Lifespan and Developmental Considerations in Health and Risk Message Design
- Jon F. NussbaumJon F. NussbaumProfessor of Communication Arts and Sciences & Human Development and Family Studies, Department of Communication Arts & Science, The Pennsylvania State University
- and Amber K. WorthingtonAmber K. WorthingtonDepartment of Communication Arts and Sciences, The College of the Liberal Arts, The Pennsylvania State University
Health and risk message design theories do not currently incorporate a lifespan view of communication. The lifespan communication perspective can therefore advance theorizing in this area by considering how the fundamental developmental differences that exist within and around individuals of different ages impact the effectiveness of persuasive message strategies. Designing health messages for older adults therefore requires an examination of how theoretical frameworks used in health and risk message design can be adapted to be age sensitive and to effectively target older adults. Additionally, older adults often make health decisions in conjunction with informal caregivers, including their adult children or spouses, and/or formal caregivers. Message design scholars should thus also consider this interdependent influence on health behaviors in older adults. Strategic messages targeting these caregivers can appeal to, for example, a caregiver’s perception of responsibility to care for the older adult. These messages can also be designed to not only promote the older adults’ health but also to alleviate caregiver stress and burden. Importantly, there is an unfounded stereotype that all older adults are alike, and message designers should consider the most beneficial segments of the older adult audience to target.
Lifespan and Developmental Considerations in Health and Risk Message Design
The foundational assumption of the lifespan perspective is that human development occurs throughout the entirety of our lives. Development refers to the changes in physiology, biology, psychology, communication, relationships, and spirituality (to name a few human characteristics) that occur with the accumulation of time. This development is best viewed as both gain and loss. Lifespan scholars do not consider any one period of a lifespan to hold supremacy over any or all other periods of life (Baltes, Smith, & Studinger, 1992). Rates of development can vary across the lifespan both intrapersonally and interpersonally. In addition, certain characteristics of human cognition and behavior may undergo critical developmental periods. Childhood is often considered a critical time for the competent development of language (Miller & DeThorne, 2013). Individuals in middle adulthood are often referred to as the “pivot generation” because of the complex relational and communicative competencies that must be mastered and enacted when interacting with young children and older parents simultaneously (Fingerman, Birditt, Nussbaum, & Ebersole, 2012). Older adulthood is when wisdom is most likely to emerge and to serve a significant, positive communicative function (Nussbaum, 2012). Significant and impactful behavior occurs throughout our lives. The structure, function, and very nature of behavior changes as people cope with the unique challenges of their lives.
Lifespan communication scholars have developed a series of proposals to help guide theory and research within the Communication discipline that borrow heavily from lifespan developmental psychology (Baltes, 1987):
The nature of communication is fundamentally developmental.
A complete understanding of human communication is dependent on multiple levels of knowledge that occur simultaneously.
Change can be quantitative and qualitative.
Lifespan communication scholars and students can incorporate all current theories of communication into this perspective as long as the theories are testable and the results are useful.
Unique methodologies are required to capture communication change across the life span (Pecchioni, Wright, & Nussbaum, 2005).
A logical extension of the lifespan communication perspective is to question whether health and risk messages and risk communication directed toward individuals of differing ages need to account for the fundamental developmental differences that exist within and around individuals of different ages. A health message that may be very sound and persuasive for an adolescent may not achieve the same persuasive affect for an older adult. Therefore lifespan and developmental considerations in health and risk message design are examined here, with a specific focus on older adults. To do so, theoretical message design principles are discussed that may be adapted to better suit this target audience. Importantly, older adults often make health decisions together with informal (e.g., adult children, spouses) and formal caregivers. Thus, this interdependent influence on older adult’s health behaviors is examined and the ways in which how messages may be strategically designed for caregivers of older adults are explored.
