The Theory of Reasoned Action and the Theory of Planned Behavior

Emotional Appeals

The communication discipline has long been interested in examining the role of emotions in strategic message design and persuasion. Attempts to understand fear appeals, or messages designed to elicit fear, have been a focal point for the past several decades (e.g., see de Hoog, Stroebe, & de Wit, 2007; Hovland, Janis, & Kelley, 1953; Janis, 1967; Mongeau, 1998; Rogers, 1975; Witte, 1992; Witte & Allen, 2000). The currently prevailing theory in this area is the Extended Parallel Process Model (EPPM; Witte, 1992), and a 2013 special issue of Health Communication entitled “The Extended Parallel Process Model: Two Decades Later” speaks to scholarly interest in this area.

Fear in the Extended Parallel Process Model (EPPM; Witte, 1992) is defined as “a negatively valenced emotion, accompanied by a high level of arousal, and is elicited by a threat that is perceived to be significant and personally relevant” (Witte, 1992, p. 331; see also Easterling & Levanthal, 1989; Ortony & Turner, 1990). According to the EPPM, fear appeals include content related to the severity of a health condition and one’s susceptibility to it. After exposure to a message with severity and susceptibility content, message recipients respond by appraising the threat of the health condition. The threat appraisal contains two components: perceived severity and perceived susceptibility (Witte, 1992). Perceived severity refers to an individual’s perception of the magnitude of the threat, and perceived susceptibility is an individual’s perception of the likelihood that the threat will impact them. If perceived threat is low, people stop processing the message and have no more reactions related to the fear appeal. If the perceived threat is high, fear is evoked, and people begin a second appraisal process. The second appraisal process involves an evaluation of the efficacy of the recommended response. Efficacy entails perceptions of how feasible and effective the response is in mitigating or eliminating the threatening health condition (labeled response efficacy) and how capable one is to engage in the recommended action (labeled self-efficacy).

As Witte (1992) put it, perceptions of threat determine the strength of the response; perceptions of efficacy determine the nature of this response. When both perceived threat and perceived efficacy are high, people engage in protection motivation by using positive strategies (e.g., the recommended action) to address the health threat, referred to as danger control. Conversely, when perceived threat is high and perceived efficacy is low, people engage in defensive motivation by using maladaptive responses (e.g., denial of the problem or derogation of the source) to cope with their fear, referred to as fear control. Message designers using the EPPM can thus strategically design messages that attempt to change or reinforce perceptions of severity and susceptibility, as well as beliefs about response- and self-efficacy so that they align with the recommended health behavior change.

Several meta-analyses have examined the empirical tests of fear appeals and the EPPM (e.g., de Hoog et al., 2007; Ruiter, Abraham, & Kok, 2001; Witte & Allen, 2000), with mixed support with respect to current theory. Main effects were consistently found for threat and efficacy; however, many of the analyses indicated that there was no evidence for the postulated interaction effect (de Hoog et al., 2007; see also Witte, 1994). The most recent meta-analysis, however, conducted by Peters, Ruiter, and Kok (2012), re-examined publications included in previous meta-analyses, and included several additional publications. Peters et al. (2012) did find a significant interaction effect between threat and efficacy, such that threat was only effective under high efficacy (d = 0.31) and efficacy was only effective under high threat (d = 0.71), noting that the failure to support this interaction previously is likely attributed to flawed methodology and improper tests of fear appeal theory. Importantly, many of the audiences in these studies were comprised of young adults, and fear appeal messages may be inappropriate and ineffective in health messages targeting older adults for several reasons. Indeed, older adults’ preference for positive information and older adults’ low perceptions of efficacy in many health contexts suggest that although fear appeals are persuasive for some, they may fail to garner the same persuasive results in older adults.

First, older adults are more likely to attend to and remember positive information as opposed to negative information (Charles, Mather, & Carstensen, 2003; Mather & Carstensen, 2003). This idea stems from Socioemotional Selectivity Theory (SST; Carstensen, Isaacowitz, & Charles, 1999). SST posits that individuals are guided by the same set of goals throughout their lifespan, but the relative importance of different sets of goals vary based on the individual’s perceptions of the amount of time left in life. Goals include, for example, future-oriented goals such as information gathering and personal development, as well as emotionally meaningful goals, which are related to deriving emotional meaning from life. Older adults are more cognizant of the approaching end of life and, according to SST, are thus more likely to hold emotionally meaningful goals than younger individuals. As such, fear appeal strategies are unlikely to be a strategic choice for older adults due to their preference for positive information.

