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Engaging Doctors and Depressed Patients: Effects of Referential Viewpoint and Role Similarity in Health Narratives.

For many people, mental illness is more difficult to understand and accept than physical illness. Mental illness is often stigmatized, and people who suffer from a mental illness--or who are afraid that they do--are often reluctant to come forward with their situation, because they feel that they will be treated as "strangers" (Baumann, 2007). Hence, underdiagnosis of mental illnesses such as depression is frequent in the primary care setting (Biegler et al., 2016). General underdiagnosis is tackled by nationwide awareness campaigns such as "Coping with Depression--Recognizing Symptoms" in the Netherlands (September 2016),2 in which narratives by mental patients serve as a means to engage target groups in experiences and solutions regarding depression. Indeed, narrative interventions such as entertaining audiovisuals have been shown to impact viewers' involvement with stigmatized characters (Chung & Slater, 2013). Although such interventions may reduce prejudice, there is little evidence to determine their effects on discrimination and social inclusion, and studies on narrative media interventions seldom address health professionals as the target group or have seeking professional care as a topic (Clement et al., 2013). In this article, we study the emotional and cognitive effects of a narrative on professional health consultancy regarding depression targeted at health professional--oriented versus patient-oriented readers.

Narrative Health Interventions

The past decades have witnessed an increasing level of interest in narrative health communication. Adding personal experiences of illness, care, and cure to analytical information and statistical evidence is thought to help people make an informed choice between alternative options in health situations (Hibbard & Peters, 2003) since anecdotal information can make descriptive and comparative health information more understandable (Damman, Hendriks, Rademakers, Delnoij, & Groenewegen, 2009). Notably, narrative information may not only increase readers' understanding, it may also influence health decisions that they make (Winterbottom, Bekker, Conner, & Mooney, 2008). Indeed, using stories to promote healthy behavior is often seen as a promising prevention and intervention strategy, and various studies have shown positive effects of narratives on health-related attitudes, beliefs, and intentions (see Shen, Sheer, & Li, 2015, for a meta-analysis).

In recent years, scientific interest has shifted to the mechanisms that underlie these persuasive effects. Two important mechanisms are engagement with the narrative and identification with the narrative's characters. In a broad definition, engagement with a narrative refers to the audience's sense of "getting lost" in a story (Nell, 1988). This experience is alternatively known as transportation (Green & Brock, 2000), absorption (Slater & Rouner, 2002), or immersion (Visch, Tan, & Molenaar, 2010). Identification with a narrative character may be part of this experience and, again in a broad definition, refers to the audience's emotional and psychological involvement with that character (Cohen, 2001). Both narrative engagement and identification have been found to function as drivers of narrative persuasion (e.g., De Graaf, Hoeken, Sanders, & Beentjes, 2012; Green & Brock, 2000).

Surprisingly little is known, however, about the narrative characteristics that prompt these processes (Green, 2008). From a review of narrative health care interventions studies, Winterbottom et al. (2008) conclude that it is not clear why and how such narratives influence readers,

while Shaffer and Zikmund-Fisher (2012) argue that most narrative health studies fail to recognize the complex structure of narratives, resulting in research that does little to inform our understanding of the impact of patient stories. In addition, the degree of similarity between readers and the persons in the health narrative is thought to influence identification and engagement in readers, but how this influence is related to narrative characteristics is unclear. For instance, in Chen, Bell, and Taylor's (2016) study of health messages, similarity between the reader and the narrative character appeared to be more effective than choices in point of view. By contrast, Hoeken, Kolthoff, and Sanders (2016) found that strategic perspective choices tend to result in readers identifying more strongly with a character even in the presence of an alternative character they perceive as more similar to themselves. What are relevant story features, then, that make readers temporarily set aside their own perspective and engage with narrative events and situations from another person's viewpoint in a similar or dissimilar health situation? Answers to this question can advance our understanding of narrative engagement and persuasion processes and inform the development of health education and health promotion materials.

The present study addresses this question by examining the effects of perspectivization on readers' identification with narrative characters in a health communication context. The narrative technique of perspectivization is used to relate a story's events from the spatial, psychological, or emotional viewpoint of a particular character. This technique is often hypothesized to affect readers' identification with that character (e.g., Farner, 2014; Leech & Short, 2007), but empirical evidence for this relation remains scarce and inconsistent. Part of this inconsistency might be explained by the fact that a character's viewpoint can be represented in divergent ways; in fact, there is not a single perspectivization technique. Rather, there are numerous linguistic resources to describe events from a particular viewpoint, to put the metaphoric camera close to a certain character and at a distance from another character. These resources include the referential expressions used to refer to characters. The present study examines the effects of such expressions on readers' identification with narrative characters by focusing on character reference and character likeness; more specifically, by varying third-person pronominal reference to health narrative characters and by adapting different degrees of similarity between readers and characters in the health narrative.

