An Integrated Approach to Consumers Processing of Health Marketing Communication Messages

An Integrated Approach to Consumers Processing of Health Marketing Communication Messages Today, our world is faced with public health issues on daily basis (e.g., cancer, obesity, H1N1 flu pandemic, HIV, AIDS, SARS pandemic, etc.). Because health responsibility lies with the individual, it is of great importance to understand how to create effective health marketing communication (HMC) messages, which aim to raise awareness, form/change attitudes and trigger behavioural change, in the context of health. Popular terms, such as Public Health (Vance et al., 2009), Health 2.0 (Wilson & Keelan, 2009), and Direct-to-Consumer (DTC) Advertisements (Ball et al., 2011) provide evidence that health practitioners (including health professionals, health communicators/marketers, and pharmaceutical companies) are trying to reach consumers and the general public by using traditional and non-traditional marketing techniques in order to enable such change. Since the inception of the attitude construct in 1862 by Herbert Spencer (Allport, 1925) many attitude change and knowledge-attitude-behaviour theories have been developed to explain how consumers form and change attitudes, how consumers attitudes influence informationprocessing and decision-making, and how elements of marketing communication messages influence consumers attitudes and behaviours (see reviews of Eagly & Chaiken 1993; Bohner & Dickel, 2011). Altogether this large body of research confirms that attitudes have a significant impact on human behaviour (Bohner & Dickel, 2011). Within a health context, attitudes also play a critical role on how consumers make health-related decisions and process health-related information (Petty & Wegener, 1998). Many attitude change and information-processing theories related to health behaviour (e.g. Health Belief Model; Theory of Reasoned Action; Theory of Planned Behaviour; Extended Parallel Processing Model) have been formulated to explain how consumer-related factors, including attitudes, affect health-related information-processing, decision-making and behaviour. These health behaviour theories have found support across-many health topics. However, they have also been criticized for their limitations. Firstly, some health behaviour theories treat consumers as rational decision-makers, others examine only emotional aspects. However, it is the combination of cognition and affect that lead to attitude change/formation (Singh, 2003). Secondly, all these health behaviour theories (except the Extended Parallel Processing Model which only focuses on the use of fear appeals to affect health behaviour) do not provide information on how persuasion occurs after exposure to HMC messages. Persuasion theories (e.g., Elaboration Likelihood Model by Petty & Cacioppo, 1981; Heuristic Systematic Model by Chaiken, 1978) could shed some light on how persuasion occurs, using both cognitive and affective components of health marketing communication messages. However, these persuasion theories have been developed for products and services that usually contain a lower level of risk than health-related decisions (e.g. detergent vs. vaccine) thus, disregarding health-related consumer factors (i.e. self-efficacy, perceived risk/threat) with significant impact of healthrelated information-processing and decision-making. Thirdly, the processing of early information may affect the interpretation and use of subsequent information (Bohner & Dickel, 2011: 412) and this aspect must be considered when designing HMC messages. Repeated behaviours may be required to prevent or treat a disease, and maintain health and well-being (e.g. HPV vaccination requires three shots) and these have to be considered in relation to the Stages-of-Change theory (i.e. the Transtheoretical Model). Different messages might also be required depending on which stage-of-change consumers are. This paper aims to address these limitations and provide a deeper understanding of how 1

