The potency of health promotion versus disease prevention messages in a college population.

Abstract: The objective of this study was to determine the effects of health promotion and disease prevention messages on college students' cognition and behavior. One hundred-sixty undergraduates read different health messages and answered questions to assess their intentions and reasons for engaging in health behaviors. Results indicated that there was a preference for cognition and behaviors that promote health rather than those designed to prevent disease. Positive reinforcement was also a significant factor related to behavioral intentions. This has important implications for health educators who develop health programs designed to affect the cognition and behaviors of college populations.

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Recent research in health education has suggested that traditional approaches to health education, including fear approaches, are not successful at promoting behavior change. One possible explanation is that people are not only searching for how to relieve their fear but also how to develop behavior that enhances feelings of health and well being (Monahan, 1995). Current efforts by health professionals to help people reach these desired outcomes have begun to move toward efforts that emphasize desirable consequences. New approaches have evolved because findings regarding the effectiveness of fear- or vulnerability-programs designed to change cognition and behaviors have been inconsistent (Rothman and Salovey; 1997). New approaches use reinforcement, specifically, positive reinforcement and positive affect messages because they may have a persuasive influence on health behavior changes (Monahan, 1995).

Reinforcement plays an important role in both health promotion and disease prevention behavior change efforts. Sidman (1989, 1993) suggests that all cognition and behaviors are developed as a result of reinforcement. Reinforcement, either positive or negative, is any consequence that tends to increase the probability of the behavior that preceded it. Positive reinforcement is defined as the process of adding or applying something to increase the probability of the behavior that preceded it. An example of positive reinforcement could be the feeling of competence, self-efficacy, or an award earned after completing a difficult task. Negative reinforcement is a process that involves the removal of something aversive to increase the probability of the behavior that preceded it. An example of negative reinforcement would be taking an aspirin to relieve a headache. If the aspirin eliminates the headache, the removal of the aversive headache would reinforce the behavior of taking the aspirin (Nemeroff and Karoly, 1997; Sarafino, 2002). Although reinforcement works, a difficulty associated with this process is that stimuli or cues that are specifically reinforcing or aversive for one person may not be for another. Sidman has demonstrated in the patients he works with that they will not repeatedly engage in a desired behavior unless they receive an immediate benefit (Sidman, 1989).

In studies regarding reinforcement, researchers have manipulated participants to have either a promotion or prevention focus. A participant with a promotion focus is one that aspires to create a sense of accomplishment or achievement and has therefore been associated with positive reinforcement. The strategic inclination with promotion is to make progress by approaching gains and advancement toward what they believe will ultimately help them attain a desired end state. On the other hand, a prevention focus is one that creates a responsibility to maintain security. The prevention focus has been associated with negative reinforcement because these individuals are in a state of vigilance to assure safety from aversive stimuli in attempts to reach their desired end state. Either positive or negative reinforcement results in a desirable state of affairs from the person's point of view (Higgins, 1998; Roney and Sorrentino, 1995; Shah and Higgins, 1997).

Other efforts by health professionals to affect cognition and behaviors have focused on health message design. Many difficulties are associated with health messages including problems associated with the technical and complex nature of health and disease. Other times, health messages are confusing because they may be based upon and reflect inconclusive findings. Other problems surface with health messages because often these health messages ask people to give things up, to change comfortable habits, or to refrain from pleasurable experiences (Levanthal, Safer, and Panagis, 1983).

Recently an effort is being made to change health messages from traditional fear- or vulnerability based messages designed to evoke behavior changes toward persuasive positive affect messages (Rothman and Salovey, 1997; Monahan, 1995). Affect refers to the whole range of feelings and emotions. Positive affect messages are designed to evoke a positive, personal emotional appeal. These messages usually have the benefit of overcoming any personal filtering devices that may cloud or block out a message because they can support and justify positive feelings and generate personal interest (Monahan).

