Effective Clinical Practice
Effective Clinical Practice, March/April 2001
John K. Worden, Brian S. Flynn
For author affiliations, current addresses, and contributions, see end of text.
In recent years, we have seen renewed interest in determining an optimal approach for applying the principles of health communication. An approach that is gaining widespread support among clinicians is to let information speak for itself so that patients can make informed decisions about the best course of action for enhancing or preserving their health.
The "information-only" approach is appropriate when the case for one alternative over another is not clear-cut, with either alternative offering an uncertain mix of costs and benefits—for example, lung cancer screening, genetic testing for cancer risk, or experimental therapies. The targeted outcome of this approach would be the quality and satisfaction of the decision made by the patient, not the nature of the choice or action taken.
However, when the case for one course of action over another is clear-cut, persuasive messages are called for. Examples of areas in which persuasive messages should be crafted include mammography, blood pressure checks, diabetes control, cholesterol reduction, weight control, and colon cancer screening. In this editorial, we stress the need for persuasive messages, show how they can be designed and implemented, and identify settings in which they should be implemented to improve health care.
When Information Alone Is Not Enough
For many medical problems that require a change in behavior, letting information speak for itself is an insufficient strategy. Cigarette smoking is a prime example. The original Surgeon General's report on smoking and disease in 1964 clearly described major problems caused by smoking. The decrease in smoking prevalence following that report may be attributed to informed decision making by many adult smokers; since then, we have seen smoking rates plateau at about 25% in the total population and actually increase among young persons in the 1980s and 1990s. Because of many factors, including marketing by tobacco manufacturers, young people in particular were taking up smoking at epidemic levels, even though they were bombarded at every turn by information that smoking was harmful to their health.
What does it take to change behavior regarding something as complex as cigarette smoking? It takes a multilevel persuasive strategy aimed at changing perceptions, attitudes, and skills, as well as imparting information. It also takes considerably more work than an information-only approach. Persuasive communication messages must be tailored to appeal strongly to persons at risk for smoking by addressing their social needs and expectations related to smoking, as well as their need for information about the connection between this behavior and health outcomes. This strategy must respond to the positive images of smokers projected by the tobacco industry. To accomplish this, persuasion efforts often use social marketing techniques to diagnose the interests and needs of targeted individuals so that messages will have enough impact to change perceptions and attitudes and improve skills, thereby leading to the desired change in behavior.
What Are Persuasive Messages?
Let's continue our discussion of the difficult problem of modifying cigarette smoking behavior by examining an approach used to prevent smoking during adolescence, a time when most smoking is initiated. To access young people through attractive and often-used communication channels, a television and radio campaign was developed to prevent smoking. Messages were designed according to a social influence model (1) to address four persuasive objectives that had been shown in previous research to encourage young people not to start smoking. These objectives for the young target audiences were to perceive fewer advantages to smoking, to perceive more disadvantages to smoking, to acquire social skills to resist peer pressures to smoke, and to perceive that most people their age do not smoke. After 4 years of intervention, students in communities receiving these messages in the media and in school were 35% to 40% less likely to be weekly smokers than those receiving the messages in school alone. (3, 4, 15) This study not only showed the power of mass media to affect youth behavior but also demonstrated how persuasion may address the many facets of youth culture to promote a healthier lifestyle.
How different is this approach from the information-only approach? In one way, it is similar. One of the education objectives used in the program was to perceive more disadvantages to smoking. Among those disadvantages could be that smoking "makes you cough, makes it harder to perform at sports" or some cosmetic effects, such as wrinkling and yellow teeth or fingers. Some of this information was included in the mass media campaign. However, most of the "disadvantages" were more socially relevant, such as "your friends don't like your smoking," or "your girlfriend will turn you down." The other objectives were also socially relevant, including perceiving that most kids don't smoke and learning how to refuse a cigarette offered by a friend.
To apply the social influences model effectively, messages were designed to show age-appropriate role models conveying their opinions in attractive situations using such formats as situation comedy, rock videos, and even cartoons. To ensure that these messages would appeal to the target audience, surveys and focus groups were conducted with the target audience to capture their interests and lifestyle. In addition, formative research was conducted to learn the audience's opinions of the ads produced in preliminary form before they were aired. When completed, ads were run in after-school paid advertising slots during television programs preferred by high-risk students, as measured in school surveys conducted each year to ensure that the persuasion campaign was working. (14)
Settings That Require Persuasion
Surely, it takes a lot of planning and effort to get health-promoting behavioral results from the persuasive approach. But in some instances in both community and clinical settings, persuasion is the only approach possible to get results.
One of these is the attempt to reach out to persons who do not routinely seek medical care for their health problems. These persons often have a variety of barriers to obtaining care that must be addressed, along with their information needs, through the use of persuasion. For example, among older women and those with lower incomes, two groups that are less likely to seek mammography screening, programs designed to facilitate mammography by addressing barriers have been successful. (5, 10) These barriers include such factors as women's perceptions of susceptibility to cancer and fears of pain and radiation. (11) To meet the needs of specific target groups in the community, factors that inhibit obtaining proper health care must be identified and strategies must be tailored to help overcome them. (7)
Another situation in which persuasion is necessary concerns at-risk individuals who do seek medical care but resist taking the advice they are given. In these situations, physicians must use persuasive strategies to ensure adherence. (13) For example, it has been found that physician enthusiasm for mammography screening is a strong influence on patient adherence to mammography recommendations. (6, 9) Persuasive techniques should also be used in the clinical settings for other recommendations that have clear-cut benefits, such as blood pressure checks, diabetes control, cholesterol reduction, weight control, and colon cancer screening.
There are two potential avenues for introducing effective persuasive techniques in the clinical setting. The first is through continuing medical education. When it was discovered that many physicians lacked confidence in their screening-related counseling skills, it was suggested that such skills could be taught in continuing medical education. (8) Continuing medical education with primary care physicians has been used effectively to promote counseling of patients to quit smoking. (12) The second method is to involve the entire medical office staff in an office-based system aimed at persuading patients to participate in screening and other recommended health behaviors. (2)
In sum, we urge a much wider application of health communication persuasion techniques than is currently used to modify behaviors that will prevent disease or detect it earlier. The clinical situations in which the case for one alternative over another is not clear-cut are exceptions; persuasive methods should not be applied here unless stronger evidence for the efficacy of these therapies or screening techniques emerge to the point where these methods become standards of care. Of perhaps greater importance, however, is the need to develop better ways of persuading at-risk populations to adopt behaviors that will minimize the need for further medical care.
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15. Worden JK, Flynn BS, Solomon LJ, Secker-Walker RH, Badger GJ, Carpenter JH. Using mass media to prevent cigarette smoking among adolescent girls. Health Educ Q. 1996;23:453-68.
John K. Worden, PhD, Office of Health Promotion Research, College of Medicine, University of Vermont, 1 South Prospect Street, Burlington, VT 05401; telephone: 802-656-4187; fax: 802-656-8826; e-mail: John.Worden@uvm.edu.