The Role of Narrative and Other-Referencing in Attenuating Psychological Reactance to Diabetes Self-Care Messages

Reactance as a Persuasive Strategy: How Health Communication Can Harness Anger to Leverage Behavior Change

According to psychological reactance theory, individuals who perceive a threat to or loss of valued behavior will experience reactance - an amalgam of anger and negative cognitions that motivates an effort to regain behavioral freedom. The limited effects of health communication interventions have often been attributed to psychological reactance, and previous research has tended to focus on how to design health messages that mitigate this phenomenon. However, the motivational nature of reactance suggests that it might also be used to promote health. When people learn that external influences circumvent a positive health behavior, this information may elicit reactance, motivating them to exhibit that behavior. This idea found support in the results of a preregistered experiment (N = 358), showing that participants were more willing to reduce meat consumption when they experienced reactance after reading about how the food industry undermines self-determined dietary decisions. The findings indicate that harnessing reactance to leverage behavior change may offer a promising alternative to established communication strategies.

Electronic Nudge Letters to Increase Influenza Vaccination Uptake in Younger and Middle-Aged Individuals With Diabetes

Background

Despite evidence demonstrating that influenza vaccination is associated with reduced risk of cardiovascular events and all-cause mortality in individuals with diabetes mellitus (DM), vaccine uptake remains suboptimal.

Objectives

The purpose of this study was to assess the effectiveness of electronically delivered nudges on influenza vaccine uptake according to the presence of DM status versus other chronic diseases.

Methods

NUDGE-FLU-CHRONIC was a nationwide, randomized, pragmatic implementation trial among younger and middle-aged (18-64 years) Danish citizens with chronic disease during the 2023/2024 influenza season. Participants were randomized in a 2.45:1:1:1:1:1:1 ratio to usual care (no electronic letter) or 1 of 6 different electronic nudge letters. The endpoint was receipt of a seasonal influenza vaccine on or before January 1, 2024.

Results

Of 299,881 participants, 57,666 (19.2%) had DM (median age: 51.6 years, 43.0% female). During the season, 43.0% of those with DM vs 34.6% of those without DM received the vaccine (P < 0.001). Any electronic letter vs usual care was highly effective in increasing vaccine uptake in participants with DM (45.6% vs 36.5%, difference: +9.1 percentage points [99.29% CI: 7.9-10.3], relative risk ratio: 1.42 [99.29% CI: 1.39-1.44]). However, DM status modified the effect of the interventions such that participants without DM at baseline experienced a greater relative gain than those with DM (37.3% vs 25.9%, difference: +12.3 percentage points [99.29% CI: 11.7-12.8], risk ratio: 1.47 [99.29% CI: 1.45-1.50]; P interaction<0.001).

Conclusions

Electronic nudge letters effectively boosted vaccine uptake in individuals with DM and in individuals free of DM but with other chronic diseases, but the effect was lower among those with DM. Electronic nudges represent a low-cost and effective strategy to boost influenza vaccination rates in the DM population. (Nationwide Utilization of Danish Government Electronic Letter System for Increasing InFLUenza Vaccine Uptake Among Adults With Chronic Disease; NCT06030739).

Promoters and Barriers of Vaccine Hesitancy

This systematic review explores the psychological antecedents of Vaccine Hesitancy, a significant determinant of vaccination behavior. Following PRISMA guidelines, an extensive search was conducted starting from 1673 papers and resulting in 48 publications from various databases. The review identifies psychological factors, specifically cognitive, personality, experiential, and social factors contributing to hesitancy. Cognitive factors include health literacy, conspiracy beliefs, trust, and perceived risk. Personality traits such as extraversion, openness, and psychological capital impact hesitancy, while psychopathy increases it. Personal experiences, like perceived stress and racial discrimination, indirectly affect hesitancy. Social factors, including social relationships and norms, play a significant role in reducing hesitancy. Tailored interventions addressing these factors can enhance vaccine acceptance.

Diminishing Psychological Reactance Through Self-Transcendent Media Experiences: A Self-Report and Psychophysiological Investigation

Health communication scholars have provided ample evidence demonstrating the ways in which freedom-threatening language used in persuasive health messages evokes freedom-threat perceptions, state psychological reactance, and intentions to engage in behaviors opposite of those recommended by the health message. This study examined a novel mitigation strategy for diminishing these outcomes. We examined whether prior exposure to entertainment portrayals of moral virtue (versus a neutral video) can dampen audiences' psychological reactance, intentions to consume alcohol, and defensive message processing via their psychophysiological responses to a subsequent, freedom-threatening excessive alcohol consumption public service announcement (PSA). The results revealed that participants who viewed entertainment portrayals of moral virtue (N = 50 college-aged participants) self-reported higher levels of elevation, moved, and inspiration relative to participants in the control condition (N = 50 college-aged participants). Participants who were exposed to entertainment portrayals of moral virtue prior to the excessive alcohol consumption PSA also self-reported less psychological reactance and fewer behavioral intentions to consume alcohol following the excessive alcohol consumption PSA than participants in the control condition. Consistent with these self-report data, participants in the entertainment portrayals of moral virtue condition exhibited less defensive message processing of the excessive alcohol consumption PSA via their psychophysiological responses relative to the control group. The results indicate that initial exposure to entertainment portrayals of moral virtue can dampen audiences' cognitive, emotional, and behavioral responses to a subsequent, freedom-threatening health message, thereby increasing the chances of improved health outcomes.

Examining Audiences' Psychological Reactance to Christian-Sourced Excessive Alcohol Consumption Messages in the United States

This study experimentally investigated the effect of dogmatic and suggestive language in Christian-sourced excessive alcohol consumption messages among college-aged participants who identify as Christians or non-Christians, as well as the role of perceived similarity with the message source, on their self-reported freedom-threat, psychological reactance, and behavioral intentions to consume alcohol. The results from this study support psychological reactance theory and demonstrate the various message strategies to effectively communicate the negative health effects of excessive alcohol consumption to individuals who identify either as Christians or non-Christians.

