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Recruiting Opinion Leaders for the United Kingdom ASSIST Programme  

Jo Holliday, Suzanne Audrey, Rona Campbell, and Laurence Moore

Addictive behaviors with detrimental outcomes can quickly become embedded in daily life. It therefore remains a priority to prevent or modify these health behaviors early in the life course. Diffusion theory suggests that community norms are shaped by credible and influential “opinion leaders” who may be characterized by their values and traits, competence or expertise, and social position. With respect to health behaviors, opinion leaders can assume a variety of roles, including changing social norms and facilitating behavioral change. There is considerable variation in the methods used to identify opinion leaders for behavior change interventions, and these may have differential success. However, despite the potential consequences for intervention success, few studies have documented the processes for identifying, recruiting, and training opinion leaders to promote health, or have discussed the characteristics of those identified. One study that has acknowledged this is the effective UK-based ASSIST smoking-prevention program. The ASSIST Programme is an example of a peer-led intervention that has been shown to be successful in utilizing opinion leaders to influence health behaviors in schools. A “whole community” peer nomination process to identify opinion leaders underwent extensive developmental and piloting work prior to being administered in a randomized trial context. Influential students were identified through the use of three simple questions and trained as “peer supporters” to disseminate smoke-free messages through everyday conversations with their peers. In response to a need to understand the contribution of various elements of the intervention, and the degree to which these achieve their aim, a comprehensive assessment of the nomination process was conducted following intervention implementation. The nomination process was successful in identifying a diverse group of young people who represented a variety of social groups, and whom were predominantly considered suitable by their peers. The successful outcome of this approach demonstrates the importance of paying close attention to the design and development of strategies to identify opinion leaders. Importantly, the involvement of young people during the development phase may be key to increasing the effectiveness of peer education that relies on young people taking the lead role.


Regulatory Focus and Regulatory Fit in Health Messaging  

Ilona Fridman and E. Tory Higgins

Regulatory Focus Theory differentiates between two motivational orientations: promotion and prevention. Promotion-oriented individuals focus on advancements, growth, and making progress toward their hopes and aspirations, whereas prevention-oriented people are more concerned about safety, security, and fulfilling their responsibilities. Promotion-oriented individuals tend to focus on moving toward a better state ensuring gains and improvements. In contrast, prevention-oriented people tend to focus on ensuring against making mistakes and maintaining a current satisfactory state rather than moving to something worse. When individuals pursue desired ends using their preferred means (ensuring gains for promotion, and ensuring against losses for prevention), they experience regulatory fit, which makes them “feel right” about what they are doing. Regulatory fit is associated with strengthening engagement and intensifying evaluative judgments. The advantages of regulatory fit could be utilized in communications to motivate individuals’ healthy behavior. The messages that encourage healthy behavior could be framed in a way that fits recipients’ personal goal orientations. For instance, to increase motivation among promotion-oriented people for getting vaccinations, the message might state, “A flu vaccine helps you to continue achieving your goals even during a flu season.” This message emphasizes advancements and gains that fit a promotion orientation. To increase motivation among prevention-oriented people to choose healthy options, the messages could instead highlight avoiding losses: “A flu vaccine helps you avoid strength-sapping illness during a flu season.” Past studies on health communications have demonstrated that regulatory fit tends to facilitate participants’ willingness to follow the message and engage in healthy behavior. Could regulatory non-fit messages also work? When individuals pursue desired ends using non-preferred means—ensure gains for prevention-oriented individuals or ensure against losses for promotion-oriented individuals—they experience regulatory non-fit. Non-fit makes them “feel wrong” about what they are doing. Regulatory non-fit is associated with weakening engagement and de-intensifying evaluative judgments. How might a non-fit health message be helpful? What if individuals’ initial attitudes toward a healthy option were negative, even anxiety producing, despite that option serving their interests better than alternative options? It would be better if the individuals could thoughtfully consider the potential benefits of the option without their negative feelings rejecting it. For a thoughtful decision to be made, the intensity of the initial negative feelings could be decreased. A regulatory non-fit message, in this case, could be an effective tool. By making people “feel wrong” about their initial reaction, it could weaken their engagement and de-intensify the negative reactions, for example, reduce anxiety about the option. Thus, the regulatory non-fit message could help an individual to reconsider potential advantages of the initially disliked option. While the ways in which Regulatory Focus and Regulatory Fit theories can be applied to improve health communications are known, important questions remain. For example, are there circumstances when fit or non-fit messages could make people feel that their decision-making autonomy is being threatened? Can fit or non-fit messages create resistance? If so, how can this be avoided? Both fit and non-fit messages are persuasive techniques. Is there a downside to these techniques? What can be done to ensure that these persuasive techniques are not just effective but are also ethical?


