e r r e s e a r c h interests i n c l u d e t h e r h e t o r i c of w o m e n ' s h e a l t h care. L i n d a S. Kay, M . P . H . , is a P u b l i c H e a l t h Analyst in t h e B e h a v i o r a l S t u d i e s Section, Behavioral a n d P r e v e n t i o n Research B r a n c h , d i v i s i o n o f S T D / H I V P r e v e n t i o n , N a t i o n a l C e n t e r for P r e v e n t i o n Services, C e n t e r s for Disease C o n t r o l a n d P r e v e n t i o n . H e r c u r r e n t research interests e m p h a s i z e h e a l t h c o m m u n i c a t i o n a n d b e h a v i o r a l science, especially as it relates t o H I V p r e v e n t i o n in a d o l e s c e n t s a n d in t h e w o r k p l a c e . R. C r a i g Lefebvre, P h . D . , is Chief T e c h n i c a l Officer a n d Vice P r e s i d e n t , H e a l t h C o m m u n i c a t i o n s at P r o s p e c t Associates, a h e a l t h c o m m u n i c a t i o n s firm l o c a t e d in Rockville, M D . H e h a s a u t h o r e d m o r e t h a n 50 p u b l i c a t i o n s in t h e areas of social m a r k e t i n g , h e a l t h p r o m o t i o n , a n d c o m m u n i t y - b a s e d p r o g r a m s . H i s c u r r e n t w o r k includes p l a n n i n g , d e v e l o p i n g , i m p l e m e n t i n g , a n d e v a l u a t i n g c a n c e r c o m m u n i c a t i o n s p r o g r a m s ; social m a r k e t i n g a n d media advocacy approaches to tobacco control; international c o m m u n i c a t i o n s efforts d i r e c t e d t o w a r d H I V p r e v e n t i o n ; a n d a p p l i c a t i o n s of social marketing to health reform.

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K a y L o u g h r e y , M . P . H . , R.D., is a P u b l i c Affairs Specialist in t h e Office of C a n c e r C o m m u n i c a t i o n s of t h e N a t i o n a l C a n c e r I n s t i t u t e . She directs t h e 5 A D a y for Better H e a l t h ' s m e d i a c a m p a i g n a n d c o o r d i n a t e s n u t r i t i o n e d u c a t i o n p r o g r a m m i n g for N C I . E d w a r d W . M a i b a c h , M . P . H . , P h . D . , is Assistant Professor in t h e Division o f B e h a v i o r a l Sciences a n d H e a l t h E d u c a t i o n a n d D i r e c t o r of t h e C e n t e r for H e a l t h a n d Risk C o m m u n i c a t i o n at t h e E m o r y School of P u b l i c H e a l t h . H e is a c o m m u n i c a t i o n scientist with research interests in t h e use of m a s s a n d interpersonal c o m m u n i c a t i o n campaigns to p r o m o t e health e n h a n c e m e n t . H e is actively involved in social m a r k e t i n g research, a n d is c u r r e n t l y c o n d u c t i n g b o t h e x p e r i m e n t a l a n d e v a l u a t i o n research studies o n effective c o m m u n i c a t i o n strategies for t h e p r e v e n t i o n of cancer, A I D S , S T D s , a n d a d o l e s c e n t p r e g n a n c y . H e has w r i t t e n a n u m b e r of articles a n d b o o k c h a p ters o n t h e s e t o p i c s , i n c l u d i n g several e x a m i n a t i o n s of t h e i m p l i c a t i o n s of B a n d u r a ' s social cognitive t h e o r y for H I V p r e v e n t i o n c a m p a i g n s . J o h n M c G r a t h is t h e Chief of t h e C o m m u n i c a t i o n s a n d M a r k e t i n g Section at t h e N a t i o n a l H e a r t , L u n g , a n d B l o o d I n s t i t u t e , p a r t of t h e N a t i o n a l I n s t i t u t e s of H e a l t h in Bethesda, M D . N.H.L.B.I. c o o r d i n a t e s n a t i o n a l h e a l t h e d u c a t i o n c a m p a i g n s o n b l o o d p r e s s u r e , cholesterol, a s t h m a , a n d w a r n i n g signs for h e a r t attacks t h a t m a k e extensive use of m a s s m e d i a . H e is a d o c t o r a l c a n d i d a t e at t h e University of M a r y l a n d . J e n n i f e r L. M o n a h a n , P h . D . , is Assistant Professor in t h e D e p a r t m e n t of Speech C o m m u n i c a t i o n at t h e U n i v e r s i t y of Georgia. H e r research focuses o n e m o t i o n a n d affect in c o m m u n i c a t i o n . She h a s p u b l i s h e d h e r w o r k in such outlets as Communication Monographs &ηά the Journal of Communication. G l e n J. N o w a k , P h . D . , is Assistant Professor in t h e D e p a r t m e n t of A d v e r t i s ing at t h e University of Georgia. H e is also a Visiting C o m m u n i c a t i o n Scientist at t h e N a t i o n a l A I D S I n f o r m a t i o n a n d E d u c a t i o n P r o g r a m at t h e U . S . C e n t e r s for Disease C o n t r o l . R o x a n n e Louiselle P a r r o t t , P h . D . , is Assistant Professor in t h e D e p a r t m e n t of Speech C o m m u n i c a t i o n a n d a Fellow in t h e I n s t i t u t e of B e h a v i o r a l R e s e a r c h at t h e U n i v e r s i t y of Georgia. She also has an a d j u n c t a p p o i n t m e n t in t h e D e p a r t m e n t of M e d i c i n e at t h e M e d i c a l College of G e o r g i a . She is c o a u t h o r (with M i c h a e l Pfau) of Persuasive Communication Campaignsana