Designing Messages for Older Adults
Strategic message design is viewed as an important element in addressing many health challenges. For example, effectively designed persuasive messages can promote regular exercise, fruit and vegetable consumption, sunscreen use, regular sleeping habits, safer sex practices, sunscreen use, helmet use, and so forth. Popular theoretical frameworks for doing so include, for example, the Theory of Reasoned Action (Ajzen & Fishbein, 1980) and the Theory of Planned Behavior (Ajzen, 1988, 1991, 2011a, 2011b), which focus on determinants of health behaviors. Several additional frameworks capitalize on the motivational drive offered by eliciting perceptions of future-oriented emotions, including fear in the Extended Parallel Process Model (Witte, 1992) and, more recently, hope in Persuasive Hope Theory (Chadwick, 2010, 2014). These models vary in their formality, predictive power, and heuristic utility, but all have empirical evidence to support their propositions. Importantly, however, the effect sizes of studies on these frameworks indicate that there is room for theoretical development and improvement.
One specific advancement in health and risk message design may be in the potential to incorporate a lifespan communication perspective. Indeed, to be maximally effective, persuasive health messages should be age sensitive. The following section therefore reviews the aforementioned theoretical frameworks, including the Theory of Reasoned Action and the Theory of Planned Behavior, as well as the Extended Parallel Process Model and Persuasive Hope Theory, with a focus on specific aspects of relevance to designing health and risk messages for older adults. This section also covers the importance of age-sensitive message design when incorporating risk information comprised of statistical evidence into messages for older adults by considering Subjective Message Construct Theory.
The Theory of Reasoned Action and the Theory of Planned Behavior
The Theory of Reasoned Action (TRA; Ajzen & Fishbein, 1980) and its extension the Theory of Planned Behavior (TPB; Ajzen, 1988, 1991, 2011a, 2011b) have gained widespread scholarly attention as useful frameworks for specifying the antecedents of health intentions and behaviors and are thus useful to message-design scholars. The TRA posits that behavior is directly determined by an individual’s intentions. Intentions motivate an individual to engage in a particular behavior and are directly predicted by (a) an individual’s attitude toward the behavior (an individual’s evaluation of the behavior as positive or negative) and (b) subjective norms (an individual’s perceptions of whether or not others think they should engage in the behavior). Attitudes are comprised of beliefs about the likelihood of behavioral outcomes weighted by the evaluation of each outcome. Subjective norms are comprised of beliefs about whether significant others think that one should perform a behavior weighted by the motivation to comply with that referent. Message designers using the TRA can thus strategically design messages that attempt to change or reinforce attitudes or subjective normative beliefs in message recipients so that they align with the recommended health behavior change.
The TPB extends the TRA by including perceived behavioral control, which is also referred to as self-efficacy. The TPB posits that a behavior is directly determined by an individual’s intentions and perceived self-efficacy. Self-efficacy encompasses the extent to which an individual believes they have control over performing that behavior. Intentions, in turn, are directly predicted by an individual’s (a) attitude toward the behavior, (b) subjective norms, and (c) self-efficacy. Self-efficacy is comprised of beliefs about the facilitators or barriers in engaging in the behavior weighted by the perceived power of each facilitator or barrier to impact performance of the behavior. Message designers using this TPB extension can thus strategically design messages that also attempt to change or reinforce self-efficacy beliefs in message recipients.
Reviews suggest that the Theory of Planned Behavior is an adequate predictor of intentions and behavior, and explains 40–49% of the variance in intentions and 19–36% of the variance in behavior (Ajzen, 1991; Armitage & Conner, 2001; Godin & Kok, 1996; Hagger et al., 2002; McEachan et al., 2011; Schulze & Whittmann, 2003). However, it is important to determine how to effectively and strategically target the attitudes, subjective norms, and self-efficacy in an older adult population.
As mentioned, the TRA/TPB define attitudes as an individual’s evaluation of the behavior as positive or negative. Importantly, Dutta (2007) notes that messages can be particularly effective if they recognize and reinforce a particular group’s values. Individuals at different life stages may have different attitudes and values regarding health and health-related outcomes that influence how they perceive the health behaviors recommended in a message. These differing values should therefore influence how message designers strategically design messages for these audiences.
