The Effects of Involvement
Using Narratives Features to Reduce Attitudinal Barriers towards Depression and Strengthen Help-seeking Intention
Raymond Qin 12050458 Master’s Thesis
Graduate School of Communication Master’s programme Communication Science
Advisor: Jeroen Lemmens January 31st 2020
Abstract
Despite its high global prevalence, individuals who suffer from mental illnesses face many barriers to obtaining professional help and receiving the treatment they need to recover. This study aims to discover how narratives can be used to remove attitudinal barriers and enable individuals who suffer from depression to seek professional help.
An online 2x2 experiment with a condition was conducted to test narrative features in interactivity and the inclusion of efficacious from the Entertainment Overcoming Resistance Model to leverage involvement to affect self-stigma, social-stigma and help-seeking intention.
The One-way Analysis of Variance conducted across all conditions with self-stigma, social-stigma and help-seeking intention as the dependent variable showed that there were no significant mean differences amongst the conditions with and without interactivity based on the inclusion and exclusion of an efficacious character in the narrative.
The Pearson’s Correlation Analysis conducted between variables (e.g., self-stigma, Social-stigma, help-seeking intention, and involvement) showed potential combinations of entertainment feature that may be effective for future interventions for depression. Self-stigma was significantly associated to involvement, Social-stigma and depression; Social-stigma was significantly associated to involvement, help-seeking intention and self-stigma; Help-seeking intention was significantly associated to social-stigma and depression; and Involvement was significantly associated to self-stigma, social-stigma and depression.
Although there were no differences in the feature narratives, future studies are recommended to use variations of the features and concepts in involvement to vet the effectiveness of entertainment education in shifting attitude and help-seeking intentions. Keywords: involvement, narratives, depression, intervention
Introduction
Despite its high global prevalence, individuals who suffer from mental illnesses face many barriers to obtaining professional help and receiving the treatment they need to recover (Kohn, Saxena, Levav, & Saraceno, 2004). According to the World Health Organisation (WHO), mental disorders are amongst the leading causes of global ill-health and disability (Mental, 2013). Anxiety and depression are the two leading disorders recognized as pandemic reasons for disability; these disorders lower both mental and physical health and they have a prevalent correlation with suicides, affecting global morbidity and mortality (Tay, Tay, & Klainin-Yobas, 2018). Although treatments for depression are available to the public, the WHO found that nearly 55% of the world’s population with known mental disorders never seek help from a health professional due to stigma and discrimination (Mental, 2013). Regardless of institutional recognition, there is a significant treatment gap between those who require professional treatment and the initiation to seek it out due to stigma (Brijnath, Protheroe, Mahtani, & Antoniades, 2016).
Although there many are interventions that have proven successful in increasing mental health literacy, interventions affecting attitudes that facilitate recognition and appropriate help-seeking (i.e., self-stigma) serve as an important bridge to connect individuals the professional help they need (Wang, et al., 2015). Forming the intention to seek help is influenced not only by the presence of the mental illness itself, but also by the presence of negative public stereotypes and discrimination referred to as stigma (Corrigan, 2004). To encompass the two components of stigma, social-stigma represents the prejudice and discrimination directed at a condition by the larger population and self-stigma occurs when people internalize negative public attitudes, which can lead to numerous negative consequences (Corrigan & Rao, 2012). Theories of behavioral
prediction and behavior change are useful to provide a framework to identify the determinants of behavior as an essential first step to develop successful interventions. The Integrative Model of Behavior Change provided a framework suggesting that only a limited number of relevant variable should be included in interventions by its relative effects on human behavior. These variables are based on background influences (e.g., past behavior, demographic and culture, stereotypes and stigma, personality moods, and emotions, perceived risk and exposure) (Fishbein & Cappella, 2006). The model suggests that there are three primary determinants of intention, first being attitude towards performing the behavior, second being perceived norms towards performing the behavior, and third being self-efficacy with respect to performing the behavior. It is explained that the more one knows about the determinants of a given behavior, the more likely it is that one can develop an effective communication strategy to reinforce or change the
behavior (Fishbein & Cappella, 2006). The weighted importance of the determinants depends on the targeted behavior and the characteristics of the population being considered for the
intervention. Understanding that the behaviors are more likely to occur if one has strong intention to perform, and given that concerned individuals hold attitudinal barriers for help-seeking, this study aims to discover how narratives can be used to remove these barriers and empower individuals to seek treatment. Other studies showed that first-person narratives can be used as a powerful health behavior persuasion tools to increase risk perception and motivate health behaviors (de Wit, et al. 2008). It was theorized that involvement was the link that
transformed narratives into potent means to change health-related attitudes, beliefs and behaviors (Gebbers, et al., 2017). Understanding that attitudes towards depression is crucial to reduce the treatment gap, this study utilizes Moyer-Gusé’s Entertainment Overcoming Resistance Model
(EORM; 2008) to introduce the application of entertainment features to reduce cognitive resistances, leading to attitudinal and behavioral change.