Neighborhood Considerations for Social Determinants of Health and Risk  

Holley A. Wilkin

When it comes to health and risk, “place” matters. People who live in lower-income neighborhoods are disproportionately affected by obesity and obesity-related diseases like heart disease, hypertension, and diabetes; asthma; cancers; mental health issues; etc., compared to those that live in higher-income communities. Contributing to these disparities are individual-level factors (e.g., education level, health literacy, healthcare access) and neighborhood-level factors such as the socioeconomic characteristics of the neighborhood; crime, violence, and social disorder; the built environment; and the presence or absence of health-enhancing and health-compromising resources. Social determinants of health—for example, social support, social networks, and social capital—may improve or further complicate health outcomes in low-income neighborhoods. Social support is a type of transaction between two or more people intended to help the recipient in some fashion. For instance, a person can help provide someone who is grieving or dealing with a newly diagnosed health issue by providing emotional support. Informational support may be provided to someone trying to diagnose, manage, and/or treat a health problem. Instrumental support may come in the help of making meals for someone who is ill, running errands for them, or taking them to a doctor’s appointment. Unfortunately, those who may have chronic diseases and require a lot of support or who otherwise do not feel able to provide support may not seek it due to the expectation of reciprocity. Neighborhood features can enable or constrain people from developing social networks that can help provide social support when needed. There are different types of social networks: some can enhance health outcomes, while others may have a more limiting or even a detrimental effect on health. Social capital results in the creation of resources that may or may not improve health outcomes. Communication infrastructure theory offers an opportunity to create theoretically grounded health interventions that consider the social and neighborhood characteristics that influence health outcomes. The theory states that every neighborhood has a communication infrastructure that consists of a neighborhood storytelling network—which includes elements similar to the social determinants of health—embedded in a communication action context that enables or constrains neighborhood storytelling. People who are more engaged in their neighborhood storytelling networks are in a better position to reduce health disparities—for example, to fight to keep clinics open or to clean up environmental waste. The communication action context features are similar to the neighborhood characteristics that influence health outcomes. Communication infrastructure theory may be useful in interventions to address neighborhood health and risk.