Reconsidering the Effectiveness of Fear Appeals: An Experimental Study of Interactive Fear Messaging to Promote Positive Actions on Climate Change

Masspersonal communication has emerged as a compelling alternative persuasive approach in response to the widespread use of social media. It is crucial to comprehend how observing online interpersonal interactions regarding the fear appeal of climate change can foster pro-environmental behaviors among users. This study examines the effects of vicarious message interactivity in promoting actions against climate change and the underlying mechanisms behind this effect. The results of an online experiment conducted in China (N = 236) revealed that psychological reactance and message elaboration mediated the effects of vicarious message interactivity on behavioral intention in a serial indirect effect. In comparison to static fear appeal, interactive fear appeal proves effective in reducing psychological reactance, promoting message elaboration, and ultimately increasing intention to take actions against climate change. Our findings not only contribute to the literature on interactive communication but also provide insights for environmental-health campaigns on social media.

Educational Interventions on Diabetic Foot Self-Care: A Study Protocol for a Pragmatic Randomized Controlled Trial

Diabetic foot is one of the most serious complications of diabetes and foot ulcer recurrence has been associated with poor foot care. Educational programs may work as a vehicle for promoting knowledge and adequate foot self-care behaviors, reducing potential ulcerative complications in the diabetic foot, and promoting a better quality of life. This study protocol will analyze the impact of two different educational strategies - an instructive video (Experimental Group 1) compared to a foot care leaflet with real-time guided reading (Experimental Group 2) and standard care (Control Group) - on adherence and knowledge about diabetic foot care and patients' perception of their foot health. This study is a Pragmatic Randomized Controlled Trial of a non-pharmacological treatment. Participants need to have a diabetic foot diagnosis and attend a Diabetic Foot Multidisciplinary Consultation at two hospitals from the North of Portugal. Participants will be assessed at the first appointment of the diabetic foot consultation (T0), two weeks after (T1), and three months later, at follow-up (T2). Primary outcomes will be adherence and knowledge about diabetic foot care and general foot health. Secondary outcomes will be illness representations regarding diabetic foot. The results of this study will inform educational interventions to decrease diabetic foot ulcers, amputation rates, and the costs associated with both, contributing to foot care adherence and improve patient's quality of life.

The Impacts of Narrative Perspectives of Anti-Prescription Opioid Campaigns: The Mediating Roles of Identification, Perceived Severity, and Anticipated Guilt

An online experiment with two between-subjects conditions was conducted among a convenience sample of American college students to test the impact of first-person internally focalized versus third-person externally focalized risk narratives on the effectiveness of anti-prescription opioid campaigns as well as factors that explain such impact. It found that first-internal vs. third-external narratives increased identification with the character, perceived severity of the dangers of prescription opioids, anticipated guilt, as well as negative attitudes toward prescription opioids. The study also found indirect positive impacts of first-internal vs. third-external narratives on negative attitudes toward prescription opioids and intentions to avoid (mis)using prescription opioids via perceived severity and anticipated guilt but not identification. The findings contribute to our understanding of the impacts of narrative perspectives in the context of health communication and provide guidance in the design of effective anti-prescription opioid campaigns.

Strategies to Improve Medical Communication

This JAMA Insights summarizes strategies for effective medical communication, with considerations for the message delivered, the messenger source, and the social context.

Resistance to Masks During the COVID-19 Pandemic: How User Comments Drive Psychological Reactance to Health Campaigns

Campaigns for mask-wearing have become widespread on digital platforms during the COVID-19 outbreak and have garnered varied responses in the form of comments. The present study conducts a 2 (comment position: pro-mask wearing vs. anti-mask wearing) × 2 (comment tone: civil vs. uncivil) between-subjects experiment to investigate whether and how the position and tone of comments accompanying a health campaign on social media affect people's psychological reactance toward the campaign. The results show that although anti-mask wearing comments following a social media mask-promoting post provoke individuals' perception about others' disapproval of the post, the perception did not trigger the individuals' psychological reactance to the post. Nevertheless, uncivil comments elicit anger, which arouses reactance and cause persuasion failure.

Electronically Delivered Nudges to Increase Influenza Vaccination Uptake in Older Adults With Diabetes: A Secondary Analysis of the NUDGE-FLU Trial

Importance

Influenza vaccination is associated with a reduced risk of mortality in patients with diabetes, but vaccination rates remain suboptimal.

Objective

To assess the effect of electronic nudges on influenza vaccination uptake according to diabetes status.

Design, Setting, and Participants

The NUDGE-FLU (Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake) trial was a nationwide clinical trial of Danish citizens 65 years or older that randomized participants at the household level to usual care or 9 different electronic nudge letters during the 2022 to 2023 influenza season. End of follow-up was January 1, 2023. This secondary analysis of the NUDGE-FLU trial was performed from May to July 2023.

Intervention

Nine different electronic nudge letters designed to boost influenza vaccination were sent in September to October 2022. Effect modification by diabetes status was assessed in a pooled analysis of all intervention arms vs usual care and for individual letters.

Main Outcomes and Measures

The primary end point was receipt of a seasonal influenza vaccine.

Results

The trial included 964 870 participants (51.5% female; mean [SD] age, 73.8 [6.3] years); 123 974 had diabetes. During follow-up, 83.5% with diabetes vs 80.2% without diabetes received a vaccine (P < .001). In the pooled analysis, nudges improved vaccination uptake in participants without diabetes (80.4% vs 80.0%; difference, 0.37 percentage points; 99.55% CI, 0.08 to 0.66), whereas there was no evidence of effect in those with diabetes (83.4% vs 83.6%; difference, -0.19 percentage points; 99.55% CI, -0.89 to 0.51) (P = .02 for interaction). In the main results of NUDGE-FLU, 2 of the 9 behaviorally designed letters (cardiovascular benefits letter and a repeated letter) significantly increased uptake of influenza vaccination vs usual care; these benefits similarly appeared attenuated in participants with diabetes (cardiovascular gain letter: 83.7% vs 83.6%; difference, 0.04 percentage points; 99.55% CI, -1.52 to 1.60; repeated letter: 83.5% vs 83.6%; difference, -0.15 percentage points; 99.55% CI, -1.71 to 1.41) vs those without diabetes (cardiovascular gain letter: 81.1% vs 80.0%; difference, 1.06 percentage points; 99.55% CI, 0.42 to 1.70; repeated letter: 80.9% vs 80.0%; difference, 0.87 percentage points; 99.55% CI, 0.22 to 1.52) (P = .07 for interaction).