consumers process HMC messages, and make health-related decisions, the research question being: How persuasion occurs at different stages-of-change? Following the informationprocessing paradigm this conceptual framework of how persuasion occurs at different stage-ofchange, focuses on the cognitive and affective processes that occur after exposure to a health marketing communication stimulus and before the behavioural response to that stimulus. By synthesizing an information-processing theory commonly used in the consumer behaviour field, the Elaboration Likelihood Model (ELM; Petty & Cacioppo; 1981), with popular health behaviour theories (Health Belief Model-HBM, Extended Parallel Processing Model-EPPM, Stages-of-Change), this paper contributes to the literature on attitude change, informationprocessing, persuasion, and health behaviour literatures by comprehensively integrating these theories (see Table 1 for a summary of relevant theories). Table 1: Summary of Relevant Theories and Models from Prior Literature Elaboration Likelihood Model (ELM) by Petty & Cacioppo, 1981; 1986 Explains how consumers process, interpret advertising messages, form/change attitudes & make decisions (Eagly & Chaiken, 1993; Petty, Priester, & Wegner, 1994). Advantages Most comprehensive & widely used informationprocessing framework (Vakratsas & Ambler, 1999). Distinguishes between two routes to persuasion based on both cognitive and affective message elements. Recognizes the impact of consumer factors (e.g., involvement, motivation, ability, opportunity) for route selection, which are absent in the popular health behaviour theories. Applied in both product & health-related (e.g., HIV prevention) situations. Disadvantages Negative emotions toward the message can also lead to cognitive (central) processing (Batra & Staynman, 1990). Lacks important health-related factors (e.g. perceived susceptibility and self-efficacy) that have been validated by extensive health behaviour research (Slater, 2000). Health Belief Model (HBM) by Rosenstock, 1966 (first introduced by Hochbaum, Rosenstock, & Kegels, in the1950s) Specifies the process of cognitive evaluation that precede action tendencies (Das, De Wit, & Stroebe, 2003). Supported across a range of health-related topics. Consumers sometimes behave irrationally Recognizes the importance of perceived (Airhihenbuwa & Obregon, 2000). susceptibility, which is the strongest predictor of Individuals cannot live without thought (cognition) or behaviour (Becker, 1974; Janz & Becker, 1984), emotions (affect), it is the combination of these two among other important consumer constructs such as, that lead to attitude change/formation (Singh, 2003). self-efficacy. Extended Parallel Processing Model (EPPM) by Witte 1992 Focuses on the use of fear appeals to form/change attitudes (Witte, 1992) Consumers sometimes behave irrationally (e.g., due Neglects to take into account: to fear of treatment method) Important consumer-related factors (i.e., perceived Recognizes the existence of two possible outcomes barriers based on HBM) that impact health behaviour. of fear appeals: danger control (success of Message-related factors (i.e., involvement based on communication message) & fear control ELM) that have an impact on the persuasive nature of (communication message fails). the marketing communication message. Identifies the importance of efficacy components: self-efficacy & response efficacy. Sheds light on how consumers process health-related information after exposure to stimuli. Stages of Change (or Transtheoretical model) by Prochaska, & DiClemente (1984) Specifies the stages people have to go through to change health-related behaviours (Slater, 2000). Suitable for addictive behaviours, or treatments that Does not identify important consumer-related health require consumers to maintain health-related actions. behaviour (i.e., perceived barriers based on HBM) Can be interpreted as a hierarchy of effects model in and message-related (i.e., involvement based on regards to how consumers make decisions. ELM) factors. 2

A Conceptual Framework of How Persuasion Occurs at Different Stages-of-Change Based on the aforementioned theories a framework is advanced regarding how persuasion occurs across different stages-of-change (Figure 1). The stages are used to identify consumerrelated and message-related factors that may impact health-related behaviour change in different scenarios (e.g., when the consumer is not aware of the threat a disease poses, or when the consumer has not yet decided whether or not to act on the recommended health-related action), not to imply that persuasion is a linear, sequential process. In addition, the conceptual framework does not assume that consumers are rational decision makers, but aims to examine factors of importance in behaviour change, no matter how consumers process HMC messages. It is important to note that all constructs identified across all stages-of-change are influenced by individual factors (according to HBM) such as, the consumer s personality, beliefs, gender, age, education level, income, sexual behaviour and prior knowledge of the health issue/disease (Devos-Comby & Salovey, 2002). The Pre-contemplation Stage is the starting point, as suggested by the Stages-of-Change and ELM. At this stage, consumers exposed to the message may not be aware of the existence of the threat the disease or health issue poses or they might have not had the motivation, ability and opportunity to think about it in an effortful and cognitive way. At this time, according to the ELM, the route selection is determined central (high elaboration) or peripheral (low elaboration), based on the consumer s perception of health issue relevance (involvement). According to the ELM, a high Motivation-Ability-Opportunity (MAO) to process the HMC message implies high involvement and thus the use of central route (cognitive) information processing. Alternatively, low MAO assumes low involvement and the use of the peripheral route (affective) information processing. The Contemplation Stage: According to ELM, if central route processing is selected, cognitive thinking is evoked in the contemplation stage. The consumer will then assess the threat/fear of the disease or health concern (HBM, EPPM models). The level of threat/fear is determined by the individual s perceived susceptibility and severity of the health issue. If the level of threat/fear is deemed high and the health issue is deemed relevant to the self (in many cases consumers think that a threat does not apply to them e.g., cancer from smoking, which prohibits them from quitting even if the fear of getting cancer is high), the consumer is motivated for danger control 1, and the perceived benefits of acting upon the recommended health action are greater than the perceived costs, then positive attitudes towards the recommended health behaviour are formed. On the other hand, if the perceived threat and relevance to self is low or if the consumer is motivated for fear control 2 this will lead to negative attitudes towards the healthrelated action. This implies that the HMC message would fail. If the peripheral route is chosen the consumer will be motivated to process salient objects and peripheral cues (e.g., music, the source, etc.) rather than cognitively elaborate the message i.e. attitudes based on their emotional response to the message (Singh, 2003). However, if the evoked emotions negative, the consumers might be motivated to process the message centrally (Batra & Staynman, 1990), or it might lead to negative attitudes if the consumers do not have high MAO & involvement to cognitively elaborate on the message. Alternatively, if the evoked emotions are positive, consumers are more likely to form positive attitudes. The Preparation Stage: Behavioural intentions are formed or changed based on consumers attitudes formed in the contemplation stage. This link is mediated by self-efficacy (i.e. 1 Motivated to engage in health actions that will minimize the danger of the health issue/disease. 2 Motivated to neglect the existence of problem/threat of the health issue/disease, for the sake of controlling the fear itself. 3