Third-Person Pronouns as Viewpoint Indicators

Narratives are often thought to engage and persuade readers more strongly than nonnarratives because narratives revolve around characters "from whose experience we humans can 'learn'" (Toolan, 2001, p. 8). We can relate to a character more easily than, for example, statistical information--particularly when we experience the narrative events from the character's viewpoint. Sasaki (1994) even posits that viewpoint is "certainly one of the most important aspects of the fictional narration, in terms of its control over the reader's responses" (p. 127). These responses include the reader's sympathy for and empathy and identification with narrative characters. The occurrence and strength of such responses are often thought to be dependent on the type of viewpoint techniques used (e.g., Farner, 2014; Leech & Short, 2007).

Important viewpoint techniques are referential expressions, and various studies have examined the effects of these expressions on readers' identification with a narrative character. Most of these studies compared the effects of first-person pronouns (I), second-person pronouns (you), and third-person pronouns (he/she; see De Graaf, Sanders, & Hoeken, 2016, for a systematic review). Studies by Brunye et al. (2009, 2011) and Andeweg et al. (2013), for instance, found that readers' identification with a narrative character is strongest if that character is referred to with the second-person pronoun you. Another study found that readers identify more strongly with a character if that character is referred to with the first-person pronoun I compared with the third-person pronoun he or she (De Graaf et al., 2012). Specifically, in a narrative with two characters who hold opposing views, readers identified more strongly with the first-person character than the third-person character, regardless of their own prior views and attitudes. Moreover, identification was found to function as a mediator of the effects of the viewpoint manipulation on persuasion. Similar results were obtained by Hoeken and Fikkers (2014), who found that readers identify more strongly with first-person characters compared with third-person characters--an effect that mediated the narrative's persuasive impact. By contrast, Chen et al. (2016) found that in health narratives, a first-person point of view did not lead to higher identification than a third-person point of view; identification was equally facilitated by third-person narratives.

First-person pronouns signal, by definition, an internal viewpoint, such that readers have privileged access to the inner life of the character, whereas third-person pronouns signal an external viewpoint, such that readers observe the character "from the outside." However, there are various ways in which a third-person character's internal viewpoint can be represented, for example, by the use of thought reports or verbs of sensory perception (see, hear; e.g., Klauk, Koppe, & Onea, 2012; Sanford & Emmott, 2012). A powerful linguistic device in third-person narrations to guide reader identification is the variation in referential expressions to characters, because these expressions can also position readers closer to or further away from a character. A third-person character can be referred to with a pronoun (he) or a noun (the man, Mr. Williams). The choice between a pronoun and a noun is determined by several discourse factors, such as the amount of text between two references and the number of characters that have to be distinguished (Ariel, 1988, 1990; Clancy, 1980). Nominal references can be required to disambiguate between multiple characters of the same gender, whereas pronominal references can be used when there is no such need. However, referring to a character with a pronoun (rather than a noun) also signals that the character is cognitively accessible (Ariel, 1988), the focus of attention (Gundel, Hedberg, & Zacharski, 1993), and conceptually proximate (Van Hoek, 2007).

Crucially, third-person pronouns may signal that the events are narrated from a certain character's viewpoint. Van Krieken, Sanders, and Hoeken (2015) analyzed news narratives and nonnarrative news reports about criminal acts on their use of referential expressions. Results of this study showed that in the news narratives, eyewitnesses to the acts were referred to with pronouns more often than nouns, whereas other news actors were referred to with nouns more often than pronouns. This means that pronouns are used strategically in news narratives to describe the events from the viewpoints of people who witnessed these events from up close, thus inviting the reader to take the position of a mediated witness (Van Krieken, Hoeken, & Sanders, 2015; see Peelo, 2006). Importantly, these patterns were not found in the nonnarrative news reports: In these reports, both eyewitnesses and other news actors were referred to with nouns more often than pronouns. The use of third-person pronouns as a viewpoint technique thus appears to be a distinctive feature of narratives. Examining the effects of this technique on the audience's identification with characters in health narratives can contribute to a clearer understanding of why narrative health communication is more engaging and persuasive than nonnarrative health communication. Our first hypothesis is, therefore, formulated as follows:

H1: Third-person pronominal references to narrative characters lead to stronger identification with these characters than do nominal references.