RQ: How does involvement in narratives affect individual attitude on depression and its related help-seeking intention?
Theoretical Background
The conceptual model in Entertainment Overcoming Resistance Model based on the Social Cognitive Theory (SCT) and the Extended Elaboration Likelihood Model (E-ELM) suggests that specific narrative features increase involvement and leads to the reduction of resistance from counter-arguing, selective avoidance, and negative outcome expectancy (Moyer-Gusé, 2008). The SCT also contends that people vicariously learn through observation; in which “knowledge, values, cognitive skills and new behaviosr” exposed to the message recipients contribute towards better learning outcomes. Involvement refers to the viewers’ interest in following the storyline as it unfolds. Across literature, it has been referred to as absorption, transportation, involvement, and immersion. The core concept, however, is consistently defined as engagement in the storyline primarily, rather than a singular serendipitous instance that have caught their momentary interest.
Narrative features
The first reduction method targeting counter-arguments derived from the E-ELM explains that involvement in entertainment education reduces interpersonal arguments afflicted between personal beliefs and the message (Slater, 2002). To avoid discounted persuasive potency, the discrepancy could be reduced by introducing characters in
narratives to fosters personal identification (Rubin & Step, 2000). Furthermore, rather than discounting the persuasive message, individuals may resist by consciously avoiding certain
content due to inertia. Inertia is the idea that individuals prefer not to change their attitudes, behaviors or beliefs based on the desire to avoid unpleasant dissonance that comes with contradictions to existing beliefs (Knowles & Linn, 2004). To overcome inertia, the EORM suggests increasing the enjoyment of narratives and including referential characters that are relatable and personally relevant to the audience (Cohen, 2001).
An individual’s subjective perception of reality can provide challenges to the acceptance of persuasive messages. If a behavior is perceived as normative (e.g., “it is normal to feel occasional mental discomfort”), individuals may engage in “false consensus” normalizing the behavior (e.g., “the mental discomfort that I suffer from is normal,
therefore I do not need help;” (Gerrard, Gibbons, Benthin, & Hessling, 2003). When the intention to seek help is present, self-stigma is a significant factor that could discourage its execution (Brijnath, et al., 2016). To reduce self-stigma and enable a smooth transition between intention and behavior, the EORM suggests the introduction of characters that resonate as normative referents among viewers in ways that contradict the existing perceived norms (Moyer-Gusé, 2008). The framing of this entertainment feature is more effective when the character overcomes the presented obstacles rather than exhibiting avoidant behavior, the character’s decision to disengage would then have the reverse effect causing resistance. (Brown, Childers, & Waszak, 1990).
Outcome expectancies refer to the observer’s perception of the consequences that could result from a behavior. A biased outcome expectancy strongly affects an individual’s intention and motivation to conduct certain actions (Bandura, 1986). To overcome the negative outcome expectancies of help-seeking intention for depression and the self-inflicted feeling of societal reprimand (i.e., self-stigma), a program narrative that rewards
characters for their wanted behavior should be included to indicate positive consequential reinforcement. Successful characters, whom the viewer perceives as similar to themselves or finds attractive, further affect the magnitude of outcome expectancies and are considered efficacious. This positively motivates and reinforces the behavior in the mind of the
viewers, whereas behavior that is punished is negatively reinforced (Bandura, 2004). H1: There is a difference between help-seeking intention for depression, social attitude and personal attitude towards depression amongst conditions with different narrative features. H2: The narratives combination of efficacious characters with positive outcomes are more involving than narratives with non-efficacious characters with negative outcomes, thus more effective in reducing barriers to message resistance.
