The first panel of the Workshop on Lessons Learned from Diverse Efforts to Change Social Norms focused on messaging from previous efforts in relevant public health fields, including such elements as dimensionality, concept, definition, and structure. Joanne Silberner, a freelance journalist and journalism instructor at the University of Washington, served as workshop moderator. The panelists included Joseph Cappella, professor of communication, Annenberg School for Communication, University of Pennsylvania, and member of the committee on the Science of Changing Behavioral Health Social Norms, who has written and published widely on health and political communication. He spoke on the topic of key principles in message design. Annie Lang, professor of telecommunications and cognitive science, Indiana University, and also a committee member, works on how people process mediated messages. Her presentation covered how to make the most of a message. Tony Foleno, senior vice president, the Ad Council, works on public service communication campaigns, and focused his presentation on behavioral economics and social marketing. Bernice Pescosolido, distinguished professor of sociology, Indiana University, and a committee member, studies negative beliefs about mental illness. Her presentation addressed public service announcements (PSAs).
Cappella began by saying that most of his work, funded by the National Cancer Institute, has been in the area of cancer communica-
tions, primarily with respect to smoking. His research focuses in three areas: message features that are most predictive of persuasiveness; features that undermine persuasiveness; and features that affect the virality and selection of messages, especially given the nature of the media environment. He said that his remarks would be based on conclusions from the evidence base, but that he would not be describing the evidence base or the methodologies used in deriving it in detail. He said he would focus on two claims—that effective messages make strong appeals and that they engage the audience.
In discussing what makes a strong appeal, Cappella first stated that appeals can be both rational and emotional, and that emotional appeals are not necessarily irrational. For example, he said, when individuals are threatened, when fear and anxiety are activated, when hope is given, the actions that follow are not necessarily irrational. Rather, such messaging appeals to people’s core values. In turn, he added, irrational appeals are not emotion free.
Cappella explained that the notion of a strong appeal goes back to work in social psychology on positive and negative thoughts induced by a message in the target audience. However, he continued, the problem with this definition is that it is operational and applies after the message has been crafted. He asserted that one needs to construct strong appeals a priori by identifying the objective features by domain and audience that make for strong appeals.
Strong appeals lead to more effective messages, Cappella argued. This point is illustrated in the area of smoking, for example, in studies of more than 200 PSAs involving 10,000 observations, finding that higher intentions to quit are seen with high argument strength and attitudes. Likewise, work in Australia showed increased attempts to quit smoking with exposure to strong as opposed to weaker messages (Kim et al., 2016; Wang et al., 2013; Falcone et al., 2013; Durkin et al., 2009). Cappella noted that argument strength also has physical correlates; for example, brain responses, cotinine reductions, and other physiological reactions (e.g., elevated heart rate and skin conductance) have been observed in response to strong arguments (Wang et al., 2013; Strasser et al., 2009).
According to Cappella, the key question is, “Can we design strong appeals?” He said there are some potential directions to this end, but they come with caveats and reservations. Specific procedures exist, for example, for selecting topics that matter to the audience with respect to the predefined goal of the campaign and the behavior change on which the campaign is focused. These are well defined and well developed, Cappella said,
and they have been widely used. He referred the audience to a summary of that set of procedures (Parvanta et al., 2013), which he did not have time to review in detail during his presentation.
Cappella pointed to a recent application of the principle of strong appeals in the Food and Drug Administration’s (FDA’s) RealCost campaign, an antismoking campaign directed at young people. In developing the campaign, he noted, it was found that four consequences of smoking are of particular concern to young audiences: addiction, loss of control, putting chemicals in their bodies, and cosmetic effects. He pointed out, however, that these are topics, not appeals, and that moving in the direction of arguments and appeals can be challenging. Appeals, he said, are really about the consequences of behavior—compliance that yields a desirable outcome or noncompliance that yields an undesirable outcome (O’Keefe, 2012). Research to date has shown that the desirability of outcomes matters more than what is known to be true (Johnson et al., 2004). Meta-analyses by Carpenter (2010, 2014) have shown that when one compares the severity and susceptibility of appeals, it is severity that matters, not susceptibility. In short, the study of topics and the personal values that underlie those topics are where strong appeals come from.