Reader--Character Similarity

Identification with a character can also be influenced by the degree of similarity between the character and the reader (e.g., Hoeken, Kolthoff, & Sanders, 2016), and this may be particularly relevant in health communication contexts. When confronted with a health issue, people frequently try to cope with the uncertainties in their situation by seeking health information (Brashers, Goldsmith, & Hsieh, 2002). Before consulting a health professional, people try to picture what to expect when they actually consult their physician, when a particular diagnosis is established, when a particular treatment is conducted, and so forth, but many experience difficulty in finding information that is relevant and understandable for their particular situation (Dubbeldam, 2016). Personal narratives of similar health consultations would help to achieve this aim, but they are--in the context of professional health information--still an exception (Damman et al., 2009). Moreover, in their review of narrative health intervention studies, Winterbottom et al. (2008) found no narratives that described how an individual might discuss his or her illness with a health professional. Specifically in mental health issues, many people in many countries experience a lack of knowledge of the help-seeking options and treatments available (Jorm, 2012). A major challenge for health campaigns targeting these issues is the stigma associated with mental illnesses (Quinn et al., 2013). This stigma can be reduced by narrative communication, in particular, when the audience identifies with the narrative's characters (Caputo & Rouner, 2011). The level of identification with narrative characters who take part in such mental health narratives may be affected by readers' similarity to that character in terms of role congruence (in this case, patient or health professional).

The audience's perceived similarity to a media character is, in some conceptualizations of identification, seen as one of various aspects of their identification (Liebes & Katz, 1990; see Brown, 2015). Other scholars distinguish between similarity and identification as two related, but inherently different, processes (e.g., Eyal & Rubin, 2003; Moyer-Guse & Nabi, 2010; Pinkleton, Austin, & Van de Vord, 2010): Perceived similarity refers to the audience's impression of sharing the character's interests, background, and/or personality traits, whereas identification refers to a process through which the audience adopts the character's perspective and imagines being that character. Perceived similarity may enhance identification because it is easier to step into the shoes of a similar rather than a dissimilar person. A recent study examined the effects of perceived role similarity in relation to the effects of narrative viewpoint on readers' identification with characters (Hoeken et al., 2016). Participants read a story with both a first-person character and a third-person character. Participants varied in their role similarity to the two characters (client or professional). Results showed that both linguistic viewpoint and perceived role similarity influenced identification, with readers identifying more with similar rather than dissimilar characters. This leads to our second hypothesis:

H2: Readers identify more strongly with characters that are similar (versus dissimilar) to them.

The study by Hoeken et al. (2016) also found that the impact of viewpoint was stronger than the impact of similarity: Participants identified more strongly with the first-person character, even if the first-person character had a dissimilar role in comparison to them and the third-person character was similar to them. By contrast, Chen et al. (2016) found that similarity affected readers' identification, whereas viewpoint (first- versus third-person) did not. In light of these inconsistent findings, we formulated the following research question about the effects of viewpoint (third-person pronouns versus nouns) and role similarity:

RQ: To what extent are pronominal references and role similarity relative determinants of readers' engagement with narrative health characters?

To test the hypotheses and answer the research question, we conducted an experiment, the details of which are discussed in the next section.

Study

Materials

A health narrative about depression was developed and presented as a part of a fictitious magazine of a health insurance company. The narrative was designed by the researchers for the purposes of the present investigation. To ensure both credibility and sensitivity, medical literature on the symptoms and treatment of depression served to inform the design of the story (Gotlib, Lewinsohn, & Seeley, 1995; Klein & Wender, 2005).

The narrative was entitled "At the Consultation Hour" and revolved around two characters: a doctor and a patient. In the story, the patient visits the doctor because he has been feeling down lately and has lost all interest in his hobbies. The doctor asks him various questions about his physical condition, social life, and eating and sleeping habits. From his answers, the doctor concludes that the patient might be suffering from a mild depression and advises him to see the practice nurse for treatment. The patient expresses his worries about the costs involved, after which the doctor reassures him that his insurance company covers all the costs. The narrative first described the setting--that is, the time and location of the narrated event. The subsequent part of the story was predominantly written in the form of a dialogue between the doctor and the patient.