Narrative Interactivity
The concept of involvement also refers to the extent that individuals are absorbed into a story or transported into a narrative world. The EORM conceptualized involvement as a mental process where the integration of attention, imagery and feelings have an impact on individual real-world beliefs (Green & Brock, 2000). It is argued that transported (involved) individuals can be so absorbed in the story that they would be less resistant to challenges that conflict with their existing beliefs (Green & Brock, 2000). To reduce stigma and strengthen help-seeking intention, mechanism to reduce counterargument by increasing involvement should be included.
H3: Narratives with interactions are more involving than narratives without interactions. Method
Sample
For reasons of feasibility, convenience and snowball sampling were employed to recruit participants for the experiment. Recruitment was completed via online social networking
platforms such as Reddit, Facebook, mental health forums, and monetary incentivized
recruitment via Amazon Mturk, Prolific and SurveySwap. Due to the nature of the study, certain traits were demanded from the participants. First, they must have shown an interest in depression and have been willing to read through explicitly stressful experiences that could trigger negative thoughts. Next, they must all score an average above 2 on the depression assessment and pass the manipulation test embedded in the experiment to be considered for analysis. Ideally, the
participants would have competent English literacy skills, so they could understand the information presented; this is required of them to reflect upon their personal feelings and thoughts in response.
There were a total of 821 individual cases gathered from the online experiment (see Appendix). Descriptive analyses were conducted to test variables in the experiment
conditions, depression assessment (M=2.21, SD=0.74), exposure check and to see if any invalid values were to be excluded from the analyses. To ensure the quality of the data is fit for inferential analyses, partially answered cases, cases with failed manipulation checks and cases with a mean lower than 2 on the depression assessment were excluded from the study. After 294 cases were removed from the total sample, there were 527 valid cases for analysis.
Procedure
A two by two experiment was conducted via Qualtrics for segmentation and featured purposes. The participant data was exported from the platform for analysis in SPSS. A text-based fiction game (Depression Quest) was used as a framework to create an environment that would include efficacious characters, positive outcomes, and interactivity (Quinn, 2003). The narrative features identified from the theoretical framework was
divided into pages for sequential exposure within each experimental condition. The theme of the narrative was presented as an everyday life scenario in the first-person perspective. The participants were guided through tasks as someone living with depression, and were presented with details about how the character attempts to manage illness, relationships, job and possible treatments.
After the initial introduction of the study, participants read a passage with background information on the character’s existing relationship status, current depression status, and a description of their current social and professional affairs. The sequence of events was the same amongst conditions. The narratives started with the character arriving home and experiencing distress from unfinished work. The character then met a friend to potentially discuss their depression, subsequently reached out to a therapist for an initial consultation, experienced a bad day at work with a migraine, and possibly have chosen to leave work without notice. Lastly, a narrative describing the outcomes of the choices that the character had made in each respective scenario was presented.
The experiment included four experimental conditions and a control condition. The experimental conditions were comprised of (Condition A, n=91) the interactive scenario with an efficacious character, (Condition B, n= 84) the non-interactive scenario with an efficacious character, (Condition C, n=105) the interactive scenario with a non-efficacious character, and (Condition D, n =94) the non-interactive scenario with a non-efficacious character. The control condition (n=153) was not exposed to any scenarios. The estimated time for the participants to complete the experiment was approximately 10 minutes (approximately six minutes to read the narrative and potentially make selections and four minutes to answer the questionnaire). All five conditions were asked to answer a series of questions about their attitudes (i.e., self-stigma and
social-stigma) towards depression and their intention to seek help for depression if it were to affect them.