Cappella cited another example from the RealCost campaign about poisons in the body from tobacco. The constituents of tobacco can be presented in a factual way, or they can be presented with strong emotional appeal. Thus one can say that tobacco contains 7,000 different chemicals and poisons, such as formaldehyde, benzene, polonium, chromium, arsenic, lead, cadmium, ammonia, butane, toluene, and hydrogen cyanide. Or one can say it contains embalming fluid; gasoline; radioactive materials used in steel making; and chemicals used in pesticides, older paints, batteries, household cleaners, lighter fluid, paint thinners, and chemical weapons. These are valenced presentations of factual information. An illustration of this distinction is a video from the FDA showing 7,000 demons (chemicals and poisons) arising out of a swamp. As smoke enters the body of a young man walking and smoking, the 7,000 constituents are listed. Cappella characterized this video as very evocative visually and emotionally. In his judgment, it is not irrational, but an effective use of an emotional appeal that has a very strong rational basis.
Cappella’s second main point was that the audience needs to be engaged with the content of the material being presented to them, and they need to be engaged with vehicles that will draw their attention to the core content, which is more challenging. He explained that people can be engaged with the core content through the use of narratives and exemplars as well as
characters, particularly ones that are similar to the audience members. The engagement, he said, takes place through people’s desire to have an interpersonal connection. He argued that exemplars—anecdotes about people that are personal and concrete—are crucial to the processing of information in messages. Sometimes activation cues (visual and audio variation) are particularly valuable, he said, as are appetitive and aversive cues.
According to Cappella, the effect of engagement through interpersonal connection has been seen in evidence from the following:
- studies of news about quitting smoking (Kim et al., 2012);
- studies of the role of narrative formats in more than 200 PSAs (Kim et al., 2016);
- the presence of characters in these PSAs (Kim et al., 2016);
- studies of mammography, objective mammography risk, and tailored exemplars (Seitz et al., 2016) that help reinforce the objective risk that is present in those tools; and
- studies from Australia showing that not just strong ads but strong ads with narrative character (Durkin et al., 2009) affect smoking cessation.
Cappella mentioned that the evidence base also shows that in adult samples, high visual activation of messages—such as many face, camera, object, and distance changes—can undermine the effectiveness of messages. This has been seen not only in data on the 200 PSAs mentioned above but also in studies of high-activation advertising directed at young people. When the arguments are weaker, there are lower levels of response.
Cappella concluded by saying that he would invest in strong appeals, narratives, and exemplars. He noted that strong appeals can be positive and deal with pride and hope, for example. But he also cautioned that, like activation, narratives can distract from core content. Thus, he concluded, a narrative needs to carry the core content of a message; if it does not, people will remember the narrative but not pay attention to the core content.
MAKING THE MOST OF YOUR MESSAGE: HOW MESSAGE STRUCTURE AND CONTENT INFLUENCE ATTENTION, COGNITION, EMOTION, AND INTENTIONS
Lang began by positing that people are not rational media consumers but are driven by appetitive and aversive systems, and that they often make irrational, biased decisions that are best for them. She argued that message producers can use these observations to control how people respond to messages in unconscious, automatic, and essentially physical ways. Effective messages, she asserted, achieve the producer’s goals that may be related
to attention, memory for information, liking, attitude creation or change, behavioral intention creation or change, or behavior change.