Two versions of the story were created: one in which the viewpoint was located with the doctor and one in which the viewpoint was located with the patient. The viewpoint was manipulated by using pronouns (versus nouns) to refer to the characters. In the version in which the viewpoint was located with the doctor, the doctor was referred to with pronouns and the patient was referred to with nouns. In the version in which the viewpoint was located with the patient, the doctor was referred to with nouns and the patient was referred to with pronouns. Nominal references could be definite noun phrases (e.g., "the doctor"/"the patient"), possessive noun phrases (e.g., "his doctor"/"her patient"), or proper names (e.g., "Miss Kruijt"/"Mister Middelkoop"). Table 1 provides excerpts of the two story versions.

A deliberate deviation from the pattern in referential expressions was established in the final sentence of the narrative, in which the patient is referred to with a pronoun in both versions of the story (see Table 1). This final sentence is a thought with an ambiguous interpretation: "Hopefully the practice nurse can really help him." This thought can either be interpreted as the doctor's thought in the direct mode (equivalent to "I hope the practice nurse can really help him") or as the patient's thought in the free indirect mode (equivalent to "I hope the practice nurse can really help me"). This sentence was included to assess whether the use of pronouns would cause readers to automatically attribute this thought to the doctor (in the story written from the doctor's viewpoint) or to the patient (in the story written from the patient's viewpoint).

Apart from the difference in referential expressions, the two versions of the story were identical. The narrative featured 13 quotes by the doctor (231 words in total) and 15 quotes by the patient (229 words in total). There were 19 references to the doctor and 20 to the patient. There were no indicators of an internal viewpoint (e.g., perceptions, emotions, thoughts) such that both characters were only described "from the outside."

Measures

A questionnaire was designed to measure readers' identification with the doctor and their identification with the patient. All participants rated both items about identification with the doctor and items about identification with the patient. To control for order effects, half of the participants first rated the items about identification with the doctor and then the items about identification with the patient; and vice versa for the other half of the participants. Unless indicated otherwise, participants were asked to indicate their agreement on a 7-point Likert scale (1 = completely disagree, 7 = completely agree).

In line with previous research, identification was operationalized as a higher-order construct comprising multiple dimensions (e.g., Cohen, 2001; Igartua & Barrios, 2012). We distinguished an emotional dimension (the degree to which the reader feels for the character and shares the character's feelings); a cognitive dimension (the degree to which the reader adopts the character's mental state and imagines being the character); and a spatial component (the degree to which the reader experiences the narrative from the spatial position of the character).

Emotional identification was measured with three items adapted from De Graaf et al. (2012): "During reading I empathized with the [doctor/patient]," "I felt for the [doctor/patient]," and "While reading I sympathized with the [doctor/patient]" ([alpha] = .88 for emotional identification with the doctor, and [alpha] = .88 for emotional identification with the patient).

The second dimension, cognitive identification, was measured with three items, also adapted from De Graaf et al. (2012): "In my imagination, it was as if I was the [doctor/patient]"; "When I was reading for awhile, it seemed as if I had become the [doctor/patient]"; "I had the feeling I went through what the [doctor/patient] went through" ([alpha] = .89 for cognitive identification with the doctor, and [alpha] = .90 for cognitive identification with the patient).

Spatial identification, the third dimension, was measured with four newly created items: "During reading it seemed as if I was looking over the [doctor's/patient's] shoulder," "I experienced the story from the [doctor's/patient's] position," "During reading I imagined what it would be like to be in the position of the [doctor/patient]," and "While reading I put myself in the position of the [doctor/patient]" ([alpha] = .88 for spatial identification with the doctor, and [alpha] = .78 for spatial identification with the patient).

In addition, one item was included to assess whether participants interpreted the final sentence of the story as the doctor's thought or the patient's thought. Participants were asked to read the final two sentences of the story again. In the story written from the viewpoint of the doctor, these sentences were (1) "She gets up and shakes the patient's hand" and (2) "Hopefully the practice nurse can really help him." In the story written from the viewpoint of the patient, these sentences were (1) "He gets up and shakes the doctor's hand" and (2) "Hopefully the practice nurse can really help him." Participants were then asked, "Whose thought, do you think, is the thought in the final sentence?" Participants indicated their response on a 7-point scale (1 = definitely the doctor, 7 = definitely the patient).

Finally, all participants indicated their gender, age, nationality, native language, and study program.