Conclusions and Relevance

In this exploratory subgroup analysis, electronic nudges improved influenza vaccination uptake in persons without diabetes, whereas there was no evidence of an effect in persons with diabetes. Trials are needed to investigate the effect of digital nudges specifically tailored to individuals with diabetes.

Trial Registration

ClinicalTrials.gov Identifier: NCT05542004.

Promoting COVID-19 booster vaccines in Macao: A psychological reactance perspective

RATIONALE

The booster vaccine plays a key role in ending COVID-19 crisis. However, promoting COVID-19 booster vaccination often interferes with individuals' freedom of choice and leads to psychological reactance.

OBJECTIVE

To promote the public's intention to receive COVID-19 booster dose, this study aimed to investigate the effectiveness of different message designs from psychological reactance theory's perspective.

METHOD

A 2 × 2 × 2 factorial experiment was conducted in Macao in January 2022 (N = 469). Partial least squares structural equation modeling and a complementary three-way ANOVA were performed to examine the effects of message frame (gain frame vs. loss frame), freedom restoration postscripts (present vs. absent), and other-referencing cues (present vs. absent) on reducing psychological reactance.

RESULTS

The present study has successfully broadened the scope of the psychological reactance theory by examining its applicability to the context of COVID-19 booster vaccination promotion. Our findings indicate that the gain-framed promotion messages tend to be the most effective in reducing perceived reactance. However, freedom restoration postscripts, other-referencing cues, and mixed message design were found to be ineffective in alleviating reactance. Besides, the insignificance of direct effect from message frame to intention suggests that the message design itself cannot influence people's vaccination intentions; rather, it must rely on reducing perceived threat, reactance, and further improving vaccination intentions.

CONCLUSIONS

Our study offered valuable insights from psychological reactance perspective, identifying message features that can be effective in health promotions. Furthermore, message design specifically aimed at reducing the threat to freedom may yield unexpected persuasive effects, an aspect currently overlooked in health promotion strategies.

The Use of Narrative in Science and Health Communication: A Scoping Review

BACKGROUND

Many people deny science and reject health recommendations despite widely distributed facts and statistics. Didactic science and health communication is often dry, and relies on the false assumption that people make purely evidence-based decisions. Stories can be a powerful teaching tool by capturing attention and evoking emotion.

OBJECTIVE

We explore the impact and appeal of, and describe best practices for, using narrative (storytelling) versus didactic methods in science and health communication.

PATIENT INVOLVEMENT

No patients were involved in the review process.

METHODS

We searched PubMed and Web of Science for articles either: assessing effectiveness of narrative science/health communication; assessing acceptability of (or preference for) narrative science/health communication; giving advice on how best to use narrative; and/or providing science-based explanations for how/why narrative succeeds.

RESULTS

Narrative science/health communication is effective and appealing for audiences across a variety of topics and mediums, with supporting evidence across fields such as epidemiology, neuroscience, and psychology. Whether narrative or didactic messaging is most effective depends on the topic, audience, and objective, as well as message quality. However, combining narrative with didactic methods is likely to be more effective than using either strategy alone.

DISCUSSION

Narrative science/health communication merits wider implementation and further research. Narrative communication creates openness to information by delaying the formulation of counterarguments.

PRACTICAL VALUE

Science and health communicators should collaborate with cultural and storytelling experts, work directly with their target audiences throughout the message development and testing processes, and rely on popular story elements (e.g., first-person point of view, relatable protagonists) to improve the comprehension, engagement, and thoughtful consideration of their intended audience.

FUNDING

This work was funded by Thirty Meter Telescope, with which two authors (GKS and SD) were affiliated. Otherwise, the funding organization had no role in the study and/or submission.

Do Descriptive Norm Appeals in Public Service Ads Reduce Freedom Threats? Examining the Effects of Normative Messages and Media Literacy Skills on Decreasing Reactance

While health communication campaigns seek to encourage and promote healthy behaviors, they are not always successful. Health communication efforts may fail for several reasons, such as viewers experiencing excessive freedom threats and reactance. This study (n = 201) proposes and demonstrates that descriptive norm appeals in health PSAs can indirectly lead to enhanced behavioral intentions toward the message advocacy via reducing perceived freedom threats, inhibiting psychological reactance, and improving message credibility. However, this serial mediation was only found for message viewers with relatively low media literacy skills - precisely, who did not show considerable critical thinking toward media content. For participants who reported a high level of critical thinking toward media content, the use of descriptive norm appeals did not decrease freedom threats, nor did it indirectly affect behavioral intentions. The findings of this study contribute to the theory of psychological reactance and norms-based research. Both theoretical and practical implications are provided for health communication scholars and practitioners.

How Ethical Ideology Influences Mask-Wearing Intention in a Pandemic: The Mediating Role of Moral Norms and Threat to Freedom

The present study examined how two types of ethical ideologies (idealism, and relativism) influenced behavioral intention to wear a mask during the COVID-19 pandemic through two appraisals (moral norms, and threat to freedom) of a mask-wearing issue. A total of 823 responses were collected through a cross-sectional survey, and 776 responses were used for testing hypotheses. The study found that idealism has a significant indirect effect on behavioral intention through increased moral norms and decreased threat to freedom. Also, the study revealed that relativism has a significant indirect effect on behavioral intention through increased threat to freedom.

