Understanding narrative effects: The impact of breast cancer survivor stories on message processing, attitudes, and beliefs among African American women

Abstract OBJECTIVE-Examine the longitudinal effects of personal narratives about mammography and breast cancer compared with a traditional informational approach. METHOD-African American women (n=489) ages 40 and older were recruited from lowincome neighborhoods in St. Louis, MO and randomized to watch a narrative video comprised of stories from African American breast cancer survivors or a content-equivalent informational video. Effects were measured immediately post-exposure (T2) and at 3-(T3) and 6-month (T4) follow-up. T2 measures of initial reaction included positive and negative affect, trust, identification, and engagement. T3 message-processing variables included arguing against the messages (counterarguing) and talking to family members about the information (cognitive rehearsal). T4 behavioral correlates included perceived breast cancer risk, cancer fear, cancer fatalism, perceived barriers to mammography, and recall of core messages. Structural equation modeling examined inter-relations among constructs. RESULTS-Women who watched the narrative video (n=244) compared to the informational video (n=245) experienced more positive and negative affect, identified more with the message source, and were more engaged with the video. Narratives, negative affect, identification, and engagement influenced counterarguing, which in turn influenced perceived barriers and cancer fatalism. More engaged women talked with family members more, which increased message recall. Narratives also increased risk perceptions and fear via increased negative affect. CONCLUSIONS-Narratives produced stronger cognitive and affective responses immediately, which in turn influenced message processing and behavioral correlates. Narratives reduced counterarguing and increased cognitive rehearsal, which may increase acceptance and motivation to act on health information in populations most adversely affected by cancer disparities. MO 63108 Phone 314-286-2016, Fax 314-286-1919.wustl.edu. Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting, fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The American Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript version, any version derived from this manuscript by NIH, or other third parties. The published version is available at www.apa.org/pubs/journals/hea NIH Public Access While stories are as old as human communication, using stories to improve the public's health prompts new and exciting research questions and applications. Stories are experiencing a resurgence everywhere. StoryCorps, the world's largest oral history project, now routinely brings stories to a nation of listeners through National Public Radio and online The process of developing stories and their function may be similar across the globe, but this process is influenced by culturally-specific rules and contexts Numerous studies, reviews, and meta-analyses have examined the effect of narrative vs. non-narrative (usually statistical) information on persuasion. Findings have been equivocal; several studies have found that narratives are more persuasive Understanding the processes and mechanisms through which stories influence health-related decisions and actions is critical to maximizing their effectiveness and developing appropriate applications for use in practice settings. In contrast to informational and expository communication that presents reasons and arguments in favor of a particular course of action, narratives use storytelling and testimonials to depict events and consequences for characters . Narratives are expected to influence behavior indirectly through attitudes, norms, self-efficacy, and intention Effects of Narrative Previous Engagement, absorption, and transportation are three terms often used interchangeably to reflect an individual's cognitive and affective immersion in a story Identification has been operationalized in different ways, but in general represents perceived similarity to and liking of the characters. A more extreme definition requires viewers to take the perspective of the character; "see through their eyes" Emotions affect what people notice and remember Counterarguing involves generating thoughts that counter, discount or reject a persuasive message or its implications, thereby reducing persuasion (i.e., attitude or behavior change). Both identification and engagement are expected to block one's ability to produce strong counterarguments while hearing or reading a message, due to less critical evaluation Study Hypotheses The power of narrative communication may lie in its ability to reduce the amount and effectiveness of counterarguing and through viewer's identification with characters, which 1. Counterarguing will be negatively associated with watching the narrative vs. informational video, greater identification with the characters, and greater engagement in the video. 2. Cognitive rehearsal (i.e., talking to others) will be positively associated with affective responses to the video, identification with the characters, and engagement in the video. Counterarguing also may be positively associated with cognitive rehearsal. 3. The recall of key messages will be positively associated with watching the narrative vs. informational video, greater emotional responses to the video, greater engagement, and greater cognitive rehearsal (i.e., talking to family). Counterarguing also may be positively associated with recall of key messages. 