The variation of the narratives was divided between the conditions with either an efficacious character (Condition A & Condition C) or a non-efficacious character (Condition B & Condition D). For the conditions with an efficacious character, the character would disclose their depression status to their friend and proceed to accept their referral to a professional therapist. The outcome of this series of events resulted in the character’s relief from some of their depression concerns, showing signs of improvement with a good night sleep and an improved mood. The non-efficacious character ignored their friend’s inquiry about their depression and did not accept the referral to the therapist. The outcome of this series of events resulted in heightened symptoms of depression, with a restless night and worsened mood.
The mechanism used as narrative interaction for transportation was conveyed through the inclusion and exclusion of the selection feature. The selection feature refers to a function in the study that gave the participants the perception of control over the
character’s behavior. These selections were implemented so participants would feel that the choices they made for the character were impactful, and directly affected the outcome. By employing the multiple-choice function in Qualtrics, participants were able to select the toggles on the page as a choice of action before proceeding to the next page. To prevent the participants from being aware of the limited narratives outcomes, two survey features were implemented accordingly. Force-response was enabled for each of the experimental conditions to prevent participants from making the mistake of skipping ahead. The function would then stop them from being prematurely exposed to the subsequent scenarios and realize that the selection feature was not impactful to the results. The back button would also jeopardize the purpose of
the selection feature for the same reason and was disabled to prevent participants from returning to previous interfaces to change their answers. At the end of the questionnaires, participants are given the opportunity to provide comments and suggestion to the experiment in open text. The last page would also provide participants with some online resources on depression self-help and educational content on different types of depression.
Measures
Help-seeking intention
This measure indicated the degree in which participants were likely to search for help when they feel the need to receive help for depression. Help-seeking intention was measured using three items based on the Mental Help-Seeking Intention Scale (Hammer & Spiker, 2018). Sample items include, ‘if I feel depressed, I will seek out professional help’, ‘if I feel depressed, I will seek out therapy’ and ‘if I feel depressed, I will not seek out for any help’ (reserve coded). Response options varied from one to five ranging from ‘Strongly disagree’ to ‘Strongly agree.’ An instrument was constructed by combining the three scaled items into one mean scale. The higher the value the stronger level of help-seeking intention. The help-seeking Intention measure proved reliable with a Cronbach’s alpha of .84
(M=3.13, SD=1.10). Social-stigma
This measure indicated the degree in which participants directs prejudice and
discrimination towards depression in the larger population (Botha, Shamblaw & Dozois, 2016). Social-stigma was measured using three items based on an instrument to measure attitudes towards depression and its treatments in patients suffering from non-psychotic depression (Gabriel & Violato, 2010). Sample items include, ‘People should not openly talk about
depression’, ‘Depression shows a weakness of character’ and ‘Depression is not a severe issue in my community’. Response options varied from one to five ranging from ‘Strongly disagree’ to ‘Strongly agree.’ An instrument was constructed by combining the three scaled items into one mean scale. The higher the value, the higher level of discrimination towards others with depression. The social-stigma measure proved reliable with a Cronbach’s alpha of .68 (M=1.88, SD=0.90).
Self-stigma
This measure indicated the degree in which participants are likely to have internalized prejudice and discrimination towards being depressed. Self-stigma was measured by three items based on an instrument to measure attitudes towards depression and its treatments in patients suffering from non-psychotic depression (Gabriel & Violato, 2010). Sample items include, ‘Depression will not happen to me’, ‘I believe that I am not
susceptible to depression’ and ‘Depression is not a serious issue to me’. Response options varied from one to five ranging from ‘Strongly disagree’ to ‘Strongly agree.’ An instrument was constructed by combining the three scaled items into one mean scale. The higher value, the higher level of internalized prejudice they hold towards themselves being depressed. The self-stigma measure proved reliable with a Cronbach’s alpha of .85 (M=1.94, SD=1.04). Involvement
This measure indicated the degree in which participants are likely to have resonated with the storyline and the character in the narrative. Involvement was measured by four items based on The Narrative Engagement Scale (Busselle & Bilandzic, 2009). Sample items include, ‘I was mentally involved in the story while viewing’, ‘While viewing I was completely immersed in the story’, ‘At key moments, I felt I knew exactly what the characters were going
through emotionally’ and ‘At important moments in the film, I could feel the emotions the characters felt.’ Response options varied from one to five ranging from ‘Strongly disagree’ to ‘Strongly agree.’ An instrument was constructed by combining the four scaled items into one mean scale. The higher the value, the more involved they are in the storyline and the character. The involvement measure proved reliable with a Cronbach’s alpha of .80 (M=3.78, SD=1.13).