How Misinformation and Rebuttals in Online Comments Affect People's Intention to Receive COVID-19 Vaccines: The Roles of Psychological Reactance and Misperceptions

This study investigated how exposure to negative and misleading online comments about the COVID-19 vaccination persuasive messages and the ensuing corrective rebuttals of these comments affected people's attitudes and intentions regarding vaccination. An online experiment was performed with 344 adults in the United States. The results showed that rebuttals by the Centers for Disease Control and Prevention, rather than those by social media users, indirectly increased people's willingness to receive the vaccine by reducing their psychological reactance to persuasive messages and their belief in the misinformation contained in the comments. Rebuttals by social media users became more effective in reducing reactance when people initially had stronger pro-vaccination attitudes.

Why Do Some Americans Resist COVID-19 Prevention Behavior? An Analysis of Issue Importance, Message Fatigue, and Reactance Regarding COVID-19 Messaging

Despite the rapid transmission of and death toll claimed by COVID-19, there is evidence of resistance toward behaviors shown to effectively prevent and slow the spread of the disease, such as mask wearing and social distancing. This study applies psychological reactance theory to examine COVID-19 message factors (i.e., message fatigue, issue importance) that may be linked to nonadherence to CDC recommendations via the experience of reactance. Participants (N = 268) were current U.S. residents over the age of 18 who completed an online survey about their perceptions of COVID-19 messaging in general as well as toward a specific COVID-19 message they recalled. Results of structural equation modeling indicated that perceived freedom threat toward a COVID-19 message was predicted positively by message fatigue and negatively by issue importance. Greater perceived freedom threat was linked to greater reactance, which in turn was associated with lower levels of adherence to hygiene- and social-related COVID-19 preventive behavior. Notably, the negative association between reactance and social-related adherence was stronger than that between reactance and hygiene-related adherence. Implications for the role of reactance in risk and crisis communication as well as for public health messaging during the COVID-19 pandemic are discussed.

Rule-Governed Behavior and Climate Change: Why Climate Warnings Fail to Motivate Sufficient Action

Climate scientists warn of dire consequences for ecological systems and human well-being if significant steps to mitigate greenhouse gas emissions are not taken immediately. Despite these warnings, greenhouse gas concentrations continue to rise, indicating that current responses are inadequate. Climate warnings and reactions to them may be analyzed in terms of rules and rule-governed behavior. The literature on rule-governed behavior in behavior analysis has identified a variety of factors that can reduce rule following, including insufficient rule exposure, insufficient learning history and rule complexity, incomplete rules, instructed behavior not sufficiently learned, rules having weak function-altering effects, conflicting rules, lack of speaker credibility, rule plausibility and inconsistency with prior learning, and insufficient reinforcement for rule following. The present paper aims to analyze how these factors might impact responses to climate change, and possible solutions and strategies are discussed. Much of the theory and research on climate-change communication has come from outside of behavior analysis. Thus, the paper also aims to integrate findings from this literature with a behavior-analytic approach to rule control. Interpreting climate warnings and climate solutions in terms of rule-governed behavior may improve our understanding of why such rules are not more effective, and aid in the development of verbal and nonverbal strategies for changing behavior and reducing greenhouse gas emissions.

Transparent communication of evidence does not undermine public trust in evidence

Does clear and transparent communication of risks, benefits, and uncertainties increase or undermine public trust in scientific information that people use to guide their decision-making? We examined the impact of reframing messages written in traditional persuasive style to align instead with recent "evidence communication" principles, aiming to inform decision-making: communicating a balance of risks and benefits, disclosing uncertainties and evidence quality, and prebunking misperceptions. In two pre-registered experiments, UK participants read either a persuasive message or a balanced and informative message adhering to evidence communication recommendations about COVID-19 vaccines (Study 1) or nuclear power plants (Study 2). We find that balanced messages are either perceived as trustworthy as persuasive messages (Study 1), or more so (Study 2). However, we note a moderating role of prior beliefs such that balanced messages were consistently perceived as more trustworthy among those with negative or neutral prior beliefs about the message content. We furthermore note that participants who had read the persuasive message on nuclear power plants voiced significantly stronger support for nuclear power than those who had read the balanced message, despite rating the information as less trustworthy. There was no difference in vaccination intentions between groups reading the different vaccine messages.

Are We More Reactive to Persuasive Health Messages When They Appear in Our Customized Interfaces? The Role of Sense of Identity and Sense of Control

Online users today are provided with a variety of customization tools to build their own information environment. A growing number of public health messages reach their target audiences via these digital venues. Given the deeply personal and individualized nature of customized environments, do online users show lesser reactance to persuasive health messages? Or, are they more likely to show reactance because they feel intruded upon? We conducted a 2 (Customization: present vs. absent) × 2 (Message threat: high vs. low) experiment (N = 145) to find out. Data showed that interface customization increases the sense of control and sense of identity among users. Sense of control is positively associated with threat to freedom of action, causing more affective reactance. In contrast, a sense of identity is negatively associated with anger toward the persuasive message. Theoretical and practical implications for online health campaigns are discussed.

Examining the Effects of Celebrity (Vs. Noncelebrity) Narratives on Opioid Addiction Prevention: Identification, Transportation, and the Moderating Role of Personal Relevance

Celebrity disclosures and narratives are popular strategies in health promotion. However, less is known about their joint effects and the mechanisms through which they function. A 2 (narrative type: celebrity vs. layperson) x 2 (personal relevance: low vs. high) online experiment (N = 248) tested the impact of different narrative types in increasing awareness about prescription opioid abuse. Results indicated that a celebrity narrative is more persuasive than its layperson counterpart. Also, personal relevance toward opioid addiction moderated the influence of narrative type. Celebrity narratives evoked more positive attitudes toward opioid prevention and greater behavioral compliance intentions with the recommended action for low-relevance individuals. Transportation and identification mediated the effects of celebrity narratives on participants' issue attitudes and behavioral intentions, but only for low-relevance individuals. Practically, the data suggest that incorporating celebrities in health narratives about opioid addiction prevention facilitates behavioral compliance, especially for individuals to whom a pressing health issue like opioid misuse is currently of low relevance.

