A Reasoned Action Approach to Depression Help-Seeking Messaging for College Students: Implications of Cognitive Biases in Depression

In this study we integrated insights from research on cognitive biases in depression with the reasoned action approach to predicting and changing behavior (RAA) with the goal of identifying implications for help-seeking messaging for college students with varying levels of depression. Findings from a sample of 374 U.S. college students support the ability of RAA to explain help-seeking intentions for non-depressed, mildly depressed students, and moderate to severely depressed students. More severe depression was associated with less favorable attitudes, perceived norms, perceived capacity, and intention; changes in the relative strength of attitudes, perceived norms, and perceived capacity in explaining help-seeking intentions; stronger expectations of negative outcomes of help-seeking and weaker expectations of positive outcomes; and to some extent, stronger expectations of negative outcomes for oneself than for others. These findings underscore that depressed students construe help-seeking differently than non-depressed students, and that depressed and non-depressed students need different help-seeking messages.

Americans' perceptions of health disparities over the first year of the COVID-19 pandemic: Results from three nationally-representative surveys

COVID-19 has illuminated health inequity in the United States. The burdens of disease are much higher among Black and Indigenous people and other people of color. Disparities by income are also profound, as lower-wage workers were less able to adopt mitigating behaviors compared to higher-income counterparts. These disparities became part of public health discourse in 2020, with commentators frequently highlighting the connection between racism, socioeconomic position, and COVID-19. But what proportion of the public-and among key subgroups-recognized these social group disparities, relative to disparities associated with age and chronic illness, and did public recognition change over the first year of the pandemic? To address these questions, we analyzed data from three nationally-representative cross-sectional public opinion surveys, collected using the NORC AmeriSpeak panel in April 2020 (N = 1007), August 2020 (N = 2716), and April 2021 (N = 1020). The key outcomes were respondents' agreement with statements about disparities in COVID-19 mortality by age, chronic illness, income, and race. We found little change from 2020 to 2021 in Americans' recognition of disparities. At all three time points, most respondents acknowledged age and chronic illness disparities, while no more than half at any time point recognized income- and race-based disparities. Political party affiliation was not statistically associated with agreement with age or illness-related disparities, but was strongly associated with views about income- and race-based disparities. Efforts to promote recognition of racial and socioeconomic health disparities in the United States need to be mindful of the ways in which public understanding of health inequities is linked to partisanship.

Effects of culturally tailored smoking prevention and cessation messages on urban American Indian youth

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American Indian youth participated in a community-engaged experiment.

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Participants viewed a comparison message or one of two antismoking messages.

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Antismoking messages either used a culturally relevant argument or a health outcomes argument.

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The message with a cultural argument moved AI youth who had ever smoked to a more negative stance towards smoking.

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Cultural arguments are useful for encouraging American Indian youth not to smoke.

American Indians (AI) face significant disparities in smoking-related diseases. In addition, smoking prevalence increases exponentially between ages 11 and 18. Smoking prevention and cessation efforts aimed at AI youth therefore are important. In order to strengthen understanding of evidence-based message strategies for smoking prevention and cessation among AI youth. The objective of this study was to test whether a message that was tailored to AI cultural values associated with the sacredness of traditional tobacco can change variables that behavioral theories have identified as predictors of smoking (i.e., instrumental and experiential attitudes, injunctive and descriptive norms, perceived capacity and autonomy, and intention with respect to smoking). We conducted a randomized field experiment among 300 never-smoking and ever-smoking urban AI youth in Minneapolis-Saint Paul between May 18 and July 27, 2019. We used a 3 (message condition: cultural benefits of not smoking cigarettes, health benefits of not smoking cigarettes, comparison message about benefits of healthy eating) × 2 (smoking status: ever-smoked, never-smoked) between-subjects design. Multivariate analysis of variance showed that for ever-smokers, the cultural consequences of smoking message significantly lowered instrumental attitude (partial eta² = 0.029), experiential attitude (partial eta² = 0.041), perceived capacity (partial eta² = 0.051), and smoking intention (partial eta² = 0.035) compared to the healthy eating comparison message and the health consequences of smoking message. This was not observed among never-smokers, who already had very negative smoking perceptions. We conclude that messages that tailor to AI culture may be effective tools for discouraging smoking among AI youth.