Hope and Health and Risk Messaging  

Amy E. Chadwick

Hope has been defined in primarily two ways, and both have implications for message design within health and risk communication. First, hope has been defined as a way of thinking, or disposition, that affects how people pursue goals. Dispositional hope manifests in beliefs about one’s capacity to initiate and sustain action toward goals (agency) and one’s ability to generate ways to reach those goals. Dispositional hope has been associated with positive physical and mental health outcomes. For example, high-hope women have greater intentions to engage in cancer prevention behaviors than do low-hope women. Numerous studies have associated higher hope with better pain management, and people who are higher in hope have a greater pain tolerance than people lower in hope. Hope is also related to better psychological adjustment. Much of the research on dispositional hope focuses on correlating hope with a variety of positive health and non-health outcomes; however, psychotherapeutic interventions have also been designed to increase dispositional hope. These interventions have shown improvements in health-related outcomes. Although their potential is not yet realized, interventions for developing dispositional hope could improve compliance with medical recommendations, increase adoption of health behaviors, and decrease risk behaviors. The second way that hope has been defined is as a discrete emotion. Discrete emotions are brief, intense, psychological, and evaluative reactions directed at external stimuli (e.g., people, events, or objects). In response to these external stimuli, emotions help individuals adapt to their environment by activating a unique pattern of thoughts (cognitions), physiological changes, subjective feelings, motor expressions, and action (or behavioral) tendencies. Lazarus’s cognitive-mediational theory has been one of the most influential theories of discrete emotions that includes a definition of hope. Lazarus identifies the core relational theme of hope as “fearing the worst but yearning for better.” Lazarus deems hope to be a problematic emotion because he believes hope contains both positive and negative elements. Despite uncertainty about the exact nature of hope, Lazarus believes that hope is vital to coping with stress. Hope enables people to believe in the possibility of better circumstances and therefore is critical as a coping mechanism against despair. Lazarus does not provide guidance for what a message might need to include to evoke hope. Drawing on Lazarus and appraisal theories in general, MacInnis and de Mello suggest tactics that consumer marketing advertisements could use to induce hope. Specifically, the authors focus on turning “impossibility into possibility” and enhancing “yearning.” De Mello and MacInnis also theorize that hope can lead to motivated processing of information resulting in both positive (e.g., coping, well-being, and goal achievement) and negative (e.g., risky behavior, self-deception) outcomes. Unfortunately, the theorizing of de Mello and MacInnis was never empirically tested. To further explore how feelings of hope are created, Prestin examined underdog narratives in entertainment media. Underdog narratives show characters who are attempting to meet a goal despite unfavorable circumstances and odds. These narratives evoke hope and make people more motivated to meet their own personal goals. Although their potential has not been fully explored, underdog narratives may assist individuals in overcoming challenging circumstances, such as battling addiction or developing new health habits. There are numerous mechanisms still to be examined that may explain the effects of underdog narratives beyond their ability to evoke hope. Recently, Chadwick defined hope as a future-oriented, discrete emotion that focuses on an opportunity to achieve a desired future outcome. Her definition builds on the work of Lazarus and Roseman and has implications for the design of messages that evoke hope. According to Chadwick, hope is evoked by appraisals of a future outcome as (a) consistent with goals (goal congruence), (b) possible but not certain (possibility), (c) important (importance), and (d) leading to a better future (future expectation). All four of these appraisals combine to create a perception of opportunity and the discrete emotion hope. Hope motivates behavior by focusing one’s thoughts on capitalizing on an opportunity. Chadwick states that hope also involves (a) an approach action tendency that motivates individuals to take, or continue, action to achieve the desired outcome, (b) increased heart rate and skin conductance, (c) an open facial expression, heightened focus, and alert body posture, and (d) a feeling of eager attention. Chadwick’s definition has clear implications for developing messages that evoke hope. Messages designed to create appraisals of the importance, goal congruence, positive future expectation, and possibility of a future event evoke hope and are called hope appeals. Like other theoretical explications of emotional appeals, a hope appeal has two components: (a) the inducement of hope through the presentation of an opportunity and (b) the presentation of recommended actions to achieve the desired outcome. The recommended actions component includes information designed to (a) increase the receiver’s perception of his or her ability to perform the recommended action (i.e., self-efficacy) and (b) demonstrate the ability of the recommended actions to achieve the desired outcome (i.e., response efficacy). Empirically, scholars have tested the effects of hope and messages that evoke hope. Hope appeals increase attention to messages about climate change and increase mitigation behavioral intention and mitigation behavior. In addition, feelings of hope increase interest in climate change protection and are positively correlated with pro-environmental behaviors and support for climate change policies. Feelings of hope significantly predict interest in climate protection, self-efficacy, interpersonal communication intention, information seeking intention, and behavioral intention. Hope and hopeful narratives have also been associated with greater perceived message effectiveness and more agreement with the message content. After a stressful experience that accelerates heart rate, evoking hope decelerates heart rate and decreases state anxiety. This research provides evidence that messages that evoke hope can counter the psychological and physiological effects of stressful events. In addition, researchers have examined the effects of hope on a variety of health, persuasion, political communication, and marketing outcomes. Preliminary evidence indicates that hope appeals are equally as or more effective than guilt and fear appeals at increasing interpersonal communication intention, self-efficacy, information seeking intention, and behavioral intention. In addition, hope appeals create less reactance (anger) than fear appeals. Together these results indicate that hope and hope appeals have substantial potential to influence health and risk behavior.


keepin’ It REAL”: A Case History of a Drug Prevention Intervention  

Michael L. Hecht and Michelle Miller-Day

Adolescent substance use and abuse has long been the target of public health prevention messages. These messages have adopted a variety of communication strategies, including fear appeals, information campaigns, and social marketing/branding strategies. A case history of keepin’ it REAL, a narrative-based substance abuse prevention intervention that exemplifies a translational research approach, involves theory development testing, formative and evaluation research, dissemination, and assessment of how the intervention is being used in the field by practitioners. The project, which started as an attempt to test the notion that the performance of personal narratives was an effective intervention strategy, has since produced two theories, an approach to implementation science that focused on communication processes, and, of course, a school-based curriculum that is now the most widely disseminated drug prevention program in the world. At the core of the keepin’ it REAL program are the narratives that tell the story of how young people manage their health successfully through core skills or competencies, such as decision-making, risk assessment, communication, and relationship skills. Narrative forms not only the content of curriculum (e.g., what is taught) but also the pedagogy (e.g., how it is taught). This has enabled the developers to step inside the social worlds of youth from early childhood through young adulthood to describe how young people manage problematic health situations, such as drug offers. This knowledge was motivated by the need to create curricula that recount stories rather than preaching or scaring, that re-story health decisions and behaviors by providing skills that enable people to live healthy, safe, and responsible lives. Spin-offs from the main study have led to investigations of other problematic health situations, such as vaccination decisions and sexual pressure, in order to address crucial public health issues, such as cancer prevention and sex education, through community partnerships with organizations like D.A.R.E. America, 4-H clubs, and Planned Parenthood.