Participant Engagement and Reactance to a Short, Animated Video About Added Sugars: Web-based Randomized Controlled Trial

Background

Short, animated story-based (SAS) videos are a novel and promising strategy for promoting health behaviors. To gain traction as an effective health communication tool, SAS videos must demonstrate their potential to engage a diverse and global audience. In this study, we evaluate engagement with a SAS video about the consumption of added sugars, which is narrated by a child (a nonthreatening character), a mother (a neutral layperson), or a physician (a medical expert).

Objective

This study aims to (1) assess whether engagement with the sugar intervention video differs by narrator type (child, mother, physician) and trait proneness to reactance and (2) assess whether the demographic characteristics of the participants (age, gender, education status) are associated with different engagement profiles with the sugar intervention video.

Methods

In December 2020, after 4013 participants from the United Kingdom completed our randomized controlled trial, we offered participants assigned to the placebo arms (n=1591, 39.65%) the choice to watch the sugar intervention video (without additional compensation) as posttrial access to treatment. We measured engagement as the time that participants chose to watch the 3.42-minute video and collected data on age, gender, education status, and trait reactance proneness. Using ordinary least squares regression, we quantified the association of the demographic characteristics and trait reactance proneness with the sugar video view time.

Results

Overall, 66.43% (n=1047) of the 1576 participants in the 2 placebo arms voluntarily watched the sugar intervention video. The mean view time was 116.35 (52.4%) of 222 seconds. Results show that view times did not differ by narrator (child, mother, physician) and that older participants (aged 25-59 years, mean = 125.2 seconds) watched the sugar video longer than younger adults (aged 18-25 years, mean = 83.4 seconds). View time remained consistent across education levels. Participants with low trait reactance (mean = 119.3 seconds) watched the intervention video longer than high-trait-reactance participants (mean = 95.3 seconds), although this association did not differ by narrator type.

Conclusions

The majority of participants in our study voluntarily watched more than half of the sugar intervention video, which is a promising finding. Our results suggest that SAS videos may need to be shorter than 2 minutes to engage people who are young or have high trait proneness to reactance. We also found that the choice of narrator (child, mother, or physician) for our video did not significantly affect participant engagement. Future videos, aimed at reaching diverse audiences, could be customized for different age groups, where appropriate.

Trial Registration

German Clinical Trials Register DRKS00022340; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022340

International Registered Report Identifier (IRRID)

RR2-10.2196/25343

Long-Term Effects of a Video-Based Smartphone App ("VIDEA Bewegt") to Increase the Physical Activity of German Adults: A Single-Armed Observational Follow-Up Study

As physical inactivity is one of the four leading risk factors for mortality, it should be intensively treated. Therefore, this one-year follow-up study aimed to evaluate the long-term effects of a preventive app to increase physical activity in German adults under real-life circumstances. Data collection took place from July 2019 to July 2021 and included six online questionnaires. Physical activity was studied as the primary outcome based on MET-minutes per week (metabolic equivalent). Secondary outcomes included health-related quality of life based on a mental (MCS) and physical health component summary score (PCS). At the time of publication, 46/65 participants completed the study (median 52 years, 81.5% women). A significant increase of physical activity was observed in people with a low/moderate baseline activity during the first four months of follow-up (median increase by 490 MET-minutes per week, p < 0.001, r = 0.649). Both MCS (median increase by 2.8, p = 0.006, r = 0.344) and PCS (median increase by 2.6, p < 0.001, r = 0.521) significantly increased during the first two months and the BMI significantly decreased during the first six months after the intervention (median decrease by 0.96 kg/m2, p < 0.001, r = 0.465). Thus, this study provides evidence for the medium-term impact of the app, since the effects decreased over time. However, due to the chosen study design and a sizeable loss to follow-up, the validity of these findings is limited.

Reactance to Social Authority in a Sugar Reduction Informational Video: Web-Based Randomized Controlled Trial of 4013 Participants

Background

Short and animated story-based (SAS) videos can be an effective strategy for promoting health messages. However, health promotion strategies often motivate the rejection of health messages, a phenomenon known as reactance. In this study, we examine whether the child narrator of a SAS video (perceived as nonthreatening, with low social authority) minimizes reactance to a health message about the consumption of added sugars.

Objective

This study aims to determine whether our SAS intervention video attenuates reactance to the sugar message when compared with a content placebo video (a health message about sunscreen) and a placebo video (a nonhealth message about earthquakes) and determine if the child narrator is more effective at reducing reactance to the sugar message when compared with the mother narrator (equivalent social authority to target audience) or family physician narrator (high social authority) of the same SAS video.

Methods

This is a web-based randomized controlled trial comparing an intervention video about sugar reduction narrated by a child, the child’s mother, or the family physician with a content placebo video about sunscreen use and a placebo video about earthquakes. The primary end points are differences in the antecedents to reactance (proneness to reactance, threat level of the message), its components (anger and negative cognition), and outcomes (source appraisal and attitude). We performed analysis of variance on data collected (N=4013) from participants aged 18 to 59 years who speak English and reside in the United Kingdom.

Results

Between December 9 and December 11, 2020, we recruited 38.62% (1550/4013) men, 60.85% (2442/4013) women, and 0.52% (21/4013) others for our study. We found a strong causal relationship between the persuasiveness of the content promoted by the videos and the components of reactance. Compared with the placebo (mean 1.56, SD 0.63) and content placebo (mean 1.76, SD 0.69) videos, the intervention videos (mean 1.99, SD 0.83) aroused higher levels of reactance to the message content (P<.001). We found no evidence that the child narrator (mean 1.99, SD 0.87) attenuated reactance to the sugar reduction message when compared with the physician (mean 1.95, SD 0.79; P=.77) and mother (mean 2.03, SD 0.83; P=.93). In addition, the physician was perceived as more qualified, reliable, and having more expertise than the child (P<.001) and mother (P<.001) narrators.