Message designers strive to cause participants to actively process messages because research indicates that participants who actively process information diligently consider what is presented. Findings also suggest that audience members are more likely to use active processing of a message when they become personally involved in circumstances relative to the message (Rothman and Salovey, 1997; Parrot, 1995). For instance, if they or one of their family members has contracted cancer, he or she is more likely to listen and become actively involved with a cancer presentation because of its relevance to their life. Message designers strive for their information to be actively processed because information actively processed has a greater chance of being translated into enduring, predictable behavior patterns (Petty, Cacioppo, and Schman, 1983; Rothman and Salovey, 1997). Suggestions to facilitate active listening include researching the intended audience to discover their perspectives, needs, and concerns. Direct contact, focus groups, or other communications channels are recommended to help health professionals gather information that can facilitate effective health message design (Slater, 1995).

For many reasons, health messages have been designed to promote active processing in low-involvement audiences. Active processing helps participants become more cognitively engaged and engender greater understanding and memory of the message. Positive affect messages have been recommended for young people, such as college students, because they are a typical example of a low-involvement audience that does not seek prevention information believing health concerns are for older people (Monahan, 1995). In situations associated with low involvement audiences, positive messages have been shown to be a useful tool to gain the attention of low involvement people (Rothman and Salovey, 1997). Positive affect messages may be effective because they will typically delineate immediate benefits, positive reinforcement, attainable from behavior change. Immediate results are a type of reinforcement that supports cognitive processing, interest, and involvement in a message (Witte, 1997).

Although helping people develop health promoting cognition and behaviors is an important function for health professionals, existing research leaves many questions unanswered regarding the appropriate design of messages to maximize their effectiveness in helping people develop desired cognition and behaviors. The current study provides an important first step for determining effective approaches that may have an impact on intentions to behave in a healthful fashion. A secondary purpose of this study was to identify self-reported reasons for particular behavior preferences.

METHODS

Three types of health messages were designed and were alternately distributed to participants in separate questionnaire packets. All three health messages were 150 words in length and were designed to encourage the intention of engaging in health promoting or disease preventing cognition and behaviors. The messages, however, differed in the consequences of the behavior or of the failure to perform the behavior. The first message was a health promotion message that focused on positive affect. This type of message identified a positive reinforcement, such as increased energy or feelings of well being for the cognition or behavior. The second type of message was a disease prevention message that identified a negative reinforcement, such as the removal of a threat of disease, for engaging in the specific preventive cognition or behaviors. The third message was a mixed message that suggested the possibility of both positive and negative reinforcement consequences for engaging in specific health cognitions and behaviors. Messages were alternately distributed to a sample of undergraduate students at a large Southwestern University. After participants read their health message, each answered the same set of 21 questions about their intention to engage in health cognition and/or behaviors. It was hypothesized that those participants that read the health promotion message and identified positive reinforcement would be more likely to intend to engage in health cognition and behaviors.

PARTICIPANTS

One hundred-sixty undergraduate volunteers from a variety of Exercise Science courses were given questionnaire packets for this study. The institutional review board for human subjects approved the study and each participant read an informed approved consent form before reading the health message and answering the questions contained in their questionnaire packet. Participants included ninety-two females and sixty-eight males between the ages of 18 and 31 years (M=23.98 years). Fifty-three students received the health promotion message, fifty-three students received the disease prevention message, and fifty-four students received the mixed message.

DATA COLLECTION

Following the reading of each message, participants were given a twenty-one-item questionnaire. The questionnaire assessed whether participants would be willing to engage in a particular health behavior for either health promotion or disease prevention reasons. Questions inquired about engaging in specific cognition's and/or behaviors to receive either positive or negative reinforcement consequences. For example, a positively reinforced statement was, "I participate in a sport to add enjoyment, activity and fun to my life." A negatively reinforced statement was, "I avoid unhealthy food choices so I won't have undesirable consequences." Eleven questions identified health promotion behaviors and were paired with positive reinforcement consequences--presence of benefit. The remaining ten questions identified disease prevention behaviors and were paired with negative reinforcement consequences--removal of fear or absence of illness. The order of the questions was randomized but was the same for all participants. Participants responded to each item by indicating how much they agreed with the item on a 5-point Likert scale, from strongly agree (1) to strongly disagree (5). A score of three (3) indicated neutrality.