Participants

A total of 120 people participated in the study. The results from three participants were excluded because Dutch was not their native language. The final sample consisted of 117 participants (41% men, 59% women). Age varied between 18 and 25 (M = 20.0, SD = 1.6). All participants were students at a Dutch university. About half of them (51.3%) studied at the Faculty of Medicine, whereas the other half studied at the Faculty of Arts (48.7%). The selection of students from these two faculties was motivated by the presumption that medicine students would feel more similar to the doctor since their study prepares them to become medical professionals, partly by means of role-plays in which they assume the role of a doctor and simulate consultations with patients. Art students were expected to feel more similar to the patient since this character was introduced as a communication specialist, a job that many art students are prepared and trained for during their studies. Hence, the selection of students from these two faculties enabled us to examine whether the use of pronouns could affect participants' identification with characters they are more or less similar to.

Design

The study used a between-subjects design. A total of 58 participants (30 medicine students, 28 art students) read the story written from the doctor's viewpoint. A total of 59 participants (30 medicine students, 29 art students) read the story written from the patient's viewpoint. Participants who read the story written from the doctor's viewpoint did not differ from participants who read the story written from the patient's viewpoint in terms of age, t(118) = 1.03, p = .308, or ratio between men and women participants, [X.sup.2](1) = .16, p = .685.

Procedure

Participants were approached individually or in small groups at the university campus. They were asked to participate in a study intended to assess people's opinions about magazines. If they agreed to participate, they were randomly assigned to one of the two conditions and asked to read the story carefully and individually and to subsequently answer the questions. The participants received a lottery ticket after having completed the questionnaire. Participation took on average 10-15 minutes.

Results

Table 2 provides the mean scores and standard deviations for participants' identification with the doctor and their identification with the patient.

A paired samples t-test indicated that, overall, participants felt a stronger emotional identification with the patient (M = 4.73, SD = 1.25) than with the doctor (M = 3.43, SD = 1.37), t(116) = 7.75, p < .001. Participants also felt a stronger spatial identification with the patient (M = 4.31, SD = 1.20) than with the doctor (M = 3.89, SD = 1.45), t(116) = 2.14, p = .034. There was no difference in participants' cognitive identification with the patient (M = 3.23, SD = 1.41) or with the doctor (M = 3.21, SD = 1.42), t(116) = 0.12, p = .907.

The hypotheses were tested using univariate and multivariate analyses of variance (MANOVA). First, a 2 x 2 (viewpoint doctor/viewpoint patient; medical students/art students) MANOVA was run with the three dimensions of identification with the doctor as dependent variables. The analysis revealed a trend toward significance for the viewpoint manipulation on identification, Wilk's [lambda] = .93, F(3, 111) = 2.64, p = .053, [[eta].sup.2] = .07. Subsequent univariate analyses showed a significant main effect on readers' emotional identification with the doctor, F(1, 113) = 7.33, p = .008, [[eta].sup.2] = .06: Participants who read the story from the viewpoint of the doctor identified more strongly emotionally with the doctor than did participants who read the story from the viewpoint of the patient. In addition, there was a trend toward an effect on cognitive identification, F(1, 113) = 3.06, p = .083, [[eta].sup.2] = .03: Participants who read the story from the viewpoint of the doctor tended to identify more strongly cognitively with the doctor than did participants who read the story from the viewpoint of the patient. There was no effect of the viewpoint manipulation on readers' spatial identification with the doctor, F(1, 113) = 2.61, p = .109. These results provide partial support for Hypothesis 1.

In accordance with Hypothesis 2, there was a main effect of study background on identification with the doctor, Wilk's [lambda] = .82, F(3, 111) = 8.10, p < .001, [[eta].sup.2] = .18. Subsequent univariate analyses showed a significant main effect on spatial identification, F(1, 113) = 23.42, p < .000, [[eta].sup.2] = .17. Medical students (M = 4.47, SD = 1.32) were more strongly inclined to assume the spatial perspective of the doctor than were art students (M = 3.26, SD = 1.34). Medical students (M = 3.92, SD = 1.15) also identified more strongly emotionally with the doctor than did art students (M = 2.88, SD = 1.38), F(1, 113) = 19.39, p < .001, [eta]2 = .15. Finally, an effect was found on cognitive identification, F(1, 113) = 34.19, p < .001, [[eta].sup.2] = 15. Medical students (M = 3.73, SD = 1.27) identified more strongly cognitively with the doctor than art students did (M = 2.63, SD = 1.34).