Understanding self-affirmation effects: The moderating role of self-esteem

OBJECTIVES

Whether people benefit from self-affirmation in overcoming resistance to health messages may depend on their level of self-esteem. However, extant theories offer rival hypotheses about the role of self-esteem. We pitted these hypotheses against each other, building on the argument that how self-esteem shapes self-affirmation effects may depend on how and when people self-affirm.

DESIGN

A 3 (Self-affirmation type: value essay, attribute scale, control task) by 2 (Timing: pre-message, post-message) plus 1 (message-only) experimental, between-subjects design.

METHODS

Participants (N = 422) completed a value essay, an attribute scale, a control task, or no task, either before or after reading a message about health risks of excessive drinking. Participants then completed defensiveness and message acceptance measures.

RESULTS

Self-esteem moderated self-affirmation effects across different types and timing of self-affirmation. While participants with relatively high self-esteem consistently benefited from self-affirmation, participants with relatively low self-esteem experienced adverse effects from self-affirmation. Self-affirmed participants with high self-esteem showed lower psychological discomfort, lower personal risk discounting, and higher message acceptance than unaffirmed participants, while self-affirmed participants with low self-esteem showed higher psychological discomfort, higher personal risk discounting, and lower message acceptance than unaffirmed participants.

CONCLUSIONS

These findings support the proposition that self-esteem serves as affirmational resources, which implies that self-affirmation interventions to reduce defensiveness to health messages may be beneficial for people with high self-esteem but less so for people with lower self-esteem. Similar to much other self-esteem research, self-esteem was negatively skewed, which warrants caution in generalization of the findings across all levels of self-esteem.

Americans' perceptions of disparities in COVID-19 mortality: Results from a nationally-representative survey

As with many other infectious and chronic conditions, the COVID-19 crisis in the United States (U.S.) reveals severe inequities in health. The objective of this study was to describe public perceptions of disparities in mortality from COVID-19 and examine correlates of those perceptions. We fielded a nationally-representative survey in late April 2020, asking participants how much they agreed with four statements describing group-level COVID-19 disparities: older people compared to younger, people with chronic health conditions compared to those without, poorer people compared to wealthier, and Black people compared to white people. We also measured personal characteristics, experience with COVID-19, and information sources. Overall agreement with age- and health condition-related disparities was high (>80%) while agreement with socioeconomic (SES) and racial disparities was lower (52%). Higher education and income were generally associated with greater agreement with disparities. Partisanship and information sources used were associated with perceptions of SES- and racial-disparities, with Democrats and those attune to national news-but not Fox cable news-more likely to perceive these disparities. As of April 2020, information about age- and health condition-related disparities in COVID-19 was well known by the U.S. public, while information about social disparities was less recognized and varied along socioeconomic and partisan lines.

Does Perceived Message Effectiveness Predict the Actual Effectiveness of Tobacco Education Messages? A Systematic Review and Meta-Analysis

Target audience ratings of the likely impact of persuasive messages, known as perceived message effectiveness (PME), are commonly used in health communication campaigns. However, applications of PME rely on a critical assumption-that is, that PME is a valid indicator of the likely effectiveness of messages. To examine the evidence supporting this assumption, we conducted a systematic review and meta-analysis of longitudinal studies in the tobacco education campaigns literature. Six longitudinal studies examining the predictive validity of PME met inclusion criteria. Results indicated that PME ratings were significantly associated with the majority of outcomes studied. In fact, each of the six studies found PME to be associated with at least one outcome, and across the six studies, PME was associated with message recall, conversations about ads, beliefs about smoking and quitting smoking, quit intentions, and cessation behavior. Meta-analyses demonstrated that PME predicted quit intentions (r = .256, p < .001) and cessation behavior (r = .201, p < .001), revealing effects that were small to medium in magnitude. Our results suggest that PME provides some predictive value as to the likely effectiveness of messages, although additional work using different validation designs, with other health behaviors, and among other populations is needed.

Is Involvement a Good Thing? The Undesirable Consequences of Topical and Conversational Involvement in the Context of Alcohol Consumption

Whereas there is evidence that interpersonal communication, or conversation, influences predictors of alcohol consumption, the role of involvement in conversation effects remains unclear. This study explored how three aspects of involvement (topical relevance, or how relevant the topic of alcohol is; conversational relevance, or how relevant a conversation about alcohol is; and conversational effort, or how much effort people put into such a conversation), influence conversation effects. After assessing topical relevance, 46 same-sex dyads were requested to talk about the negative consequences of heavy drinking. Within each dyad, one participant was asked to take on an active talking role and the other participant a passive listening role. Next, conversational relevance, effort, and predictors of heavy drinking were measured. Results showed that participants who drank more alcohol found the topic of heavy drinking more relevant. This topical relevance increased conversational relevance and conversational effort. Conversational effort further increased when a talking role was assigned. Furthermore, participants who put more effort in the conversation and found it more relevant had more positive norms, identified more strongly with alcohol, and had higher intentions to drink. These findings suggest that more involvement in an alcohol-related conversation does not always lead to desirable outcomes.