About the

Contributors

303

p r i m a r y a u t h o r of Women's Health Care Campaigns: The Rhetoric of Reproduction. H e r r e s e a r c h interests i n c l u d e a n e x a m i n a t i o n o f h o w m e d i a t e d a n d i n t e r p e r s o n a l c o m m u n i c a t i o n interface, affecting i n d i v i d u a l s ' involvement with message content. M i c h a e l P f a u , P h . D . , is Professor in t h e S c h o o l of J o u r n a l i s m a n d M a s s C o m m u n i c a t i o n at t h e U n i v e r s i t y of W i s c o n s i n - M a d i s o n . H e h a s a u t h o r e d m o r e t h a n 4 0 articles, m a n y d e a l i n g w i t h influence strategies i n h e a l t h c a m p a i g n s , a p p e a r i n g in s u c h j o u r n a l s as Communication Monographs, Human Communication Research, a n d o t h e r s . H e h a s c o a u t h o r e d four b o o k s , t h e m o s t r e c e n t , Persuasive Communication Campaigns ( 1 9 9 3 ) w i t h R o x a n n e P a r r o t t . H e is a p a s t r e c i p i e n t of t h e Speech C o m m u n i c a t i o n Association's Golden Anniversary M o n o g r a p h Award. M i c h a e l J. Siska, M.S., is H e a l t h C o m m u n i c a t i o n R e s e a r c h Specialist in t h e N a t i o n a l A I D S I n f o r m a t i o n a n d E d u c a t i o n P r o g r a m of t h e C e n t e r s for Disease C o n t r o l a n d P r e v e n t i o n . M i c h a e l D . Slater, P h . D . , M.P.A., is Associate Professor i n t h e D e p a r t m e n t o f T e c h n i c a l J o u r n a l i s m at C o l o r a d o State U n i v e r s i t y in F o r t C o l l i n s . H e received his d o c t o r a l d e g r e e in C o m m u n i c a t i o n at S t a n f o r d U n i v e r s i t y in 1988, a n d was a p r e d o c t o r a l fellow w i t h t h e S t a n f o r d C e n t e r for R e s e a r c h in Disease P r e v e n t i o n ; p r i o r t o t h a t , h e was a p u b l i c r e l a t i o n s e x e c u t i v e in N e w Y o r k City specializing in t e c h n o l o g y , h e a l t h , a n d e d u c a t i o n . H e is c u r r e n t l y p r i n c i p a l investigator of a s t u d y f u n d e d b y t h e N a t i o n a l I n s t i t u t e o n A l c o h o l Abuse a n d Alcoholism on adolescent responses to alcohol advertising, a n d recently conducted or consulted on audience research a n d message/channel e v a l u a t i o n s t u d i e s for A M C - C a n c e r Research C e n t e r a n d t h e U . S . D e p a r t m e n t o f A g r i c u l t u r e ( o n m i n i m i z i n g e x p o s u r e t o pesticides). H i s r e s e a r c h o n m e s s a g e effects, a t t i t u d e influence processes, a n d a u d i e n c e s e g m e n t a t i o n h a s a p p e a r e d in j o u r n a l s i n c l u d i n g Communication Research, Health Education Quarterly, Journal of Communication, Journal of Public Relations Research, a n d Journalism Quarterly. S h a r y n M . S u t t o n , P h . D . , is c u r r e n t l y t h e D i r e c t o r , N u t r i t i o n M a r k e t i n g a n d E d u c a t i o n in F o o d a n d N u t r i t i o n Services at t h e U . S . D e p a r t m e n t of A g r i c u l t u r e w h e r e she is d i r e c t i n g t h e n a t i o n a l n u t r i t i o n e d u c a t i o n efforts of F.N.S. P r i o r t o j o i n i n g U S D A , she was C h i e f of t h e I n f o r m a t i o n Projects B r a n c h , Office of C a n c e r C o m m u n i c a t i o n s at t h e N a t i o n a l C a n c e r I n s t i t u t e

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w h e r e she d i r e c t e d N C I ' s health c o m m u n i c a t i o n s a n d c o m m u n i c a t i o n s r e s e a r c h activities. She teaches, speaks, a n d p u b l i s h e s o n social m a r k e t i n g issues, c o n s u m e r research, a n d h u m a n i n f o r m a t i o n p r o c e s s i n g . B a r b a r a J. T i n s l e y , P h . D . , is Associate Professor in t h e D e p a r t m e n t of P s y c h o l o g y at t h e U n i v e r s i t y of California at Riverside a n d Clinical Associate Professor in t h e D e p a r t m e n t of G y n e c o l o g y a n d O b s t e t r i c s at L o m a L i n d a U n i v e r s i t y M e d i c a l C e n t e r . She received h e r M.S. a n d P h . D . degrees in H u m a n D e v e l o p m e n t , E d u c a t i o n a l Psychology at t h e U n i v e r s i t y of Illinois at U r b a n a . H e r research interests i n c l u d e family h e a l t h risk m a n a g e m e n t , i n t e r a c t i o n s in health c o n t e x t s , child health socialization, a n d p r e d i c t o r s of m a t e r n a l a n d child health services utilization. K i m W i t t e , P h . D . , is Assistant Professor in t h e D e p a r t m e n t of C o m m u n i c a t i o n at M i c h i g a n State University. H e r research focuses o n t h e role of fear in p u b l i c h e a l t h c a m p a i g n s . Recently, she has b e g u n t o e x a m i n e h o w m e m b e r s of diverse cultures r e s p o n d to fear appeals. H e r w o r k has a p p e a r e d in International Quarterly of Community Health Education, Social Science and Medicine, Communication Monographs, a n d elsewhere.