Second, a 2 x 2 (viewpoint doctor/viewpoint patient; medical students/art students) MANOVA was run with the three dimensions of identification with the patient as dependent variables. The analysis showed no main effects of the viewpoint manipulation, Wilk's [lambda] = .97, F(3, 111) = 1.25, p = .297, or participants' study background, Wilk's [lambda] = .97, F(3, 111) = 1.19, p = .317. These results do not support the hypotheses.

The interaction between the viewpoint manipulation and participants' study background was probed to answer the research question. Results showed no interaction between viewpoint and study background on readers' identification with the doctor (F < 1). There was neither an interaction effect between these two variables on readers' identification with the patient (F < 1). (3)

Finally, an analysis of variance was run to determine whether the viewpoint manipulation had influenced readers' interpretation of the thought in the final sentence of the narrative. The results showed a significant main effect of the viewpoint manipulation on thought attribution, F(1, 116) = 49.46, p < .001, [[eta].sup.2] = .30. Participants who read the narrative from the viewpoint of the doctor attributed the thought more strongly to the doctor (M = 2.22, SD = 1.79) than did participants who read the narrative from the viewpoint of the patient, who attributed the thought more strongly to the patient (M = 4.64, SD = 1.97). There was no main effect of study background, F(1, 116) = 1.50, p = .223, and no interaction effect between the viewpoint manipulation and participants' study background, F(1, 116) = 1.22, p = .271.

Conclusion and Discussion

The results of this study show that health narratives can be strategically designed to steer readers' identification with characters. Specifically, the use of personal pronouns rather than nouns to refer to a specific character in the health situation can increase readers' emotional identification with that character. The results also suggest that pronouns can increase readers' cognitive identification with a character. The present study thus provides experimental evidence for the presumption that in narrative discourse, third-person pronouns are salient viewpoint indicators that can align readers closely to narrative characters (Van Krieken et al., 2015). Interesting in this respect is that these results were found only for readers' identification with the doctor and not for their identification with the patient. In combination with the result that, overall, readers identified more with the patient than with the doctor, this seems to indicate that pronouns might be particularly effective in increasing identification with characters one would normally not strongly identify with.

The finding that pronouns affect emotional, but not spatial, identification is in line with theoretical accounts positing that pronouns decrease the conceptual distance between the reader on the one hand and the character on the other (Van Hoek, 2007). This result is relevant in the context of health communication, because emotional engagement with a character has been found to explain for the persuasive effects of narratives on readers' health attitudes and behavioral intentions (e.g., Murphy, Frank, Chatterjee, & Baezconde-Garbanati, 2013). But it is unclear to date whether assuming a character's spatial perspective also plays a role in persuasion processes.

Importantly, this study finds that people automatically attribute narrative information to a character that is referred to with pronouns, even in the absence of internal viewpoint signals. This result serves as an additional clue that readers put themselves closer to characters that are referred to with pronouns than to characters that are referred to with nouns. In addition, it indicates that a character that is referred to with pronouns is recognized as a "subject of consciousness," even if its consciousness itself remains implicit (Sanders, Sanders, & Sweetser, 2012). In this respect, third-person pronouns have the ability to facilitate the meeting between the minds of character and reader (see Oatley, 1999).

This result is furthermore in line with the results of a study that found that readers are more likely to attribute narrative information to characters that are referred to with a proper name ("Malcolm") than to characters that are referred to with a descriptive noun phrase ("a tour guide"), presumably because readers think of the former as main characters and of the latter as secondary characters (Sanford, Clegg, & Majid, 1998). In a similar way, readers appear to assign characters referred to with pronouns the role of main characters, whereas characters referred to with nouns are assigned the role of secondary characters. This is relevant because it shows how subtle linguistic cues can make characters more or less prominent. As such, third-person pronouns may function as a useful rhetorical device for authors to shift attention between characters and, for example, to make the beliefs and values of a given character more salient while deemphasizing the beliefs and values of other characters.

In contrast to the study by Hoeken et al. (2016), the present study did not find narrative viewpoint to overrule the effects of participants' role similarity to the character on identification. This seems to indicate that the use of third-person pronouns as a viewpoint technique is not powerful enough to cause readers to identify strongly with a character they are dissimilar to. An additional explanation might be that the students of the Faculty of Arts did not feel similar to the patient, even though the patient was introduced as a communications specialist, which is a popular job prospect for Dutch art students. A limitation of this study is that perceived similarity was not measured, which inhibits us from drawing firm conclusions about the impact of similarity on identification. Future studies could control the manipulation of role similarity by assessing participants' perceived similarity to the narrative characters and, as such, provide further insight into the relative impact of similarity and viewpoint on identification.