Depression
This measure indicates the degree of severity of self-reported depression symptoms. The level of depression was measured by nine items based on an assessment on the Validity of a Brief Depression Severity Measure (Kroenke, Spitzer, & Williams, 2001). The assessment items include, ‘Have you found little pleasure or interest in doing things?’ ‘Have you found yourself feeling down, depressed or hopeless?’ ‘Have you had trouble falling or staying asleep, or sleeping too much?’ ‘Have you been feeling tired or had little energy?’ ‘Have you had a poor appetite or been overeating?’ ‘Have you felt that you’re a failure or let yourself or your family down?’ ‘Have you had some trouble concentrating on things like reading the paper or watching TV?’ ‘Have you been moving or speaking slowly, or been very fidgety, so that other people could notice?’ ‘Have you thought that you would be better off dead?’ Response options varied from one to four ranging from ‘not at all’ to ‘all the time.’ An instrument was constructed by combining the nine scaled items into one mean scale. The higher the value, the higher levels of self-reported symptoms of depression. The depression measure proved reliable with a Cronbach’s alpha of .80 (M=2.21, SD=0.74).
Main Analysis
To find out if there was a mean difference between help-seeking intention for
depression, social-stigma and self-stigma towards depression across conditions, an One-way Analysis of Variance was performed using these variables as the dependent variable, and the experimental condition groups as the independent variable. The One-way ANOVA revealed that there were no significant mean differences in Help-seeking Intention, Social-stigma, and Self-stigma between the conditions. Help-seeking Intention, F(4,621) = 0.817, p=.515. Social-stigma, F(4,615) = 0.97, p=.421. Self-Social-stigma, F(4,610) =1.92, p=.106.
Table 1
Mean scores on Help-seeking intention, Social-stigma, Self-stigma and across conditions Condition A Condition B Condition C Condition D Control Help-seeking M=3.21 SD=0.06 M=3.18 SD=1.02 M=3.11 SD=1.08 M=2.97 SD=1.20 M=3.16 SD=1.16 Social-stigma M=1.93 SD=0.93 M=1.89 SD=0.77 M=1.81 SD=0.89 M=1.85 SD=0.90 M=1.89 SD=0.95 Self-stigma M=2.14 SD=1.05 M=1.88 SD=0.99 M=1.87 SD=1.07 M=1.96 SD=1.04 M=1.88 SD=1.04 Note: Mean scores within rows with identical superscripts (a,b,c,d,e) indicate significant differences at least p <.05.
For Help-seeking Intention, there were no significant mean differences between the conditions. Although the differences are not significant, the results showed that individuals who scored high on the depression assessment have relatively strong help-seeking intentions.
For Social-stigma, there were no significant mean differences between the conditions. individuals who scored high on the depression assessment in the sample reported to have relatively low Social-stigma, showing that the participants were not particularly discriminatory towards others who are depressed.
For Self-stigma, there were also no significant mean differences between the conditions. individuals who scored high on the depression assessment in the sample reported to have low Self-stigma, showing that the participants do not hold strong internalized discrimination against depression.
Efficacious Character
To find out if a narrative with an efficacious character is more involving than a narrative with a non-efficacious character, an independent sample T-test was performed with involvement as the dependent variable and the combination of the conditions with efficacious character (Condition 1 and Condition 2) and non-efficacious character (Condition 3 and Condition 4) as the independent variables. The Leven’s Test for Equality of Variance indicated a non-significant mean difference between the conditions with efficacious character and with non-efficacious character (Mdiff=0.04). F(372)=0.23, p=.631, t(372)=0.37, 95% CI [-0.19, 0.27]. The t-test has shown that the inclusion of efficacious characters in narratives does not affect involvement regardless of interactivity.