Health messages often stress the ability of the recommended health behavior to impact the message recipient’s own health outcomes. However, older adults may place greater value on behaviors that have a positive impact on their family members or friends rather than on behaviors that only impact themselves. In other words, an older adult may hold more positive attitudes toward a health behavior that is framed in terms of other-oriented outcomes rather than personal health-related outcomes, as health messages targeting older adults can be used to not only persuade older adults to adopt different health behaviors for their own benefit but also to adopt health behaviors that impact people important to these older adults. For example, a health message that aims to increase older adults’ physical activity may emphasize that engaging in such behaviors will allow the older adult to more fully interact and play with their children or grandchildren (relational-focused outcome) rather than the notion that such behaviors will, for example, decrease their blood pressure (personal health-focused outcome).
This strategy may be particularly effective for older adults, according to research related to generativity. Erikson (1950) introduced the term generativity, defining it as “the concern in establishing and guiding the next generation” (p. 267). Generativity was first viewed as a mid-life phenomenon, involving mid-life adults’ responsibility to bear, nurture, and guide the children and adolescents who will follow them as adults (Erikson, Erikson, & Kivnick, 1986), but other scholars have also proposed that generativity is an important contributor to successful aging (e.g., Baltes & Baltes, 1990). Indeed, McAdams and Logan (2004) note that different forms of generativity are more or less important across the lifespan. Older adults may have more generative beliefs, or a concern for the next generation, than individuals at other points in the lifespan. Thus, their attitudes toward other-focused outcomes of health behaviors may indeed be more positive than their attitudes toward personal health-focused outcomes.
Subjective Normative Beliefs
The TRA/TPB define subjective norms as an individual’s perceptions of whether or not others think they should engage in the behavior, and these frameworks predict that these subjective norms influence behavioral intentions. However, additional normative beliefs may be more or less important depending on the lifespan stage of the message recipient. An additional framework, the Social Norms Approach (Berkowitz, 1997; Perkins, 2003; Perkins & Berkowitz, 1986), thus appears important. This Social Norms approach posits that the relevant norms for predicting intentions are categorized into two types: descriptive norms and injunctive norms (i.e., norms that refer to social approval of the act; see also Cialdini, Reno, & Kallgren, 1990).
Park and Smith (2007) examined five types of perceived norms at the personal and societal level: subjective norms, personal and societal injunctive norms, and personal and societal descriptive norms. Subjective norms were defined as “perceptions of important others’ expectations for a given individual’s behavior,” personal injunctive norms as “perceptions of important people’s approval of a given individual’s behavior,” personal descriptive norms as “perceptions of important people’s own behavior,” societal injunctive norms as perceptions of society’s approval of a given behavior, and societal descriptive norms as perceptions of society’s behaviors (Park & Smith, 2007, p. 197).
These different forms of normative beliefs may be more or less important across the lifespan when predicting health intentions and behaviors. For example, societal level norms may be relatively more important for older adults when predicting intentions and subsequent behaviors, as older adults are particularly concerned about behaviors that have important implications for one’s family, friends, and society at large. This idea again draws on generativity. Specifically, McAdams and de St. Aubin (1992) proposed a theory of generativity that posits that generativity exists within a psychosocial space that includes individual, interpersonal, and societal dynamics. This theory posits that generativity is motivated by both cultural demands (e.g., an older adult’s felt expectations regarding cultural pressure to take responsibility for younger individuals) and generative desire (e.g., an older adult’s need to be needed by others and to leave a legacy behind after death). These motivational forces then lead to generative concern (e.g., an older adult’s conscious preoccupation for individuals in the next generation) and belief that the human enterprise is worthwhile (e.g., an older adult’s respect and trust for other humans). Concern and belief lead an individual to a commitment to be generative, which then leads to generative actions and narration. As generative concern varies across the lifespan, so, too, may the importance of subjective norms, personal and societal injunctive norms, and personal and societal descriptive norms. Message designers should thus determine the types of normative beliefs with the most influence at different points in the lifespan.
As mentioned, the TPB defines self-efficacy as an individual’s beliefs about the facilitators or barriers in engaging in the behavior weighted by the perceived power of each facilitator or barrier to impact performance of the behavior. For health and risk message designers, self-efficacy then refers to the individual’s beliefs in their ability to adhere to message recommendations and enact the health behavior in question. Of particular interest when strategically designing messages for older adults are their perceptions of self-efficacy over health behaviors when they may face physical or cognitive impairments.