A second limitation of this study is that it examined the impact of narrative features in a health information context and not in a health persuasion context. Hence, a remaining question is whether the use of third-person pronouns can also affect readers' health-related beliefs, attitudes, and behavioral intentions. The occurrence of such effects is not unlikely in the light of previous studies showing that identification with a narrative character functions as an important driver of narrative persuasion (De Graaf et al., 2012; Hoeken & Fikkers, 2014). Whereas these previous studies examined the effects of first-person pronouns versus third-person pronouns, the present study shows that more subtle viewpoint phenomena within third-person narratives can also affect readers' identification with narrative characters. To expand our knowledge of the reach of such viewpoint effects, future research would benefit from including additional measures to assess the persuasive impact of health stories.

These limitations notwithstanding, this study makes an important contribution to research on character identification in health narratives. Whereas previous studies on narratives have examined the effects of reading instructions and character likability on identification (e.g., Cupchik, Oatley, & Vorderer, 1998; Hoeken & Sinkeldam, 2014; Tal-Or & Cohen, 2010), the present study provides insight into the linguistic features of stories that play a role in this process as well. Even though more research is necessary to gain a comprehensive understanding of how viewpoint affects identification and, more specifically, to delineate the conditions under which the use of pronouns might increase identification, results of the present study can inform the design of narrative health messages in several respects.

First, the result that pronouns increased identification with the doctor can be relevant for health campaigns to raise the audience's awareness of how professionals view patients suffering from mental illnesses. Such increased awareness might reduce mental health stigma, which is a major challenge for health campaigns (Parcesepe & Cabassa, 2013; Quinn et al., 2013). Stories in which medical professionals acknowledge the seriousness of mental health issues and provide treatment options can facilitate help-seeking behavior by empowering patients to overcome barriers raised by, for example, embarrassment or negative reactions from their social environment. Specifically for low--health literacy target groups, the use of narratives seems a promising tool. For instance, a study found that the understanding and acceptance of mental health care can be increased for such groups by depicting diagnosis and treatment of mental illness in fotonovelas (Unger, Cabassa, Molina, Contreras, & Baron, 2013). In a similar fashion, printed stories could exert a positive influence on a broad public's beliefs and attitudes toward mental illnesses and their treatment. Increasing identification with medical professionals through the use of pronouns is a recommendable strategy for health communication targeted at these issues.

A second application derives from the finding that readers tend to attribute narrative information to characters that are referred to with pronouns rather than with nouns. This means that in designing health narratives, a strategic and careful use of referential viewpoint can help to increase the salience of desired beliefs and attitudes and, conversely, to decrease the salience of undesired beliefs and attitudes. For example, a character referred to with pronouns could express a positive attitude toward mental health care, whereas a character referred to with nouns could express negative, stigmatizing attitudes. Such interplay could increase a story's realism and credibility by acknowledging the existence of negative attitudes while subtly guiding readers into favoring the more positive attitudes. This could also reduce the potential risk of arousing resistance in readers, which is seen as a significant challenge in the development of health education and promotion materials (e.g., Crossley, 2002) and which is an underexamined topic in narrative mental health interventions (Clement et al., 2013). Crafting health stories that are informative, realistic, and engaging requires a strategic use of language as a way to foreground favorable perspectives and reduce the "strangeness" of people in unfamiliar situations and roles, thus guiding readers toward more inclusive attitudes that are essential in the destigmatization of mental illnesses such as depression (Baumann, 2007). Linguistic perspective, specifically the application of third-person pronouns, might play an important role in accomplishing this aim, as suggested by the results of the present study.

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KOBIE VAN KRIEKEN

JOSE SANDERS (1)

Radboud University, Netherlands

Kobie van Krieken: k.vankrieken@let.ru.nl

Jose Sanders: j.sanders@let.ru.nl

Date submitted: 2016-08-30

(1) The authors would like to thank Carolien van Krugten, Freek Voorthuijsen, Muriel Wassink, Bregje van de Weijer, and Stijn Wessels for their assistance with the data collection.