Second, as mentioned previously, older adults have low perceptions of efficacy in many health contexts. This may be due to physical and cognitive impairments that impact an older adult’s beliefs about their ability to engage in a health behavior. In their meta-analysis of fear appeals, Peters and colleagues (2012) found that under low efficacy, the effect of threat was negative and almost significant, suggesting that, in conditions of low efficacy, heightened perceptions of threat and threatening information can cause individuals to engage in health-defeating behavior. Thus, the use of a fear appeal should be avoided in conditions of low self-efficacy (Peters et al., 2012). Perceptions of fear when considered in conjunction with older adults’ low efficacy may thus be an ineffective strategy. Indeed, “threatening communication only works when either the baseline efficacy is high in the relevant behavior-population combination, or when the intervention also includes a potent efficacy-enhancing element” (Peters et al., 2012, p. S26). Instead of using negative emotions as a persuasive tool, new theoretical developments in Persuasive Hope Theory (PHT; Chadwick, 2010, 2014), therefore, appear to be more promising for older adults.

Hope within Persuasive Hope Theory (PHT; Chadwick, 2010, 2014) is defined as a positively valenced “discrete emotion that involves appraisals of a stimulus as novel and relevant to a future or unknown outcome that is consistent with goals, possible but not certain, important, and consistent with a better future” (Chadwick, 2010, p. 28). A hope appeal consists of two parts: eliciting hope and efficacy. To experience hope, an individual must: (a) appraise the stimulus as novel and relevant and (b) appraise the future or unknown outcome central to the stimulus with assessments of importance, possibility, future expectation, and goal congruence. The appraisal of importance focuses on the future implications of the desired outcome. An appraisal of possibility is an assessment of the desired outcome as possible, not certain. If the outcome is certain, other positive emotions, including happiness or relief, are provoked, not hope. An appraisal of future expectation requires that the felt emotion, in this case hope, be future oriented or directed toward a future outcome. Appraisals of goal congruence assess whether a future outcome is consistent with, or favorable to, the individual’s goals or motives. Hope, then, is elicited when the future outcome is consistent with goals to attain a desired outcome or reward, or goals to avoid negative outcomes or punishments.

Similar to fear appeals, the efficacy appraisal in a hope appeal involves an evaluation of the efficacy of the recommended response. Efficacy entails perceptions of how feasible and effective the response is in mitigating or eliminating the threatening health condition (again labeled response efficacy) and how capable one is to engage in the recommended action (again labeled self-efficacy). Persuasive Hope Theory posits that the feeling of hope, when coupled with efficacy, motivates people to engage in behavior that helps them achieve the desired future outcome. Appeals to hope could be used in strategic communication to create a vision for an important, desirable future related to older adults’ health goals and outcomes that is possible to achieve. Thus, instead of creating a problem-focused, dystopian vision of the future like many fear-focused health messages, appeals to hope create an opportunity-focused vision that builds older adults’ excitement and enthusiasm for positive future health outcomes. In drawing on generativity again, these hope appeals may be particularly effective at changing older adults’ health behaviors if they create a vision of an important and desirable future for older adults’ family members or friends.

Health Risk Information

Health messages often use statistical evidence, including statistics, probabilities, and mathematical information, when communicating risk. Subjective Message Construct Theory (SMCT; Morley, 1987) posits that both message features and recipient characteristics predict subjective constructions and comprehension of such statistical evidence. Past research has examined message features that may impact message recipients’ comprehension, including, for example, whether the evidence is presented as natural frequencies versus probabilities (e.g., Gigerenzer & Hoffrage, 1995; Hoffrage & Gigerenzer, 1998; Hoffrage, Gigerenzer, Krauss, & Martignon, 2002) or presented visually versus verbally (e.g., Parrott, Silk, Dorgan, Condit, & Harris, 2005). However, less work on SMCT has examined how individual message perceivers’ characteristics may influence their comprehension of statistical evidence. If message designers are able to identify specific characteristics or target audiences, the theory will be of greater use to strategically design health and risk messages (see Parrott et al., 2005). In attempts to identify such audience patterns, Parrott and colleagues (2005) examined the impact of message recipient numeracy skills, culture (operationalized as race as black or white), and gender on judgments of statistical evidence. However, they did not find that these audience characteristics related to comprehension, assessments of evidence quality, or judgments of a message’s persuasiveness (Parrott et al., 2005).

Parrott and colleagues (2005) interpret their results by referring to the “likelihood that perceivers construct meaning based on a learned heuristic associated with a familiar form when it is used to represent quantitative information” (p. 447). In line with this reasoning, one additional audience characteristic that may influence subjective assessments about and comprehension of statistical evidence is age; older adults may be less familiar with, and therefore less able to interpret, statistical evidence than younger adults. Indeed, Donelle, Hoffman-Goetz, and Arocha (2007) found that some numeracy scales indicate that numeracy is influenced by increases in age, and past research has also found that older adults have limited health literacy skills (e.g., Donelle et al., 2007), which relates to their ability to comprehend such evidence.