Physical impairments, including muscular-skeletal conditions like arthritis or osteoporosis, as well as visual impairments or blindness, become more prevalent with increasing age. In addition, chronic conditions such as cardiovascular disease, hypertension, stroke, diabetes, and cancer are prevalent in an aging society, and many older adults have one or more of these chronic conditions. Importantly, these physical impairments and chronic conditions are associated with disability (Jagger et al., 2007; McGuire, Ford, & Ajani, 2006). Cognitive impairments in older adulthood may include dementia, Alzheimer’s disease, or depression. All physical and cognitive impairments may impact an older adult’s ability to engage in any given health behavior, thus impeding their self-efficacy beliefs and ability to enact health message recommendations. Together, these impairments may account for the fact that older adults have low self-efficacy for many health behaviors (e.g., Grembowski et al., 1993; McAuley et al., 2006). Message designers should therefore be cognizant of the potential low self-efficacy in this target population and should potentially include additional content intended to increase self-efficacy beliefs. Importantly, however, not all older adults face physical or cognitive impairments, and the idea that increasing in age is synonymous with increasing disability has led to a negative image of aging and stereotypes that all older adults are impaired. Thus, it is important for message designers to consider the additional needs of older adults when designing messages by including additional efficacy-related information; however, message designers should avoid stereotyping this audience as always facing some sort of impairment.
In addition to physical and cognitive impairments in older adulthood that may impact an older adult’s self-efficacy, older adults’ self-efficacy beliefs may be unique because older adults often make health decisions in conjunction with family members and/or caregivers. Thus, control over any given health behavior is the result of not only the older adult’s efficacy but also the efficacy beliefs of other relevant others. The section on designing health messages for caregivers of older adults further explores this idea.
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.
Designing Messages for Caregivers of Older Adults
The shared decision-making process about health behaviors changes across the lifespan. Like young children and their parents, older adults may also be involved in dyadic decisions about health. Indeed, older adults often make health decisions in conjunction with their family members, including their adult children or their spouses, and/or formal caregivers. The health behavior of one or both members in a dyadic system is likely a function of input from both individuals (i.e., the older adult and their family member or the older adult and their formal caregiver). This idea draws on Interdependence Theory, which is a dyad-level social psychological theory that aims to understand the interpersonal context of social situations and the manner in which individuals respond to social situations (Kelley, Bercheid, Christensen, Harvey, & Huston, 1983; Kelley & Thibaut, 1978; Rusbult & Van Lange, 1996). Interdependence refers to the way partners in a dyad influence each other’s outcomes. Health and risk message design for older adults may thus target and strategically design messages not only for the older adults themselves but also for informal caregivers, including adult children or spouses, as well as formal caregivers. Importantly, however, health communication theories used in health and risk message design do not currently address how to strategically design these messages for interdependent dyads. One type of message often seen in these older adult-caregiver situations is one that specifically appeals to the responsibility of the caregiver to promote the health and health behaviors of the older adult.
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).
In general, the strongest tie between two individuals is the tie between married individuals (Rossi & Rossi, 1990; Umberson, Crosnoe, & Reczek, 2010). In older adulthood, spouses, when present, are most likely to serve as the primary caregiver than any other primary caregiver type (Wolff & Kasper, 2006). Health messages to spousal caregivers may, for example, stress the power of spouses to influence each other’s health. For example, Stinchfield (2009) notes, “Try to find new ways to stay active as a couple, whether it’s hitting the tennis courts or hiking trails . . . couples who work out together are more likely to stick with an exercise program.” This is particularly important, as research suggests, for example, that if one spouse becomes obese, the other spouse is more likely to become obese as well (Christakis & Fowler, 2007).