4. Perceived risk and pro-message attitudes (i.e., low perceived mammography barriers) will be positively associated with watching the narrative vs. informational video and identifying with the characters. Methods Data were collected as part of a randomized trial to compare women's mammography use after watching either a narrative or informational video . The narrative video was comprised of personal stories from African American breast cancer survivors. A content-equivalent informational video provided information about breast cancer and mammography in a didactic, expository form narrated by an African American woman. This report focuses on the longitudinal effects of watching the video with particular focus on the inter-relations between constructs that are important in theories of health communication and narrative effects. Details about the trial including recruitment, participation, and intervention development, pre-testing, and content are reported elsewhere and follow from previous studies . Study materials and procedures were approved by the Institutional Review Boards at Saint Louis University and Washington University in St. Louis. Participants and Procedures Between Eligibility criteria included being female, African American, age 40 years and older, never diagnosed with breast cancer, and able to complete a brief literacy screener written at the fifth-grade level. Onboard the Neighborhood Voice, participants provided informed consent and were randomly assigned to watch either the narrative or informational video and complete surveys on a 20″ touch-screen computer monitor in one of two private interview areas. Surveys were completed in the van immediately before (baseline; T1) and immediately after (T2) women watched either the narrative or informational video. Telephone surveys were completed at 3 (T3) and 6 (T4) months post-intervention. Measures Immediate outcomes were measured immediately after viewing the video (T2) and measurement models for all latent variables were tested previously Message processing variables were included in the telephone survey at 3-month follow-up (T3). Counterarguing was assessed with two items (r = .30, p < .001): "Since watching the video I had a lot of thoughts against the things said in the video" and "The information in the video is different from what I believe". Response options ranged from strongly disagree to strongly agree on a 5-point scale. A single item assessed cognitive rehearsal, "After watching the video did you talk to any family members about the new information?" (yes/ no). Behavioral correlates were measured on the 6-month follow-up survey (T4) and were selected because they have been correlated with mammography use in the literature. Cancer fear (alpha = .78) was assessed with three items from a previously validated 8-item scale e.g., "Thinking about breast cancer scares me a lot" (V.L. Data Analysis We used a structural equation model (SEM) to examine the hypothesized direct and indirect effects of narrative vs. informational cancer communication. SEM is well suited to our aims because in a single analysis we can examine the inter-relations between multiple variables over time. Additionally, we can include a combination of latent and manifest variables and account for measurement error which allows for greater precision in our estimates. We tested a saturated structural equation model (SEM) that conformed to our three periods of data collection which included all possible structural paths. Measures at each timepoint were allowed to correlate. Non significant paths and covariances were deleted from the final model. Modification indices were consulted for potential improvements in model fit. SEM analyses were conducted with Mplus 5.2. Two endogenous variables (talked to family, message recall) were dichotomous and therefore we used the WLSMV estimation method with full information maximum likelihood. Tests of indirect effects were computed in Mplus using the Delta method to identify significant mediators in the model. We used multiple fit indices to evaluate overall model fit including the comparative fit index (CFI) and Root Mean Square Error of Approximation (RMSEA). CFI values between 0.90-0.95 or above suggest adequate to good fit Results Sample characteristics Most women had a high school education or less (67%), an annual household income of $20,000 or less (77%), and a prior mammogram (89%). Among women age 40-49, 59% had a mammogram in the 24 months prior to the intervention. Among women age 50 and older, 56% had a mammogram in the 12 months prior to the intervention and 78% had a mammogram in the 24 months prior to the intervention. The average age was 61 years old (SD=12). Intervention groups were equivalent at baseline (T1) on demographics, cancerrelated beliefs, and behaviors . Affect, identification, trust and engagement were all measured immediately after watching the video (T2) and were positively correlated As shown previously Indirect effects We identified significant, indirect effects of the narrative video on all follow-up measures Discussion This study addressed a need for more theory-based experimental research on the effects of narrative communication Counterarguing played a central and important role in our model of the longitudinal effects of narrative vs. informational videos. Effective counterarguing is typically associated with less attitude change. Not all individuals process risk information in a rational, unbiased way, and knowing the counterarguments people generate may allow researchers to address and circumvent these thoughts in health communication materials. Similarly, health communications that elicit a large amount of counterarguments and increase the likelihood of message rejection should be abandoned. Consistent with the literature Researchers often ask recipients of health information whether they shared the materials or talked about the information with others. Such sharing suggests the information was perceived as interesting or useful, and talking about it with others provides cognitive rehearsal and social reinforcement Strengths and Limitations As with all structural equation models, model fit could have been better and alternative models may fit equally well if not better. Modification indices did not suggest substantive changes to the measurement or structural models that made theoretical or methodologic sense. The variables included in the model were selected based on the available data and the desire for parsimony and were not meant to be an exhaustive list of the important effects of narratives. Additionally, this study used brief measures to reduce participant burden while assessing numerous constructs, which negates established validity; however, our prior work demonstrated the independence and utility of latent measures, strengthening our confidence in their construct validity In this study, the effect of message format (i.e., narrative vs. information videos) was confounded with message source (multiple breast cancer survivors vs. one African American female narrator). The purpose of this study was not to isolate the storyteller from the story, but to examine the effect of experiential stories concerning a public health problem. Future studies interested in teasing apart the effects of message format vs. message source could compare cancer survivor(s) who share factual information only vs. stories. McQueen et al