(2) https://www.omgaanmetdepressie.nl/?utm_campaign=sea-t-campagne_omgaan_met_depressie-a-home&utm_term=depressie

(3) Because the two narrative characters differed in gender (the patient was a man, and the doctor was a woman), the MANOVAs were also conducted with participants' gender as an additional factor. There was no main effect of gender on readers' identification with the doctor, F < 1, or on their identification with the patient, F(3, 110) = 2.01, p = .117. There was an interaction effect between gender and study background on readers' identification with the patient, Wilk's [lambda] = .92, F(3, 110) = 3.33, p = .022. Univariate analyses revealed a trend toward an interaction effect on emotional identification with the patient, F(1, 112) = 3.76, p = .055, [[eta].sup.2] = .03. Women students from the Faculty of Arts tended to emotionally identify more with the patient (M = 5.19, SD = 1.03) than did women students from the Faculty of Medicine (M = 4.71, SD = 1.25; p = .084). Male students from the Faculty of Arts did not differ significantly in their emotional identification with the patient (M = 4.23, SD = 1.44) from male students from the Faculty of Medicine (M = 4.63, SD = 1.17; p = .294). Results for the other two dimensions of identification with the patient were not significant, and no other interaction effects were found.
Copyright [c] 2017 (Kobie van Krieken & Jose Sanders). Licensed under
the Creative Commons Attribution Non-commercial No Derivatives
(by-nc-nd). Available at http://ijoc.org.

Table 1. Excerpts of the Two Versions of the Narrative.

Version 1:                      Version 2:
Doctor's viewpoint (671 words)  Patient's viewpoint (673 words)

"How can I help you?" she
asks Mister Middelkoop.         "How can I help you?" he is asked by
                                Miss Kruijt.
Her patient moves uneasily
back and forth in his           He moves uneasily back and forth in his
                                chair. "I
chair. "I have no physical
complaints. At least,           have no physical complaints. At least,
                                nothing
nothing serious. It is rather
that I... Well, it's not        serious. It is rather that I... Well,
                                it's not easy
easy for me to talk about."     for me to talk about."
She nods encouragingly.         His doctor nods encouragingly.
"I don't know if you can
help me, but lately I have      "I don't know if you can help me, but
                                lately I have
been feeling very down. I
can't enjoy anything            been feeling very down. I can't enjoy
                                anything
anymore," the patient finally
answers her. "I prefer          anymore," he finally answers the
                                doctor. "I prefer
lying in bed every day with
the curtains closed."           lying in bed every day with the
                                curtains closed."
She nods again. "How long
have you been                   The doctor nods again. "How long have
                                you been
experiencing these feelings
of depression?" she             experiencing these feelings of
                                depression?" the
asks.                           physician asks.
The man answers: "About
two, three months, I            He answers: "About two, three months, I
                                think."
think."
She looks at the patient
for awhile. "Has something      The doctor looks at him for awhile.
                                "Has something
important happened in your
life recently, positive or      important happened in your life
                                recently, positive
negative? Or has there
been a change in, for           or negative? Or has there been a change
                                in, for
example, your living or
work environment?"...           example, your living or work
                                environment?"...
She gets up and shakes
the patient's hand.             He gets up and shakes the doctor's
                                hand.
Hopefully the practice
nurse can really help him.      Hopefully the practice nurse can really
                                help him.

Table 2. Means (With Standard Deviations) for Readers' Identification
With Doctor and Patient as a Function of Viewpoint Manipulation and
Participants' Study Backgrounds (1 = Low, 7 = High).

                        Version 1:               Version 2:
                   Doctor's viewpoint       Patient's viewpoint
                Medicine  Arts    Total   Medicine  Arts    Total

Identification
with doctor
Emotional        4.30      3.15    3.75    3.54      2.67    3.11
                (1.04)    (1.39)  (1.34)  (1.14)    (1.37)  (1.33)
Cognitive        4.01      2.80    3.43    3.46      2.51    2.99
                (1.04)    (1.43)  (1.38)  (1.42)    (1.32)  (1.44)
Spatial          4.82      3.33    4.10    4.12      3.24    3.89
                (1.11)    (1.38)  (1.44)  (1.43)    (1.34)  (1.45)
Identification
with patient
Emotional        4.71      4.85    4.78    4.63      4.75    4.69
                (1.36)    (1.33)  (1.33)  (1.04)    (1.30)  (1.17)
Cognitive        3.08      3.57    3.32    3.06      3.23    3.14
                (1.37)    (1.57)  (1.48)  (1.08)    (1.58)  (1.34)
Spatial          4.07      4.46    4.25    4.23      4.49    4.36
                (1.29)    (1.23)  (1.27)  (0.96)    (1.28)  (1.13)
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Publication:International journal of communication (Online)
Date:Nov 1, 2017
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