Lang said that, as with Cappella’s discussion of engagement, people have to be motivated to pay attention, and to pay attention to the whole message. One way to control attention, she suggested, is to elicit an orienting response—a physiological response to novelty and to things that are self-relevant or signal important information. She explained that several structural features of different media elicit orienting responses to make people pay attention for about 2 seconds (Lang, 1990; Lang et al., 2002, 2013a). The introduction of the images or sounds increases attention as long as the motivationally relevant material is on screen (Lang, 2006; Lang et al., 2013b). According to Lang, features that can solicit orienting responses include a change from sound to silence, scene changes, movement from off screen to on, movement toward the thing the communicator wants the audience to remember, changes from one voice to another, animation, and pop-up windows (Lang, 1990; Lang et al., 2002; Potter et al., 2008).
The second way to motivate attention, Lang continued, is to incorporate motivationally relevant content. Such content compels attention as long as it lasts longer than an orienting response. Motivationally relevant content can be (1) threats and opportunities; (2) primary motivators, such as things needed for the species to survive (e.g., food, sex), presented through appetitive or approach cues, or things one needs to escape from to survive (e.g., danger, spiders), presented using aversive, avoidance cues; and (3) learned motivators, which can be appetitive or aversive based on one’s life experience.
Lang considered how one controls real-time attention to messages so the audience gets the whole message. Referring back to Cappella’s use of narratives, she suggested it is necessary to tell a story with a beginning, a middle, and an end (Schneider et al., 2004; Lang, 1989). She asserted that orienting responses should be elicited (5 to 7 every 30 seconds, at least 3 seconds apart) to get people’s attention for 2-second intervals (Lang et al., 1999, 2000), and that emotionally and motivationally relevant material should be included throughout the message so that people remain engaged continuously (Lang et al., 2013b; Bolls et al., 2001).
Memory for Information
Lang pointed out that people’s memory is a tradeoff between a message’s structural features and content complexity: if the content is complex, structure needs to be simple, whereas if the content is simple, it may be
driven home by a more complex structure. Orienting responses increase memory only if what people are intended to remember is what elicited the orienting response and if they have sufficient time to encode that information (2-4 seconds) (Lang et al., 1993, 2002). And motivationally relevant material increases memory only if what is motivationally evocative is what one wants people to remember (Sparks and Lang, 2015). Referring back to Cappella’s example of the video with 7,000 demons, Lang said that its goal would not be for people to remember the demons but rather the chemical names incorporated for activation and memory. Thus, Lang pointed out, the motivationally relevant content is integrated with the information one wants the audience to remember.
To increase memory of seeing a message but not details of its content, Lang suggested using many structural features to draw attention to the message, highly arousing emotional material (in particular, negative in nature), and simple messages (Grabe et al., 2000; Lang et al., 1996, 2007). To increase memory of the message and its content, she suggested using some but not too much emotion, explaining that positive emotion widens while negative emotion narrows focus and memory (Yegiyan and Yonelinas, 2011). She said narratives should be used to simplify the message, and structural features should be placed so that important information follows them and is available for at least 3 seconds (Schneider et al., 2004; Lang, 1989; Lang et al., 2015). Audio-video (multiple channel) redundancy should also be used, she continued, especially for important points (Lang, 1995).
Lang cautioned that highly arousing negative appeals can be effective but often are not. People will remember the negative thing and what follows it very well, but they will not remember much that preceded it. Also, people may process the material in a defensive way, especially if they are living that negative thing. When this happens, people may experience some elevated physiological response and tend not to store the information.
Liking the Message and Credibility
Lang went on to explain that various strategies can be used to make people like a message, such as using attractive and similar sources that have friendly dominant personalities, being polite, flattering the message recipient, and criticizing with caution. To be credible, she advised labeling sources as experts, making strong arguments in words and weak arguments in pictures, using camera techniques that look up at the source to boost importance, and using lower voice tones (Reeves and Nass, 1996; Lang and Yegiyan, 2008).