Stereotypes may also play an important role in older adults’ ability to comprehend risk information presented using statistical evidence. Indeed, both older and younger individuals are aware that older people are stereotyped as less capable than younger people, and math incompetence of older adults is one aspect of this stereotype (Cuddy, Norton, & Fiske, 2005). Stereotype activation in older adults affects a range of cognitive abilities consistent with the negative stereotype (see Hess, Hinson, & Statham, 2004), as these situations raise anxiety levels (Steele, 1997). It is therefore important to consider such stereotypes because they may further influence a message recipient’s ability to comprehend risk information by leading to an activation of stereotype threat in older adults. This stereotype threat activation may act as a self-fulfilling prophecy, wherein older adults begin to believe they are less capable at math, with subsequent inabilities to comprehend mathematically focused statistical evidence. Message design scholars should thus examine how age may be a perceiver characteristic in SCMT that impacts older adults’ comprehension of statistical evidence.

This section of the article examined how preexisting health communication theories used in strategic message design could be extended to incorporate a lifespan view of communication, specifically with respect to designing health messages for older adults. However, older adults often make health decisions and health behavior changes in conjunction with family members or other caregivers. The next section examines how messages can be strategically designed for both informal and formal caregivers of older adults.

Adult Children Caregivers

The proportion of older adults has increased over the last decades, and, as a result, more adult children are acting as caregivers for their aging parents (Roberto & Jarrott, 2008; Wolff & Kasper, 2006). These adult children become responsible for activities such as household chores, behavioral assistance, financial support, and social support (Roberto & Jarrott, 2008). Health messages directed to adult children caring for their parent often focus on the child’s responsibility to help foster health-promoting behaviors in their older adult parents that are as yet undiagnosed. For example, WebMD (2015) notes: “Make sure your parent is eating a balanced diet. Accompany him or her to the market to guide shopping choices [and] discuss the importance of all the food groups, vitamins, fiber, and calcium.” Additionally, Espat (2015) urges children to “Encourage parents to do activities they enjoy and that will keep them active. Gardening, golfing, playing tennis and swimming are all great choices.” Both examples stress the power of adult children caregivers to influence their aging parents’ health behaviors.

Research suggests that adult-child caregivers experience psychological distress and burden (Amirkhanyan & Wolf, 2006; Choi & Marks, 2006), particularly among daughters (Bookwala, 2009). Hence, these health messages should also attempt to ease the guilt, burden, and distress associated with responsibility for caring for an older adult parent. One strategy to do so may be not only to assign overall responsibility to the adult child to care for their parent but also to encourage them to also distribute that responsibility to others. For example, the Family Caregiver Alliance (2015) notes that if “What you think you ‘should’ do is in conflict with what you want to do, [you] end up feeling guilty, depressed or frustrated” and suggests the following adaptive response “It’s okay for me to take a break from caregiving and enjoy myself. I will ask a friend or neighbor to check in on Mom.” An additional strategy is to empower adult child caregivers with the responsibility to also care of themselves. For example, Smith and Kemp (2015) note, “As a busy caregiver, leisure time may seem like an impossible luxury. But you owe it to yourself—as well as to the person you’re caring for—to carve it into your schedule . . . You will be a better caregiver for it.”

Research within communication has begun to examine the conversations that adult children have with aging parents about planning for future caregiving needs. For example, Fowler and Fisher (2009) found that aging parents’ and adult children’s attitudes about autonomy and aging anxiety were associated with awareness of older adults’ care needs and discussion of future care arrangements. Further, Pitts, Fowler, Fisher, and Smith (2014) examined ways in which adult children planned to initiate conversations with their aging parents about future care needs and found that these conversation “openers” use both positive and negative politeness strategies to do so. Fowler, Fisher, and Pitts (2014) built on this previous research to examine older adults’ perceptions of these caregiving conversations by having older adults read different scripts of an adult daughter raising the topic of future care needs with her aging mother. Results indicated that older adults who read a script in which the adult daughter implemented face-work behaviors were more likely to evaluate the daughter as supportive and were more willing to engage in a similar discussion with their own adult children if they approached the conversation about future care needs in a similar way (Fowler, Fisher, & Pitts, 2014).

Spousal Caregivers

Formal Caregivers

Older adults rely more on formal care (e.g., paid or subsidized care) than do younger adults (Laplante, Harrington, & Kang, 2002). These caregivers include, for example, nurses and staff in assisted living facilities and nursing homes. Health messages do not likely target these individuals to persuade them of their responsibility to care for older adults, as it is part of the formal job of these facilities or nursing homes to do so. However, these formal caregivers still experience caregiver burden (e.g., Miyamoto, Tachimori, & Ito, 2010), and research has also shown that job satisfaction of nurse aids in nursing homes is an important predictor of their intent to leave and turnover (Castle, Engberg, Anderson, & Men, 2007). As such, health messages for formal caregivers may, like those for informal caregivers, attempt to ease these negative consequences associated with responsibility for caring for older adults.