Beliefs underlying stress reduction and depression help-seeking among college students: An elicitation study

OBJECTIVE

This study illustrates how a theory-based approach can identify college students' beliefs about stress reduction activities and help-seeking for depression. These beliefs are the basis for intervention design.

PARTICIPANTS

A sample of 53 undergraduate students at a public university in the Midwest participated in this research during March 2016.

METHODS

An open-ended belief elicitation survey was administered online. Beliefs were identified through qualitative thematic analyses.

RESULTS

Exercise was students' most preferred stress reduction activity. Beliefs about exercise emphasized physical benefits yet also not having time for exercise. Beliefs about help-seeking for depression emphasized treatment efficacy, support from others, stigma, and time constraints.

CONCLUSIONS

Whereas beliefs about positive outcomes inform educational and motivational messages, beliefs about time constraints underscore the need to also consider structural factors that can help students find time to attend to their well-being.

Eye Movement Patterns in Response to Anti-Binge Drinking Messages

Health message design combines selected visual and textual components that are thought to work in concert to produce a particular intended message effect. Most health message effects research assumes rather than determines that message recipients attend to those visual and textual components. In contrast, the present research mapped viewing patterns of 50 participants in response to a set of anti-binge drinking print messages using eye-tracking methodology. Results showed that participants primarily viewed faces of persons portrayed in the messages, as well as alcohol use cues and cryptic one-liners. Textual components (e.g., information about consequences of heavy drinking) were viewed infrequently and briefly. Viewing patterns were associated with perceptions of message effectiveness, but more so for women than for men. Additionally, men, for whom anti-binge drinking messages were more self-relevant than for women, viewed message components more often and longer than women. These findings suggest that when message recipients view a self-relevant health message, they may attend primarily to a subset of components that do not necessarily convey the full message.

Explaining Intentions to Seek Help for Depressive Symptoms in the Context of Responsibility Message Framing

U.S. college students are disproportionally affected by depression but typically do not seek help. To advance understanding of the role of health messages in shaping college students' help-seeking intentions, we used a reasoned action approach to experimentally investigate help-seeking intentions for depressive symptoms. Due to negative interpretation biases among those who suffer from depression, scholars have previously warned against attempts to decrease feelings of responsibility for one's depression in health messages. We tested the determinants of help-seeking intentions as a function of exposure to depression help-seeking messages that differed in responsibility cues. Findings revealed that in our sample low responsibility health message framing did not affect determinants of help-seeking intentions. We identified instrumental attitude (β = .53) and descriptive norms (β = .24) as determinants of intentions to seek help (R² = .42) across message conditions and across levels of depression. These findings indicate potentially important targets for messages that seek to increase help-seeking among depressed college students.

Perceived Message Effectiveness Measures in Tobacco Education Campaigns: A Systematic Review

Target audience ratings of the likely impact of persuasive messages, known as perceived message effectiveness (PME), are commonly used during message development and selection. PME is also used to examine receptivity of messages after they are fully developed or deployed. Despite this, we know little about the conceptual and methodological characteristics of extant PME measures used in the literature. We conducted a systematic review of tobacco education video, print, and audio campaign studies to examine conceptual and methodological characteristics of PME measures. One hundred twenty-six PME measures from 75 studies conducted in 21 countries with more than 61,000 participants were reviewed. Results indicated considerable variability in measures' focus on general perceptions of a message (i.e., message perceptions) versus perceptions of expected message effects (i.e., effects perceptions). Considerable variability was also found on underlying persuasive constructs, use of referents, and referencing of behavior in PME items and measures. We conclude with several recommendations for future research on PME measurement and validation.