Table 2
Mean scores on involvement across scenarios with efficacious and non-efficacious character. Efficacious (n=175) Non-efficacious (n=199)
Involvement M=3.80 SD=1.13
M=3.76 SD=1.13
Note: Mean scores within rows with identical superscripts (*) indicate significant differences at least p <.05
Interactivity
To find out if a narrative with interactivity is more involving than a narrative without interactivity, an independent sample T-test was performed with involvement as the dependent variable and the combination of the conditions with interactivity (Condition 1 and Condition 3) and without interactivity (Condition 2 and Condition 4) as the independent variables. The Leven’s Test for Equality of Variance indicated a non-significant mean difference between the conditions with interactivity and without interactivity (Mdiff=0.07), F(372)=0.21, p=.648, t(372)=-0.62, 95% CI [-0.30,0.16]. The T-test has shown that interactivity does not affect involvement regardless of the efficacious character.
Table 3
Mean scores on involvement across scenarios with and without interactivity. With (n=196) Without (n=178)
Involvement M=3.75 SD=1.11
M=3.81 SD=1.14
Note: Mean scores within rows with identical superscripts (*) indicate significant differences at least p <.05
Correlations between variables
To evaluate the strengths of association between the variables, Pearson’s correlation was performed between Involvement, Help-seeking intention, Self-stigma, Social-stigma and
Depression. Involvement
The variables involvement and self-stigma were found to be weakly and negatively correlated, r(361)=-.27, p<.01, showing the association that stronger involvement leads to weaker self-stigma with 7% variance explained (R2=.07). The variables involvement and social-stigma were found to be weakly and negatively correlated, r(265)= -.12, p=.026, showing the association that stronger involvement leads to weaker social-stigma with 10% variance explained (R2=.01) The variables involvement and depression were found to be moderately and positively correlated, r(341)= .36, p<.01, showing the association that stronger involvement leads to higher levels of depression with 13% variance explained (R2=.13). Involvement was significantly associated to self-stigma, social-stigma and depression.
Help-seeking intention
The variables help-seeking intention and social-stigma were found to be weakly and negatively correlated, r(514)= -.15, p<.01, showing the the association that stronger help-seeking intention leads to weaker social-stigma with 2 % variance explained (R2=.02). The variables help-seeking intention and depression were found to be weakly and negatively correlated, r(485)= -.16, p<.01, showing the the association that stronger help-seeking intention leads to weaker lower levels of depression with 3% variance explained (R2=.03). Help-seeking intention was significantly associated to social-stigma and depression.
Self and Social-stigma
The variables self-stigma and social-stigma were found to be strongly and positively correlated, r(509)= .60 p<.01, showing the the association that stronger levels of self-stigma leads to stronger levels of social-stigma, and vice-versa. There was 36% of the variance explained between the two variables (R2=.36). The variables self-stigma and depression were found to be weakly and negatively correlated, r(485)= -.25, p=.01, showing the the association
that stronger levels of self-stigma leads to lower level of severity in self-reported depression with 6% variance explained (R2=.06). However, the variables social-stigma and depression were not found to be correlated with a slight margin for significance, r(485)= .08 p=0.08. Social-stigma was significantly associated to involvement, help-seeking intention and self-stigma. Self-stigma was significantly associated to involvement, Social-stigma and depression.