Conclusions

Although children may be perceived as nonthreatening messengers, we found no evidence that a child narrator attenuated reactance to a SAS video about sugar consumption when compared with a physician. Furthermore, our intervention videos, with well-intended goals toward audience health awareness, aroused higher levels of reactance when compared with the placebo videos. Our results highlight the challenges in developing effective interventions to promote persuasive health messages.

Trial Registration

German Clinical Trials Registry DRKS00022340; https://tinyurl.com/mr8dfena

International Registered Report Identifier (IRRID)

RR2-10.2196/25343

Effect of a story-based, animated video to reduce added sugar consumption: A web-based randomized controlled trial

BACKGROUND

Short and animated story-based (SAS) videos, which can be rapidly distributed through social media channels, are a novel and promising strategy for promoting health behaviors. In this study, we evaluate the effectiveness of a SAS video intervention to reduce the consumption of added sugars.

METHODS

In December 2020, we randomized 4159 English-speaking participants from the United Kingdom (1:1:1) to a sugar intervention video, a content placebo video about sunscreen use (no sugar message), or a placebo video about earthquakes (no health or sugar message). We nested six list experiments in each arm and randomized participants (1:1) to a control list or a control list plus an item about consuming added sugars. The primary end-points were mean differences (on a scale of 0-100) in behavioral intent and direct restoration of freedom to consume added sugars.

RESULTS

Participants (N = 4013) who watched the sugar video had significantly higher behavioral intent to cut their daily intake of added sugar (mean difference (md) = 16.7, 95% confidence interval (CI) = 1.5-31.8, P = 0.031), eat fresh fruit daily (md = 16.7, 95% CI = 0.5-32.9, P = 0.043), and check food labels for sugar content (md = 20.5, 95% CI = 2.6-38.5, P = 0.025) when compared with the sunscreen (content placebo) video. The sugar video did not arouse intent to restore freedom and consume added sugars when compared with the two placebo videos.

CONCLUSIONS

Our SAS intervention video did not arouse reactance and increased short-term behavioral intent among participants to reduce their consumption of added sugars. SAS videos, which draw on best practices from the entertainment-education media, communication theory, and the animation industry, can be an effective strategy for delivering emotionally compelling narratives to promote health behavior change.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00022340.

COVID-19 vaccine hesitancy: The effects of combining direct and indirect online opinion cues on psychological reactance to health campaigns

This study aims to examine whether and how user-generated comments and reaction emojis on COVID-19 vaccine-promoting Facebook posts induce psychological reactance to posts and vaccine hesitancy in audiences of the posts. An online experiment including 465 American adults showed that, compared with COVID-19 vaccine promotion posts accompanied by pro-vaccine comments, those accompanied by anti-vaccine comments provoked greater reactance in audiences through the mediating effects of bandwagon perception and the presumed influence of the posts on others. Greater reactance, in turn, increased audiences' COVID-19 vaccine hesitancy. Additionally, reaction emojis altered the comments' effects such that pro-vaccine comments triggered less reactance than anti-vaccine comments when the pro-vaccine comments were accompanied by agreement emojis (i.e., "like" and "love"); whereas there was no significant difference between pro-vaccine comments and anti-vaccine comments in reactance when the pro-vaccine comments were accompanied by rejection emojis (i.e., "angry" and "sad"). Furthermore, audiences' pre-existing attitudes did not affect the effects of opinion cues on their' reactance and vaccine hesitancy.

Seeing is Believing: The Impacts of Visual Exemplars on American Young Adults' Reactions to Anti-Prescription Opioid Campaigns

Many public health campaigns are designed to combat the opioid crisis in America. However, these campaigns are often ineffective or even counterproductive. To explore what contributes to the (in)effectiveness of these campaigns, an online experiment was conducted among a convenience sample of college students to test American young adults' reactions to four anti-prescription opioid campaign messages from local and national health organizations that vary in the presence of visual exemplars and statistical information. The study found that including a visual exemplar showing the negative consequences of misusing prescription opioids increased perceived susceptibility, psychological reactance, and perceived campaign effectiveness. The impacts of visual exemplars on psychological reactance and perceived campaign effectiveness were moderated by statistical information and (partially) explained by the believability of the campaigns.

Effects of narratives, frames, and involvement on health message effectiveness

An online 2 (evidence type: narrative vs. informational) × 2 (message frame: gain vs. loss) × 2 (involvement: low vs. high) between-subjects factorial experiment was conducted to examine their effects in skin cancer awareness campaigns. Results showed that loss-framed narratives were convincing for high-involved individuals, whereas both gain-framed informational and loss-framed narratives evoked higher issue attitudes and behavioral intentions for low-involved ones. Mediation analyses showed that identification with the story protagonist mediated narrative effects on the outcome variables. Theoretical and practical implications for sun protection awareness campaigns are discussed.

Reactance to Social Authority in Entertainment-Education Media: Protocol for a Web-Based Randomized Controlled Trial

Background

Entertainment-education media can be an effective strategy for influencing health behaviors. To improve entertainment-education effectiveness, we seek to investigate whether the social authority of a person delivering a health message arouses the motivation to reject that message—a phenomenon known as reactance.

Objective

In this study, using a short animated video, we aim to measure reactance to a sugar reduction message narrated by a child (low social authority), the child’s mother (equivalent social authority to the target audience), and a family physician (high social authority). The aims of the study are to determine the effect of the narrator’s perceived social authority on reactance to the sugar reduction message, establish the effectiveness of the video in improving behavioral intent to reduce the intake of added sugars, and quantify participants’ interest in watching the entertainment-education intervention video.

Methods

This is a parallel group, randomized controlled trial comparing an intervention video narrated by a low, equivalent, or high social authority against a content placebo video and a placebo video. Using a web-based recruitment platform, we plan to enroll 4000 participants aged between 18 and 59 years who speak English and reside in the United Kingdom. The primary end points will include measures of the antecedents to reactance (proneness to reactance and threat level of the message), its components (anger and negative cognition), and attitudinal and behavioral intent toward sugar intake. We will measure behavioral intent using list experiments. Participants randomized to the placebo videos will be given a choice to watch one of the sugar-intervention videos at the end of the study to assess participant engagement with the entertainment-education video.