Creation or Change in Attitudes and Behavioral Intentions
Lang stressed that creating or changing attitudes and behavioral intentions requires changing the response of the audience’s motivational systems to the topic of the message. She suggested that messages should associate appetitive activation with what one wants people to like and should associate aversive activation with what one does not want them to do (Lang et al., 2014). She said the message should be designed to condition those motivational systems (Almond et al., 2014). She explained further that using positive and negative emotions sequentially in messages helps increase memory for the message (Keene et al., 2014), and that pictures elicit more physiological and biological responses relative to words. She suggested using pictures to shift implicit attitudes or motivational responses and using words to shift thoughtful opinions (Lang and Bailey, 2015; Almond et al., 2014).
Foleno began by saying that his talk about behavioral economics would be much in line with the remarks of Lang and Cappella with regard to the emotional and somewhat irrational way in which people make decisions and behave. He explained that behavioral economics focuses on changing the framing and context of messages to appeal to the part of the brain that is making the decisions, although the audience is not really conscious of this. Whether or not they know it, he said, marketers have been applying behavioral economic principles for years in the impulse-buying sections of supermarkets, where people do not weigh the pros and cons of a purchase before making it. Simply giving people the information and the facts, he asserted, will not necessarily change their attitudes and behavior.
Foleno pointed to a number of publications in behavioral economics that have started changing the way people think, arguing against the rational actor school of thought that underlies much of mainstream economic theory (Kahneman, 2011; Ariely, 2008; Thaler and Sunstein, 2009). Basically, he said, they suggest that for big decisions (e.g., whom one is going to marry, whether one should buy a particular house), people tend to be more rational actors. But for the many daily, small-scale decisions that are habituated (e.g., whether one is going to go to the gym this morning, what one is going to order from a menu), the psychological, social, and emotional components of behavior come into play. These more intuitive—what Lang referred to as somewhat primal—emotive urges (system 1) govern decision making that happens rapidly. Thus, he explained, behavioral economists talk about fast thinking, fast decision making, and processing
that take place in ways that one’s more rational brain (system 2) cannot really register.
The implication for public health behaviors and public health messaging, Foleno explained, is that humans, regardless of cultural background, level of education, or level of affluence, generally tend to be bad at
- assessing both short- and long-term risk,
- assessing all available evidence and weighing the pros and cons of different effects,
- privileging scientific fact over personal experience,
- choosing among many options,
- breaking habits, and
- delaying gratification.
Given these attributes within a highly competitive environment of cause communications, Foleno continued, a public health messaging strategy needs to be very thoughtful and to be positioned against all the other competing issues. The tactics of messaging, he argued, need to follow the principles and science laid out by the previous presenters with regard to environmental cues, framing and priming, and social cues. He said that, while it may be overly simplistic, he looks for messages that can be described as easy, attractive, social, and timely. He suggested that the most important of these attributes is easy: the easier a call to action is, as well as the more attractive one makes it and the more seamless the interaction with the audience is, the more likely it is that the message will be able to effect sustainable change. He said this observation applies not just to a television ad, but also to other media platforms and the actual services or resources that are being provided.
Foleno described an Ad Council toothbrushing campaign for children’s oral health that was informed primarily by researchers going into families’ homes and observing everyday behaviors and interactions. The message developed for parents was very simple: “Two minutes twice a day.” A utility was built in to the campaign in the form of a 2-minute video game for children, which made it easier for parents to make the toothbrushing ritual fun and engaging.
Foleno concluded that a great deal of innovative research is being conducted now to understand how the brain works at a subconscious level in response to messages. In testing messages, he explained, people are not only being asked questions about how they are processing the messages, but often people’s biometric responses are being charted in terms of both eye tracking and brain wave data to achieve a more accurate assessment of how people are processing messages.
