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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 lowinvolvement 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
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