Table 4
Pearson correlations on involvement, help-seeking intention, self-stigma, social-stigma, and depression. 1 2 3 4 5 1. Involvement 2. Help-seeking intention 3. Self-stigma 4. Social-stigma 5. Depression - -.05 -.27** -.12* .36** - .03 -.15** -.16** - .60** -.25** - 0.08 -
*Correlation is significant at the 0.05 level (2-tailed) ** Correlation is significant at the 0.01 level (2-tailed)
Discussion
Through experimentation, this study examined the effect of narrative features on attitudes towards depression and stigma reduction towards depression via involvement enhancement. The EORM suggests interventions of a narrative structure are an effective method for persuasive behavior change in this context. As such, the narrative structure included an efficacious character who was relatable and perceived to be similar to
intention and the integration of interactions between the participant and the character. These features should affect the level of involvement from the audience resulting in the best learning outcomes and persuasion for actionable behavior change. Recognizing the importance of attitude as a determinant to behavioral change, this study attempted to test whether different narrative features and interactivity can be used to make a positive impact on
formulating innovative interventions for people suffering from depression. From initial
expectations, the inclusion of interactivity and a narrative featuring an efficacious character were expected to be more involving than its exclusion. However, results showed that although the participants all exhibited strong help-seeking intention and positive attitude towards depression, there were no clear differentiation factors that proved that interactivity and the inclusion of an efficacious character had influenced them.
As definition for involvement in the Narrative Engagement Scale extends to 10 factors (e.g. empathy, sympathy, cognitive perspective taking, loss of time, loss of self-awareness, narrative presence, narrative involvement, distraction, ease of cognitive access, narrative realism) (Busselle & Bilandzic, 2009), the operationalization of involvement was limited to scale items pertaining to only empathy in the study. Future studies are recommended to recreate the experiment using the combination of different instrument to find out if there are significant differences between the condition groups with varied narrative features.
Understanding the complexity in a patients’ road to recovery, it should also be noted that illnesses such as depression and anxiety exhibit both chronic and acute symptoms and are usually not resolved within a short period of time (Fu & Parahoo, 2009). Although the narratives
presented told participants that the efficacious character was no longer suffering from insomnia caused by depression, it did not provide any long-term resolution or tools. The study’s practical
implication was to improve the attitudes towards help-seeking intention, leading towards more appropriate help-seeking behavior. The purpose of this study was to use the findings to raise awareness and increase proactivity towards depression issues in a positive, reactive matter. The indicator of successful intervention would be that individuals who have identified their
depression problems would reach out to resources for treatment and receive the healthcare attention they need to recover. Effective interventions for reactive measures with fear appeals often require the message content to provide the targeted receiver with effective tools to solve the presented issues (Tannenbaum, et al., 2015). It is possible that the presented solution in the study was not apparently useful enough for the participants to recognize the solution to alleviate symptoms of depression. It is also possible that the participants from the study did not experience the need for help or elicit concerns high enough for the tested variables to be affected by the conditions. Remedies for mental illnesses are complex formulas for physical and mental recovery, involving not only medicinal prescriptions but also therapy-based intervention that help patients to overcome personal barriers and learn how to cope with certain emotional distress. Understanding that it takes times and effort therapy-based intervention to take preventative effect in the escalation of mood worsening triggers for depression, the study attempted to depict the character’s gradual recovery towards alleviating symptom of depression as an effort to make the expected outcome of an one-time therapy session more realistic.
However, the lack of immediate resolution to a problem could be limitation to finding a
significant relationship between the independent variables (interactivity and narrative features) and the dependent variables (help-seeking intention, social-stigma and self-stigma) because the audience might not view the character as efficacious. To ensure the effectives of entertainment education as a mean to improve attitude and strengthen health-seeking intention, future studies
are encouraged to provide explicit clarification to how performing certain tasks can combat and prevent certain depression symptoms. This would assert the efficaciousness of the character and make narratives more involving, thus contributing towards shifting attitudes and strengthening help-seeking intention.