Pescosolido explained that she is not a communication scientist but a basic social scientist drawn to thinking about the stigma of mental illness and what to do about it and understanding pathways to care. Years ago, she found there had been no study in the United States in 40 years on issues of mental health stigma. This realization led her to conduct the General Social Sciences National Stigma Study in 1996, which was replicated in 2006. During that period, much attention was focused on the issue of stigma. The good news from the replication study was that Americans understood that mental illness is a disease like any other, but there was no change in stigma or the prejudice and discrimination potential associated with mental health (Pescosolido, 2013; Pescosolido et al., 2010). Working with the Carter Center and the Bring Change to Mind campaign, Pescosolido started rethinking, reworking, and considering the next step, focusing on understanding how PSAs and other strategies can be used to address such challenges.
Pescosolido explained that she became a user of the communication research presented by the earlier speakers. Stemming from the President’s New Freedom Commission in 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) developed a national antistigma campaign, What a Difference a Friend Makes. At the request of the National Institute of Mental Health, Pescosolido and colleagues (2010) conducted a national survey of the approach taken in this campaign. They found that the overall campaign was effective, but effects of its various components varied. A “Friendster” video had the best results, a “door” component was probably not as useful as one might have hoped, and a video game actually turned out to work for a younger but not an older audience. This work led Pescosolido and colleagues to conclude that national testing could be done to evaluate such campaigns using social science methods and nationally representative samples.
Based on research by Lang, Pescosolido said it is important in messaging to think about whether one is “talking to the choir”—those who have contact with people with mental illness—or trying to reach beyond that audience. She then showed a video aimed at reaching people who do not know individuals with mental illness. This video, titled “Schizo,” was a PSA from a British campaign called Time to Change. It begins with abstract, dark, and shadowy visual images and music that is associated with horror films. It then zeroes in on a shadowy door, which suddenly opens to a normal, bright kitchen in which a man is standing and his wife is moving around. The two appear to be making a routine meal. The man then stops and says he was diagnosed with schizophrenia many years ago.
Pescosolido reported that a voiceover of this PSA was created for an American audience to study the PSA’s effect in this country. A simulated before/after design was used whereby one-half of the audience viewed the video before an attitude questionnaire was administered, and one-half viewed it after. Pescosolido described this method as a validated scientific approach to avoiding the social desirability effect.1 In addition, one-half of the audience was asked about their attitudes toward a person with “mental illness” and one-half about a person with “schizophrenia” to see whether the particular label mattered. The researchers found that both video conditions had an equally positive effect, and it was a slightly better effect than that found in the tests in the British population. Both video condition groups showed decreased stigmatizing views, as well as an increase in positive views (although less than the decrease in negative views), between the before and after viewing of the video. And responses differed when people were asked about a person with schizophrenia versus one with mental illness. Pescosolido also showed the audience a new PSA made for the United States, based largely on the original British “Schizo” video. Test results were positive for that video as well.
Pescosolido concluded with several points learned from her research. First, she said, researchers can rigorously evaluate PSAs nationally and work across disciplines. Incorporating the evaluation results during the development of a campaign may be more expensive, she said, but it helps clarify the investment in the campaign itself. She also noted that many challenges are entailed in developing and implementing PSA campaigns, such as selecting the best venue and the best placement of the PSA for the target audience. Finally, a question to be studied is whether the effects of these campaigns dissipate over time.
Vicky Rideout, a committee member, initiated the discussion by synthesizing some of the highlights of the presentations. First, she noted that the research that feeds into formulating a message can be the difference between success and failure. She explained that the research methods may be formative, ethnographic, or survey. Second, she noted that panelists had argued for strong appeals that will result in audience engagement in a highly competitive message environment. Third, she said, panelists had reported that because humans are not just rational actors, emotional appeals can be very effective. The fourth point she highlighted was that the
structural features (e.g., images, sound, voice, text, and timing) for delivering a message have to be strongly connected to the core message.
The discussion then addressed questions about the dramatic effects used in the “Schizo” video, how cultures such as the military need to be considered in messaging, evaluation of SAMHSA campaigns, challenges in working with advertising agencies’ creative agendas, messaging and components of the Health Belief model, and use of the term “stigma.”