The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity.

Health disparities persist despite ongoing efforts. Given the United States' rapidly changing demography and socio-cultural diversity, a paradigm shift in behavioral medicine is needed to advance research and interventions focused on health equity. This paper introduces the ConNECT Framework as a model to link the sciences of behavioral medicine and health equity with the goal of achieving equitable health and outcomes in the twenty-first century. We first evaluate the state of health equity efforts in behavioral medicine science and identify key opportunities to advance the field. We then discuss and present actionable recommendations related to ConNECT's five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training. The framework holds significant promise for furthering health equity and ushering in a new and refreshing era of behavioral medicine science and practice

Social Isolation and Mortality in US Black and White Men and Women

Social isolation is associated with higher mortality in studies comprising mostly white adults, yet associations among black adults are unclear. In this prospective cohort study, we evaluated whether associations of social isolation with all-cause, cardiovascular disease, and cancer mortality differed by race and sex. Adults enrolled in Cancer Prevention Study II in 1982/1983 were followed for mortality through 2012 (n = 580,182). Sex- and race-specific multivariable-adjusted hazard ratios and 95% confidence intervals were estimated for associations of a 5-point social isolation score with risk of death. Social isolation was associated with all-cause mortality in all subgroups (P for trend ≤ 0.005); for the most isolated versus the least isolated, the hazard ratios were 2.34 (95% confidence interval (CI): 1.58, 3.46) and 1.60 (95% CI: 1.41, 1.82) among black men and white men, respectively (P for interaction = 0.40) and 2.13 (95% CI: 1.44, 3.15) and 1.84 (95% CI: 1.68, 2.01) among black women and white women, respectively (P for interaction = 0.89). The association did not differ between black men and black women (P for interaction = 0.33) but was slightly stronger in white women than in white men (P for interaction = 0.01). Social isolation was associated with cardiovascular disease mortality in each subgroup (P for trend < 0.03) but with cancer mortality only among whites (P for trend < 0.0001). Subgroup differences in the influence of specific social isolation components were identified. Identifying and intervening with socially isolated adults could improve health outcomes

The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity.

Health disparities persist despite ongoing efforts. Given the United States' rapidly changing demography and socio-cultural diversity, a paradigm shift in behavioral medicine is needed to advance research and interventions focused on health equity. This paper introduces the ConNECT Framework as a model to link the sciences of behavioral medicine and health equity with the goal of achieving equitable health and outcomes in the twenty-first century. We first evaluate the state of health equity efforts in behavioral medicine science and identify key opportunities to advance the field. We then discuss and present actionable recommendations related to ConNECT's five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training. The framework holds significant promise for furthering health equity and ushering in a new and refreshing era of behavioral medicine science and practice

The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity

Health disparities persist despite ongoing efforts. Given the United States’ rapidly changing demography and socio-cultural diversity, a paradigm shift in behavioral medicine is needed to advance research and interventions focused on health equity. This paper introduces the Con-NECT Framework as a model to link the sciences of behavioral medicine and health equity with the goal of achieving equitable health and outcomes in the twenty-first century. We first evaluate the state of health equity efforts in behavioral medicine science and identify key opportunities to advance the field. We then discuss and present actionable recommendations related to ConNECT’s five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training. The framework holds significant promise for furthering health equity and ushering in a new and refreshing era of behavioral medicine science and practice