Informing Tobacco Cessation Benefit Use Interventions for Unionized Blue-Collar Workers: A Mixed-Methods Reasoned Action Approach

Blue-collar workers typically have high rates of tobacco use but low rates of using tobacco cessation resources available through their health benefits. Interventions to motivate blue-collar tobacco users to use effective cessation support are needed. Reasoned action theory is useful in this regard as it can identify the beliefs that shape tobacco cessation benefit use intentions. However, conventional reasoned action research cannot speak to how those beliefs can best be translated into intervention messages. In the present work, we expand the reasoned action approach by adding additional qualitative inquiry to better understand blue-collar smokers' beliefs about cessation benefit use. Across three samples of unionized blue-collar tobacco users, we identified (1) the 35 attitudinal, normative, and control beliefs that represented tobacco users' belief structure about cessation benefit use; (2) instrumental attitude as most important in explaining cessation intention; (3) attitudinal beliefs about treatment options' efficacy, health effects, and monetary implications of using benefits as candidates for message design; (4) multiple interpretations of cessation beliefs (e.g., short and long-term health effects); and (5) clear implications of these interpretations for creative message design. Taken together, the findings demonstrate how a mixed-method reasoned action approach can inform interventions that promote the use of tobacco cessation health benefits.

On the conceptual ambiguity surrounding perceived message effectiveness

Health message quality is best understood in terms of a message's ability to effectively produce change in the variables that it was designed to change. The importance of determining a message's effectiveness in producing change prior to implementation is clear: The better a message's potential effectiveness is understood, the better able interventionists are to distinguish effective from ineffective messages before allocating scarce resources to message implementation. For this purpose, research has relied on perceived message effectiveness measures as a proxy of a message's potential effectiveness. Remarkably, however, very little conceptual work has been done on perceived message effectiveness, which renders its measures underinformed and inconsistent across studies. To encourage greater conceptual work on this important construct, we review several threats to the validity of existing measures and consider strategies for improving our understanding of perceived message effectiveness.

Construal level theory and theory of planned behavior: time frame effects on salient belief generation

This study tests implications of different time specifications in behavioral definitions as used in belief-elicitation research. Using construal level theory and the theory of planned behavior as complementary frameworks, the authors examined temporal frame effects on beliefs about eating fruits and vegetables and beliefs about condom use generated in a belief-elicitation study. Consistent with propositions from construal level theory, the authors found that temporal perspective (performing the behavior tomorrow, in 3 months, in 6 months, or in 5 years) affects the type of salient behavioral beliefs, such that individuals generate more feasibility (efficacy) beliefs when thinking about proximal behaviors, but more desirability (attitudinal and normative) beliefs when the behavior in question is distal. The authors' results indicate the importance of time frame in behavioral definitions in belief-elicitation research.

Interpersonal communication as an indirect pathway for the effect of antismoking media content on smoking cessation

In the context of health campaigns, interpersonal communication can serve at least 2 functions: (a) to stimulate change through social interaction and (b) in a secondary diffusion process, to further disseminate message content. In a 3-wave prospective study of 1,079 smokers, the authors demonstrate that mass media messages (antismoking campaigns and news coverage relevant to smoking cessation) have an indirect effect on smoking cessation intention and behavior via interpersonal communication. Exposure to campaigns and news coverage prompts discussion about the campaigns, and, in turn, about smoking cessation. Interpersonal communication regarding smoking cessation then influences intention to quit smoking and attempts to quit smoking. The study finds evidence not only for the social interaction function of interpersonal communication, but also for the secondary diffusion function. A substantial number of smokers who are not directly exposed to the antismoking campaigns are nevertheless indirectly exposed via communication with people who have seen these campaigns. These results imply that encouragement of interpersonal communication can be an important campaign objective.

HIV interventions affect behavior indirectly: results from the AIDS Community Demonstration Projects

Behavioral theory informs HIV prevention programs by identifying important predictors of the relevant behavior. Changes in those predictors brought about by program messages should theoretically translate into behavior change. Program evaluation, however, may examine only whether message exposure is associated with behavior change, assuming that if people changed their behavior, the intervention must have effectively changed the determinants. This practice obscures how intervention programs work in the field. We use data from the AIDS Community Demonstration Projects (ACDP) to illustrate this important idea. Earlier research found that the ACDP moved at-risk communities to more consistent condom use with both main and non-main partners. This study demonstrates that these behavioral effects are explained by the ACDP's ability to improve intention and self-efficacy for condom use with both main and non-main partners. We conclude that to understand how HIV prevention programs work, program evaluations need to assess how the intervention affected what it was designed to change: one or more critical behavioral determinants.