Effects Used in the “Schizo” Video
William Holzemer, committee member, started the discussion of the “Schizo” video by saying that he initially thought it was an ad about child molestation or some other disturbing subject, and he believed the emotional aspect of the video overwhelmed the message. He asked the panelists who had spoken about the physiology and emotion of messaging what they thought about that reaction.
Cappella replied that he had a similar reaction upon first viewing the video, which he said elicited a strong negative emotional response and felt threatening. But he said if such a message has strong empirical backing, it is difficult to dismiss. With respect to message evaluation, he said, people all have their own opinions. For the most part, he argued, everyone is wrong except the people in the target audience, and the only question is whether the evaluation is a good test of the messaging.
Lang said that structurally, the message in the video would be successful for several reasons. First, it starts negative and turns positive, which is the best-remembered type of message. The negative content is aversive with respect to schizophrenia and elicits a strong response in the viewer, but then the video shifts to the positive scene of the man in a happy home. The initial memory of schizophrenia is broadened; the viewer now associates it with positive aspects as the man talks about the support of his family and friends. This is the message that is intended, Lang noted, and it is associated with positive emotion and good memory. Pescosolido commented that the messaging of the video was aimed at reaching beyond the “choir,” but that the researchers also were concerned about its negative emotional content. However, they were also attuned to the target audience of young adults who watch violent movies, thinking that the shock might get their attention. Cappella added that he thought that the remake was better than the original because the interpersonal connections at the end were better defined than in the British original, which, he said, did not feel as supportive.
Culture of the Military in Messaging
Stephanie Weaver of SAMHSA said that her work is focused on the military population and their behavioral health needs. She asked Lang whether core messaging principles are adjusted to cultural needs, and she asked the panel whether they believe these principles differ for military or veteran populations.
Lang replied that culture does matter, and it is important to determine how. Some things that are positive for a general population are negative for certain subpopulations. If one wants to elicit appetitive or aversive activation, the message must be matched to the culture. Lang noted that structural elements, such as movement toward, movement sideways, and scene changes, typically do not matter, but signals that important information is coming up may change with culture. So, one must be careful with those types of structural features.
Foleno agreed that culture matters. He said that a good part of his job is to puncture the New York City advertising world’s bubble and help creative teams feel more connected to the audiences they are trying to reach and establish relevance with. He described the Ad Council’s experience with the military as one of its signature success stories. The organization worked with the nonprofit Iraq and Afghanistan Veterans Association (IAVA) on issues of soldiers returning home and not being able to adjust because of posttraumatic stress disorder (PTSD), who needed suicide prevention, mental health, employment, and other services. Foleno explained that formative research helped the Ad Council understand the cultural nuances behind why stigma was even stronger among these returning combat veterans than among the general population. The one overarching theme was the general sense that if one has not experienced combat, one cannot understand. Thus only other veterans would be in a position to help, and that is what the Ad Council centered its campaign on. A website for the veterans’ community was developed to provide a sense of exclusivity and empathy.
Lang added that as a sociologist, culture matters to her, but structure matters as well. She noted that active military personnel report that the major barrier they experience is not stigma, although that is an issue, but the anticipated consequences of superiors discriminating against them in the future. So in some ways, she asserted, campaigns need to deal with the people in power because they must be either persuaded against or prevented from discrimination. She said the military culture needs stigma reduction on multiple levels.
Cappella pointed out that sensitivity to cultural differences among target populations within the same culture is necessary. It is known, for example, that the cosmetic appeals in the FDA’s RealCost campaign that are targeted to youth simply do not work with and are not consequential to
adult populations. This observation is consistent with the idea that a strong appeal is ultimately a value-based appeal. The question then becomes what the value system is within the target populations.