ability to take the recommended health-related action) and response-efficacy (i.e. perceived ability of the recommended health action to prevent or fight the disease or health concern). We propose both variables are critical to forming positive behavioural intentions. The Action and Maintenance Stage: If consumers have formed positive intentions towards the recommended health behaviour, and have the necessary cues to action (based on the HBM), they are more likely to engage in the recommended health action. The health behaviour is then sustained consistently if consumers have positive prior experience with the recommended health behaviour and high self and response efficacies. Figure 1: How Persuasion Occurs at Different Stages-of-Change Suggested Methodology and Propositions A qualitative methodology should be used to gain a deeper understanding of consumer and message factors that impact on behaviour change, as identified by the proposed conceptual framework, after consumers are exposed to HMC messages. Focus groups and in-depth interviews will be used to explore consumers responses to different HMC messages, by using 4

real-world HMC messages as props. A quantitative approach should follow, in the form of a large-scale questionnaire, to test the factors identified in the proposed conceptual framework (after any necessary adjustments). Table 2 presents the propositions developed based on the proposed framework (which may be adapted based on qualitative findings). A series of experiments with existing HMC messages should be conducted for the different parts of this model. Given its complexity, the framework will be tested in stages and ethical issues will be considered throughout i.e. in terms of the design of each chosen methodology and corresponding data collection instrument. P1 P2 Table 2: Summary of Developed Propositions Consumers who have high motivation, ability, opportunity, and topic involvement to process the HMC message will be more likely to move from the pre-contemplation to the contemplation stage. Consumers with high topic involvement will process the HMC message more cognitively, and consumers with low topic involvement will process the HMC message more peripherally. P3.1 Within the central route, only consumers who are motivated for (a) danger control (b) perceive the threat of the disease as relevant to self and (c) perceive the benefits of taking the recommended health action to out weight its costs will form positive attitudes toward the recommended action. P3.2 Within the central route, consumers who i) (a) perceive low threat/fear, and (b) perceive the threat of the disease not relevant to self or ii) are motivated for fear control, or iii) after being motivated for danger control and considering the threat applicable to self, the costs are greater than the benefits of taking the recommended health action, will form negative attitudes toward the recommended action. P4.1 Within the peripheral route, consumers with a positive emotional response will form positive attitudes toward the message. P4.2 Within the peripheral route consumers with (a) a negative emotional response and (b) high motivation, ability, opportunity, and topic involvement will be motivated to process the HMC message cognitively through the central route. P4.3 Within the peripheral route, consumers with (a) a negative emotional response and (b) low motivation, ability, opportunity, & topic involvement will form negative attitudes toward the HMC message. P5 Consumers who have positive attitudes towards the recommended health-related action will be more likely to move from the contemplation stage to the preparation stage. P6 Consumers positive attitudes and behavioural intentions are mediated by (a) perceived self-efficacy and (b) perceived response-efficacy. P7 Consumers with high efficacies and positive behavioural intentions are more likely to move from the preparation stage to the action stage, and take the recommended health action. P8 Cues to action moderate the relationship between behavioural intentions and behaviour P9 change/formation. Consumers who have (a) a positive prior experience with taking the recommended health action and (b) maintain high efficacies will be more likely to move from the action stage to the maintenance stage and sustain the health behaviour. Managerial Implications This proposed framework provides a first step towards social change by providing new cross-disciplinary insights and perspectives in terms of how consumers process HMC messages and make health-related decisions. In doing so, it identifies consumer and message factors that promote health behaviour change, at each stage of change. The HMC messages should 1) promote danger control and intensify the idea of relevance to self while increasing the portrayed benefits and minimising the perceived costs of taking the recommended health action 2) encourage positive emotional responses through peripheral cues, 3) increase the perceived selfefficacy and response-efficacy of taking the recommended health action, 4) remind or portray positive experience(s) associated with the recommended action. These factors should be tested (validating framework) in terms of their effects on health behaviour change, in order to provide guidelines for health practitioners designing HMC messages. 5