Eight days after completing the questionnaire, follow-up questionnaires were distributed to all subjects. The researchers used eight days so the same set of participants could be accessed, yet they let enough time pass so participants would not accurately recall the content of the health messages read at time 1. At time 2, participants responded to the follow-up questionnaire without reading a health message. The follow-up questionnaire contained thirty-one items. The questionnaire at time 2 contained ten additional questions beyond the repeated original 21 questions. The additional questions asked participant's to indicate their dominant reason for engaging in specific health cognition's and behaviors, and in their response to these questions, participants had to choose either to promote health or to prevent disease as their reason. They could choose only one response. Specifically, the additional ten items at time 2 asked about a variety of wellness activities: religious activities, sport/exercise, food choices, reading, learning new things, working, learning about healthy behavior, maintaining contact with friends, environmental responsibility, and searching for a deeper meaning. If the behavior identified was not a behavior the individual engaged in, he or she was asked to leave that question blank.

DATA ANALYSIS

The 21 questions were designed to inquire about all types of health behaviors. Health has been described as having seven dimensions of behavior: social, emotional, physical, vocational, intellectual, spiritual, and environmental (Payne and Hahn, 2000). A Principle Components analysis with a varimax rotation was conducted to identify the dimensions of health behavior covered with the questions administered. A Kaiser criterion was used, in that those dimensions with eigenvalues greater than one were identified as a unique dimension (Tabachnick B.G. and Fidell, 1996).

At time 1, a 2x3 ANOVA was conducted to test for differences in responses for each type of behavior (health promotion, disease prevention) relative to the type of message received (health promotion, disease prevention, mixed). These tests were run to determine if the type of message had an impact on intended cognition and behaviors relative to the type of behavior. At time 2, no groups existed because no message preceded the answering of the questions assessing health promotion and disease prevention behaviors. A one-way ANOVA was run for the ten additional questions administered at time 2 to determine response differences relative to the type of behavior (health promotion, disease prevention). Chi-square tests were calculated for the additional 10 items given at time 2.

RESULTS

Factor analysis confirmed that all seven theoretical dimensions of wellness--physical, social, emotional, spiritual, intellectual, vocational, and environmental were represented by the administered questions. The eigenvalue of the eighth dimension did not meet the Kaiser criteria, as the eigenvalue was 0.973

Question score averages were calculated for each group by dividing the number of questions (10 prevention, 11 promotion) by the sum for each group of questions. At time 1, the main effect for the type of message received by each group, F (2, 122) = 0.229, p> .05 was not significant. Significant differences were discovered between items that identified health promoting cognition and behaviors and those that identified disease prevention cognition and behaviors, F (1,122) = 380.964, p<.001. Mean scores indicated that participants were closer to neutral about the disease prevention cognition and behaviors than they were about health promoting cognition and behaviors. A score of 3 indicated a neutral response while a score of 2 indicated agreement, and 1 indicated strong agreement (Disease Prevention, M = 2.75, Health Promotion, M = 1.88).

At time 2 significant differences again existed between health promotion cognition and behaviors and disease prevention cognition and behaviors, F (1,119) = 255.416, p<.001. Again participants were more neutral regarding disease prevention behaviors than they were about health promoting behaviors (Disease Prevention M=2.63, Health Promotion M =1.85).

Chi-square tests yielded significant differences for all ten behaviors inquired about at time 2. Participants indicated that they had a significant preference to engage in each of the ten behaviors for health promotion reasons rather than for disease prevention reasons (see Table 1).