Evaluation of Ad Council Campaigns
Rideout asked Foleno about lessons learned from the Ad Council’s campaigns on mental health and substance abuse issues. Foleno replied that the organization has worked on a variety of campaigns related to stigma and that his presentation that afternoon would be focused on an evaluation of a campaign to prevent bullying of gay and lesbian teens. He also pointed to Pescosolido’s presentation on SAMHSA campaigns, specifically What a Difference a Friend Makes, on which the Ad Council worked with SAMHSA. He noted that Pescosolido’s research and data were better resourced than the Ad Council’s, but that the campaign tested very well in the formative research stage and through all of the creative effectiveness research that the Ad Council conducted. The organization typically conducts tracking surveys and digital analytics and did see some attitude shifts when the campaign was being conducted. Overall, Foleno believes the effects of the campaign were good but could have been better. He suggested the issue was one of dosage. The Ad Council works with a donated media model. A typical Ad Council campaign receives about $30 million in donated media, with a range of $10-50 million. Since media time was not being purchased, it was not possible to select the optimal mix, and some trade-offs were involved. The Ad Council’s national campaigns with SAMHSA did have measurable effects, but, Foleno said, more is more. The more dose, messages, assets, and researchers there are, the better the effect, as long the message is crafted in the right way.
Cappella responded to a somewhat related question from Jeff Jordan, Rescue Social Change Group, about how to change habitual behavior in young people by arguing against their direct experience. Cappella replied that this cannot be done, but one needs to attempt to identify counter pressures. In the FDA’s RealCost campaign, for example, the message is that tobacco addiction can take people away from the social experiences they value the most because they need to go outside to have a cigarette and, say, stop the movie they are watching. The RealCost campaign is attempting to tap the loss of control and of the kinds of values teens have, such as the value of social interaction. Cappella counseled against trying to create a message that goes directly against a person’s immediate experience because the message is simply not going to be effective in that context.
Working with Advertising Agencies
Jordan also asked Foleno to speak to the group about how to work with ad agencies. Foleno replied that the Ad Council works with dozens of large ad agencies and has some tactics for ensuring that the work it receives is on point and on strategy. The main tactic is to create a sense of empathy with the creative team doing the work and proposing the ideas. Foleno stressed that involving the creative team in the qualitative research for a campaign is important because it is one thing to read a creative brief and another to go to a small town and actually talk to people who are dealing with the issue targeted for change. Another tactic is not to pit research against creative work but to ensure that everyone involved is aligned very early on in terms of what the objectives of the campaign are. Great campaigns, Foleno said, are both creative and unexpected and effective.
The Health Belief Model and Messaging
Silberner asked Cappella to elaborate on a statement he had made that severity is more important than susceptibility. Cappella explained that this observation was the result of a meta-analysis that examined the widely tested health belief model, which posits three broad components associated with behavior change: the susceptibility that the individual experiences to a disease, a condition, or a behavior; the severity of the disease or its treatment, the condition, or the behavior; and the efficacy of the advocacy in the change message. The meta-analysis he referred to (Carpenter, 2010, 2014) showed across a variety of studies that only severity matters. He placed the issue in the context of identifying the most important aspect of an argument: Is it its truth value, its factual character, or its underlying consequences? And the fact that the meta-analysis showed severity to be consequential, but not susceptibility, was consistent with the notion that the underlying truth value of the claim is less important than the value or desirability of the outcome.
Use of the Term “Stigma”
Tom Coderre from SAMHSA noted that Pescosolido had used the term “stigma”, and commented that the agency struggles with that term and refers instead to “negative public attitudes.” He asked Pescosolido whether there is any research on the use of the term “stigma” and whether she knows how the word impacts how people feel about stigmatizing people with behavioral health issues. Pescosolido replied that she does not know of any scientific research on this issue, and it appears to represent a debate with reasonable people on both sides. She said, however, that the term is
relevant to the young adults with whom she works. She noted that the public associates “prejudice” and “discrimination” more with race than with health issues, and she uses the word “stigma” because “if we do not name it and frame it, then we cannot fight it.”
Foleno added that he also has seen no research on the use of the term. He suggested such research would be most meaningful in the context of a creative campaign, instead of testing use of the term separately.
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