References Airhihenbuwa,C.O. & Obregon, R. (2000). A Critical Assessment of Theories/Models Used in Health Communication for HIV/AIDS. Journal of Health Communication, 5 (Supplement), 5-15. Allport, G.W. (1925). Attitudes. In C. Murchison (Ed.), Handbook of Social Psychology (pp..), Clark University Press, Worcester. Ball, J.G., Manika, D., & Stout, P.A. (2011). Consumers Young and Old: Segmenting the Target Markets for Direct-to-Consumer Prescription Drug Advertising, Health Marketing Quarterly, 28 (4), 337-353. Batra, R. & Staynman, D. M. (1990). The Role of Mood in Advertising Effectiveness. Journal of Consumer Research, 17 (September), 203-214. Becker, M.H. (1974). The Health Belief Model and Personal Health Behavior. Health Education Monographs, 2, 324-473. Bohner, G., & Dickel, N. 2011. Attitudes and Attitude Change. Annual Review of Psychology, 62, 391-417. Chaiken, S. (1978). Unpublished doctoral dissertation. University of Massachusetts, Amherst, MA. Das, E.H.H.J., De Wit, J.B.F. & Stroebe, W. (2003). Fear Appeals Motivate Acceptance of Action Recommendations: Evidence for a Positive Bias in the Processing of Persuasive Messages. Personality and Social Psychology Bulletin. 29(5), 650-664. Devos-Comby, L. and Salovey, P. (2002). Applying Persuasion Strategies to Alter HIV-Relevant Thoughts and Behavior. Review of General Psychology. 6(3), 287 304. Eagly, A., & Chaiken, S. (1993). Psychology of Attitudes. NY: Harcourt, Brace Jovanovich. Janz, N.K., & Becker, M.H. (1984). The Health Belief Model: A Decade Later. Health Education Quarterly, 11(1), 1-47 Petty, R.E., & Cacioppo, J.T. (1981). Attitudes and Persuasion: Classic and Contemporary Approaches. Dubuque, IA: Wm. C. Brown. Petty, R., & Cacioppo, J.T. (1986). The elaboration likelihood model of persuasion. In L. Berkowitz (Ed.), Advances in Experimental Social Psychology (vol.19, pp. 123-205), New York: Academic Press. Petty, R. E., Priester, J. R., & Wegener, D. T. (1994). Cognitive processes in attitude change. In R. S. Wyer and T. K. Srull (Eds.) Handbook of Social Cognition (2nd ed.), (vol. 2, pp.69-142), Hillsdale, NJ: Erlbaum. 6

Petty R.E., & Wegener, D.T. (1998). Attitude change: multiple roles for persuasion variables. In D Gilbert, ST Fiske, G Lindzey (Eds.), Handbook of Social Psychology, (pp. 323 390). New York: McGraw-Hill Prochaska, J.O., & DiClemente, C.C. (1984). The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, IL: Dow Jones-Irwin. Singh, A. (2003). From The Periphery to The Center: An Emotional Perspective Of The Elaboration Likelihood Model. University of Florida, retrieved from http://etd.fcla.edu/uf/ufe0000791/singh_a.pdf Slater, M. D. (2000). Integrating Application of Media Effects, Persuasion, and Behavior Change Theories to Communication Campaigns: A Stages-of-Change Framework. Health Communication. 11(4), 335 354. Vakratsas, D. & Ambler, T. (1999). How Advertising Works: What Do We Really Know? Journal of Marketing, 63, 26-43. Vance, K., Howe, W., & Dellavalle, R.P. (2009). Social internet sites as a source of public health information. Dermatologic Clinics, 27 (2),133 136. Wilson, K. & Keelan, J. (2009).Coping with public health 2.0. Canadian Medical Association Journal, 180 (10), 1080-. Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs, 59, 329-349. 7