Caregiving for sick spouses can have negative consequences, including stress, guilt, depression (Capistrant, Berkman, & Glymour, 2014), and increased risk for cardiovascular disease (Capistrant, Moon, Berkman, & Glymour, 2011). Health messages should thus attempt to ease these negative consequences associated with responsibility for caring for a sick spouse. One strategy to do so is to attribute negative outcomes such as weight gain, weight loss, or a fall to causes beyond the control of the caregiver. An additional strategy is to acknowledge the feeling of guilt and state that the responsibility for care requires an ongoing perception of what those responsibilities should entail. For example, Lunde (2013) notes, “Guilt is often the result of refusing to accept that some things are beyond our control and accepting that there are often no perfect solutions. The promise to keep a loved one with dementia living at home may have been made with the best intentions and hopes some time ago, but inherent in that commitment is the idea that you need to do what’s best given all that you know now.” These appeals to spousal caregivers’ responsibility may have an important lifespan component, as older caregivers with preexisting health problems experience stronger negative physical effects, whereas younger caregivers experience more caregiver burden, depression, and guilt (Pinquart & Sörensen, 2007).
Cultural Differences in Informal Caregivers
Some key cultural differences can influence how to strategically design health and risk messages for informal caregivers of older adults based on cultural differences in filial responsibility. Filial responsibility, which refers to societal attitudes about rights and duties that specify how family members should care for and provide support for each other, appears to be culturally determined (Rossi & Rossi, 1990; also referred to as filial obligation and filial piety). For example, research has shown that Chinese students value filial responsibility more than U.S. students (Kline & Zhang, 2009). Additionally, a recent study in the Netherlands found that older adults in immigrant groups, including Turks and Moroccans, expressed stronger filial obligations than the Dutch (de Valk & Schans, 2008). Further, Chow (2009) notes that within Asian societies, perceptions of filial responsibility have the highest value in regulating the behavior of adult children toward their aging parents. Additionally, this perception of filial responsibility is so strong in Taiwan, Hong Kong, and Singapore that federal state measures (e.g., tax allowances) encourage children to live with and care for their older adult parents.
Perceptions of filial responsibility also change with acculturation. For example, Diwan, Lee, and Sen (2011) found that, among middle-aged and older Asian Indian immigrants, shorter length of time living in the United States (used as a proxy for level of acculturation) is associated with a stronger adherence to the traditional pattern of living arrangements and a desire to move in with their adult children than among those with a longer length of residence who expressed a preference only for moving closer to their children. This finding is consistent with Modernization and Aging Theory (Burgess, 1960), which posits that modernization, individualism, and secularization combine to weaken filial obligation norms and break down traditional family structures. Together, this evidence situates responsibility under a culturally deterministic lens by suggesting that an individual’s expectations about filial responsibility develop through opinions and norms that are shared during socialization and that living in developed societies may lead to different expectations about how family members are expected to behave toward one another. As such, message designers should be aware of the potential cultural differences in feelings of responsibility in caregivers and design their messages in a culturally sensitive manner. Dutta (2007) further examines how message design scholars can incorporate culturally sensitive persuasive strategies.
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.
Conclusions and Future Directions
Potential strategies to be used in designing messages for older adults have been outlined here. Importantly, however, there is a stereotype that all older adults are alike, but this stereotype is, of course, unfounded (Harwood, 2007). A key question of interest to message design therefore considers what are the most beneficial audience segments to target from the older adult population. Moschis (2003) notes: “while age appears to be the most common and easiest way of segmenting the mature market, it is probably the least effective in most cases. This is because people’s behavior does not correlate well with age. Instead, older people’s behavior is more sensitive to their needs and lifestyles, which are in turn influenced by life-changing events and circumstances they experience” (p. 521). Indeed, audience segmentation based on life experience appears to be more effective than segmentation based on age (Moschis, 2003). This position highlights the need for future empirical work to examine whether the ideas presented here are indeed due to age or are instead due to cohort effects.
Health communication theories as they currently stand fail to adequately theorize on how health and risk messages may be effectively designed for individuals across the lifespan. Therefore, current theories used in strategic message design have been presented and ways in which messages could use these frameworks to target older adult audiences have been suggested; These ideas pave the way for future empirical work to examine these ideas. Indeed, much of the research in message design research has examined the persuasive effects of message variations on younger adults, thus necessitating the need to understand how the persuasiveness of different strategies may differ across the lifespan.
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