Results

The study was approved by the ethics committee of Heidelberg University on March 18, 2020 (S-088/2020). Participant recruitment and data collection were completed in December 2020. The data analysis was completed in April 2021, and the final results are planned to be published by August 2021.

Conclusions

In this trial, we will use several randomization procedures, list experimentation methods, and new web-based technologies to investigate the effect of perceived social authority on reactance to a message about reducing sugar intake. Our results will inform the design of future entertainment-education videos for public health promotion needs.

Trial Registration

German Clinical Trials Registry DRKS00022340: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022340.

International Registered Report Identifier (IRRID)

DERR1-10.2196/25343

The Effects of Agency Assignment and Reference Point on Responses to COVID-19 Messages

As the COVID-19 pandemic poses severe threats to human life around the globe, effective risk messages are needed to warn the public and encourage recommended actions for avoiding infection, especially as steps are taken to ease physical restrictions and restart economies. The present study examines the effects of agency assignment and reference point on perceptions of SARS-CoV-2 threat and assesses key message responses, including psychological reactance, source derogation, counterarguing, and behavioral intentions. Participants (N = 207) were randomly assigned to one of four conditions crossing agency assignment (SARS-CoV-2/human) and reference point (self/self-other). Results show, relative to human agency, SARS-CoV-2 agency assignment generated significantly more psychological reactance in the form of greater perceptions of freedom threat, anger, and negative cognitions, as well as more source derogation and counterarguing. No significant effects were found for reference point, and the interaction between agency assignment and reference point was not significant. The study findings, limitations, and implications are discussed.

Predictors of Staying at Home during the COVID-19 Pandemic and Social Lockdown based on Protection Motivation Theory: A Cross-Sectional Study in Japan

During the COVID-19 pandemic, a social lockdown should be put in place and individuals should stay at home. Behavioral change is the only way to prevent the pandemic and overwhelmed healthcare systems until vaccines are available. We aimed to examine the psychological factors that predict staying at home during the COVID-19 pandemic and social lockdown. A total of 1980 participants in Japan completed a survey for this study from 9 to 11 May 2020, when the state of emergency covered all prefectures in the country. Self-reported behavior in terms of staying at home, the perceived severity of the pandemic, vulnerability to the pandemic, response efficacy, and self-efficacy based on protection motivation theory were assessed. Multiple regression analysis showed that perceived severity (standardized β = 0.11, p < 0.001) and self-efficacy (standardized β = 0.32, p < 0.001) significantly predicted greater levels of staying at home, after controlling for socio-demographics. However, perceived vulnerability and response efficacy did not. To encourage people to stay at home during the pandemic and social lockdown, increasing the perceived severity of infection by COVID-19 and self-efficacy in terms of exercising restraint with respect to going out may consequently encourage people to stay at home.

Choosing not to follow rules that will reduce the spread of COVID-19

In response to the COVID-19 pandemic, many authorities have implemented public health measures that place restrictions on individuals. Understanding how individuals respond to these new rules, particularly whether they are likely to follow or break them, is extremely important. Relational frame theory offers unique insights into rule-governed behavior, allowing researchers to develop functional-analytic interpretations of why a listener may understand a rule, have the required response established in their behavioral repertoire, and still choose not to follow the rule. Drawing from research on rule-following in accordance with relational frame theory and cognitive neuroscience, social psychology, and health literature, this paper presents reasons why a rule may be understood but not followed, identifying important considerations for implementing public health measures to reduce the spread of COVID-19. Specifically, rule-givers should attend to their credibility, authority and ability to mediate consequences, rule plausibility, establishing adequate motivative augmental control, whether the behavior specified in the rule opposes habits, and whether the message incites counterpliance.

Smoking Status Matters: A Direct Comparison of Smokers' and Nonsmokers' Psychophysiological and Self-Report Responses to Secondhand Smoke Anti-Tobacco PSAs

Extensive research demonstrates that exposure to threatening anti-tobacco messages can lead to defensive message processing which reduces message effectiveness. However, research investigating whether this effect is moderated by the smoking status of the message viewer is lacking. In this study, participants (N = 48 smokers and N = 51 non-smokers) viewed and rated secondhand smoke anti-tobacco messages depicting both smoking cues and threat content, or messages depicting neither while heart rate, skin conductance, and facial EMG were recorded. Post viewing, self-reported emotional experience, level of counterarguing, and recognition memory were measured. In support of the LC4MP, there were no differences between smokers and non-smokers' responses for non-threatening messages absent in smoking cues. However, messages that contained both smoking cues and threat content were defensively processed by smokers - but not non-smokers - as indicated by significantly faster heart rate, lower recognition memory and higher self-reported negativity, arousal, and counterarguments. The theoretical and practical implications are discussed.

Increasing Chance-Based Uncertainty Reduces Heavy Drinkers' Cognitive Reactance to Web-Based Personalized Normative Feedback

OBJECTIVE

Despite its prominence in the health communication literature, psychological reactance has rarely been considered as a factor that may undermine web-based Personalized Normative Feedback (PNF) alcohol interventions for college students. This study built on recent gamification work to examine how chance-based uncertainty, a popular game mechanic associated with motivation and attention in digital games for learning, might be leveraged to reduce the psychological reactance experienced by heavy drinking students receiving alcohol PNF, thereby leading to larger reductions in their alcohol consumption.

METHOD

Psychological reactance, perceptions of norms, and drinking behaviors were assessed during a 3-week period following random assignment of binge drinking students (N = 141, 51% female) into one of four web-based PNF conditions. These conditions asked the same questions about drinking and delivered identical PNF on alcohol use but differed in whether animated slot-machine spinners appeared to select participants' question and feedback topics as well as the number of additional topics (beyond alcohol) on which questions were asked and PNF was delivered.