DISCUSSION

The results of the study indicate that this college student population

had a preference for cognition and behaviors that promote health rather than cognition and behaviors that prevent disease. Evidence from this study indicates that the dominant reason college students choose to engage in behavior is to promote health and not necessarily to prevent disease. The findings from this study may help both justify and clarify the aims of health professionals on college campuses that conduct health programs for college students. Our results suggest that health promotion not disease prevention is the driving force behind the intent for future behavior change. This is an especially important finding in light of the current prevention style of health message and program design being used on college campuses.

Contrary to the hypothesis, participant responses were not influenced by message type. One reason for this could be due to the single exposure to the health message itself. This single exposure to a health message may have revealed that behavioral intentions are not so malleable, and that they are affected by a single message presentation. In addition, behavior recall at eight days post-exposure may not be a sufficient period of time to capture any differences. These findings reveal that it may be beneficial for future studies to examine the potential influence of repeated exposure to different health messages at different time points on their reports of behavioral intentions.

Although the study had the limitation of using a non-random sample of students enrolled in activity courses, the study has revealed important findings. Overall, health professionals should take note that this study indicates that people are more likely to engage in behaviors designed to promote health whether or not a health promotion of disease prevention message precedes a behavioral decision. In addition, results also indicate that people have a preference and possibly an increased interest in activities that promote health over activities that focus on disease prevention. Finally, because participants react more favorably to health promotion than disease prevention, this suggests that health promotion may facilitate cognitive engagement through active processing. Future studies will need to address this possible underlying mechanism; however the findings clearly have relevance regarding the implementation of future health communication and any future health programs designed to help people make behavior changes that aim to improve health status.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility IV: Evaluating Effectiveness of Health Education Programs

Competency D: Infer implications from findings for future program planning.

Subcompetency 1: Explore possible explanations for important evaluation findings.

Table 1
Chi Square Tests for items 23-32
                                                    Engage in
                                                    for Health
    Behavior                          N     Sig.    Promotion

23. Religious activities             103   p<.001     84.5%
24. Sport/Exercise                   121   p<.001     85.1%
25. Healthy Food choice              120   p<.001     80.0%
26. Read                             118   p<.001     89.0%
27. Learn new things                 120   p<.001     89.2%
28. Work with passion                119   p<.001     92.4%
29. Learn about lifestyle behavior   118   p<.001     67.8%
30. Maintain contact with friends    118   p<.001     93.2%
31. Environmentally Responsible      119   p<.001     68.1%
32. Search for deeper meaning        114   p<.001     91.2%

                                       Engage in for
    Behavior                         Disease Prevention

23. Religious activities                  15.5%
24. Sport/Exercise                        14.9%
25. Healthy Food choice                   20.0%
26. Read                                  11.1%
27. Learn new things                      10.8%
28. Work with passion                      7.6%
29. Learn about lifestyle behavior        32.2%
30. Maintain contact with friends          6.8%
31. Environmentally Responsible           31.9%
32. Search for deeper meaning              8.8%

REFERENCES

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Slater, M. D. (1995). Choosing Audience Segmentation Strategies and Methods for Health Communication. In E.Maibach and R. L. Parrot (Eds.), Designing Health Messages (pp. 186-197). Thunder Oaks: Sage Publications.

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Ref Type: Internet Communication

Witte, K. (1997). Preventing Teen Pregnancy through Persuasive Communications: Realities, Myths, and the Hard-Fact Truths. Journal of Community Health, 22, 137-154.

Craig M. Becker, Ph.D. is an Assistant Professor at Oswego State University of New York. Jennifer Etnier, Ph.D. is an Assistant Professor at Arizona State University. Shari McMahan, Ph.D is an Associate Professor at California State University at Fullerton. J. Ron Nelson, Ph.D. is an Associate Professor at University Nebraska at Lincoln Address all correspondence to Craig M. Becker, Ph.D., Assistant Professor, Oswego State University of New York, 206 Laker Hall, Oswego, NY 13126; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].