RESULTS

All conditions similarly reduced drinking norms but differed in the degree to which they aroused cognitive reactance and reduced drinking. Relative to a no-spinner alcohol-only condition, increasing chance-based uncertainty by giving question and feedback topics the appearance of being selected by gamelike spinners substantially reduced cognitive reactance, which, in turn, reduced drinking 20 days later. Overall, participants experienced the least cognitive reactance when spinners first selected three question topics and later selected two of these topics to deliver feedback on.

CONCLUSIONS

Findings suggest that introducing chance-based uncertainty through gamelike spinners, asking questions about multiple topics, and delivering feedback on additional topics unrelated to alcohol together work to reduce the degree to which the task feels like an alcohol intervention overtly aimed at reducing consumption, thereby making the alcohol PNF more effective among heavy drinking students.

Effects of Messaging and Psychological Reactance on Marijuana Craving

Background: Psychological Reactance Theory asserts that people experience reactance (a motivational state characterized by negative affect and cognition) when they perceive threats to their autonomy. Reactance may lead to "boomerang effects" by which individuals engage in the opposed behavior. Objectives: This experiment sought to determine whether a message encouraging marijuana (MJ) abstinence evoked greater reactance than a harm-reduction message and whether the message and reactance influenced individuals' attitudes, MJ craving, and intent to comply with the message request. Methods: College students and community members (n = 388) participated in an online study where they were randomly assigned to receive a message promoting MJ abstinence or harm reduction. Regression analyses adjusting for MJ use, alcohol use, and age determined the effects of the message and reactance on individuals' attitudes, MJ craving, and intent to comply. Follow-up analyses determined the significant reactance subscales. Results: The abstinence message evoked greater reactance than the harm reduction message and led to less favorable attitudes toward the advocated behavior. Across messages, reactance (specifically negative cognitive appraisal) was related to less favorable attitudes toward the advocated behavior and the study, as well as lower intent to comply. Additionally, reactance (specifically anger) was associated with greater self-reported craving. Conclusions/Importance: Anti-MJ messages designed to discourage use might heighten reactance and inadvertently lead to greater craving and intent to use. The link between reactance and craving may be more affectively mediated than the link between reactance and message rejection.

Functionalized chitosan-modified defect-related luminescent mesoporous silica nanoparticles as new inhibitors for hIAPP aggregation

Human islet amyloid polypeptide (hIAPP or amylin) forms the amyloid deposits that is an important factor in the induction of type II diabetes. Accordingly, it is essential to efficiently and accurately inhibit the aggregation of hIAPP for the treatment and prevention of the disease. Here, defect mesoporous silica (DLMSN), with blue fluorescence, can perfectly achieve the accurate positioning in cells or organisms. DL@CS@NF cannot only specifically bind to a hIAPP monomer, but also effectively inhibit hIAPP aggregation, reduce cytotoxicity and overcome the instability and inefficiency of NF(N-Me)GA(N-Me)IL (NF). Furthermore, DL@CS@NF nanoparticles can significantly improve the survival rate of islet cells, stabilize the mitochondrial membrane potential, reduce the content of intracellular reactive oxygen species. In summary, DL@CS@NF nanoparticles may have broader implications in inhibiting the aggregation of hIAPP and reducing cytotoxicity.

The Attitudinal and Motivational Effects of Anti-waterpipe Messages

Objectives: Waterpipe smoking can lead to negative health outcomes. In this study, we examined responses to anti-waterpipe smoking public service announcements (PSAs). Methods: In a pilot study, current waterpipe smokers (N = 20) and susceptible waterpipe never smokers (N = 25) were randomized to view either 3 anti-waterpipe PSAs, created by the Truth campaign, or 3 control videos. Participants answered questions pertaining to message acceptance at 3 time-points and perceived risk and motivation to quit or avoid waterpipe at 4 time-points. Results: Participants were recruited from the community (N = 45; Mage = 22.4 years). Whereas waterpipe smokers and never smokers who viewed the PSAs significantly increased in acceptance of (p < .05) and positive attitudes towards (p < .05) the messages with increased viewing of the mes- sages, waterpipe never smokers did so at a significantly higher rate (p < .05). Waterpipe never smokers who viewed the PSAs had increased perceived severity and susceptibility of health harms of waterpipe compared to the control (ps < .05). We also found gender differences. Conclusions: The 3 tested PSAs from the Truth campaign show evidence of effectiveness against waterpipe use.

Vape Shop Employees: Public Health Advocates?

INTRODUCTION

E-cigarettes have increased in popularity and given rise to a new type of sales outlet—the vape shop. Expanding on work examining vape shop employee e-cigarette and tobacco attitudes and behaviors¹, this study examined key messages that vape shop employees communicate to customers.

METHODS

Using informal interviews, observations, and a cross-sectional survey, we examined vape shop employees’ (n=16) perceptions and e-cigarette use. Data were collected in nine vape shops in Louisville, Kentucky. We used open coding to analyze the qualitative interviews, observation notes, and open-ended survey responses. Descriptive statistics were used to analyze survey data.

RESULTS

The findings revealed that nearly all employees were former smokers (93.8%), who now only use e-cigarettes. Over one-third of the employees (37.5%) began using e-cigarettes as a replacement for traditional cigarettes, and 93.8% reported better health (e.g., easier breathing, less coughing) since starting to use e-cigarettes. Although most employees believed e-cigarettes should be regulated, 56.3% thought regulations should be different from those governing traditional cigarettes. Analysis of qualitative data revealed that employees see themselves as health advocates who: 1) provide instructions on vaping and promote a vape community, 2) encourage cessation of traditional cigarettes, and 3) support some regulations.

CONCLUSIONS

The findings reveal that vape shop employees regard e-cigarettes as viable smoking cessation tools and relish their role in assisting others in taking what employees view as positive health actions. Future research addressing communication between vape shop employees and customers, especially related to smoking cessation and health, is needed.