Correlational analysis was conducted to evaluate the strengths of associations between the variables (e.g., Involvement, Help-seeking Intention, Self-stigma, Social-Stigma and
Depression). Through analysis, implications for future research could be derived from the results to develop effective interventions for attitude change and strengthening help-seeking intentions. The results showed that higher level of empathy is associated to lower levels of stigma and higher levels of depression. This association can be explained that those who felt more empathetic towards the character would report lower level of stigma (e.g., self and social) and those are who exhibited lower levels of stigma would empathize more with the character in the narrative. Naturally, viewers who were more involved would also feel more depressed as a result. Individuals are often perceived as abnormal for self-identifying as being depression due to the absence of empathy to their distress (Issakainen, 2014). A study conducted to examine
whether individuals with and without depression differ in their perspective and valuations of depression showed that the general population valued depression less negatively than those suffering from depression (Papageorgiou, et al., 2015). Thus, the discussions from the study concluded that using a public lens to developed interventions for depression to be less effective for people affected by mild to severe depression. To ensure the evaluation of the severity of depression and the risks of manifesting depression is recognized by a spectrum of individuals in the public, strategies emphasizing on empathy is hypothesized to reduce stigma for depression. Evidence showed that stigma reducing interventions for unemployed males in the construction
industry had successfully changed attitudes towards depression and strengthened help-seeking behavior (Milner, Witt, Burnside, Wilson, & Lamontagne, 2015). Understanding that the intervention was successful partially due to tailoring content for specific target groups by
addressing the behavior change determinants relevant to developing effective interventions. This study can be further improved and replicated by defining specific background characteristics of individuals to find the effects of involvement on attitude and help-seeking intention. From the previously mentioned limitation that the involvement scale was solely operationalized by empathy, it is possible that under the influence of empathy, interactivity and the presence of an efficacious character could be significantly associated to help-seeking intention.
The result also reported that higher levels of depression and stronger social-stigma led to weaker help-seeking intentions. This association can be explained that those who were more depressed and held stronger discriminatory social values towards those with depression are less likely to seek help for depression. There are many factors to consider when explaining why someone suffering severe level of depression would have less intention to seek help. Many of the symptoms for depression include loss of energy, loss of motivation, substance abuse, and loss of sense of self can discourage individuals to seek help. One study also showed that half of the depressed individuals from a longitudinal study for major depression were not aware of their depression, and not identified by their general health practitioner either (Kleinberg, Aluoja, & Vasar, 2012). This raised awareness to the importance of improving public understanding of mental health problems like depression for its prevalence in society. Without proper
identification of depression from those who are susceptible to symptom escalation, it would be even more difficult for them to seek initial help considering the associated physical and mental disabilities (e.g. loss of motivation, loss of energy, substance abuse). Understanding that
professional treatment for depression might not always be accessible to the public, a study has also shown that treatments for major depressive disorder are not very successful in improving functional and health outcomes (Buntrock, et al., 2016). It recommended that the attention should be focused on the prevention of the disorder with web-based guided self-help
interventions to deescalate the development of major depressive disorder (Buntrock, et al., 2016). With the presented barriers to strengthen help-seeking intention amongst those with major
depression, it seems like there are more feasible opportunities for narrative to be effectively executed in prevention and self-help interventions. Prospective researchers are advised that intervention with narrative structures should be targeted towards individuals who are not severely depressed.
Lastly, since self-stigma and social-stigma are derived from the same concept, there was a strong positive reciprocal association between the two variables in the study. From the results, it also showed that social-stigma was significantly associated to involvement, help-seeking intention and self-stigma but not depression. Self-stigma was significantly associated to involvement, social-stigma and depression but not help-seeking intention. Perceived public stigma and self-stigma both significantly delay help seeking (Wang, et al., 2015) and in other studies, self-stigma has been found to mediate the relationship between public stigma and help-seeking attitudes among people suffering from depression (Brown, et al. 2010 & Wang, et al. 2015). The study suggested that willingness to seek help is predicted not only by public opinion but also by that individual’s perception of mental illness. Public stigma is proven to deter individuals to seek help for depression due to negative stereotypes on the well-being of individuals (Wang, et al., 2015). These discriminatory labels are often held collectively by a community of people, and individuals often do not intent to seek help due to not wanting to be
ostracized by the collective. With a plethora of studies mentioning that both self-stigma and social stigma are determinants for behavior change in help-seeking intention for depression, health practitioners are recommended to use these findings to create effective intervention to overcome help-seeking resistance. The Entertainment Overcoming Resistance Model in the study presented an effective entertainment feature that changes perceived norms. By developing a para-social relationship between the audience and the media character in a narrative
intervention, it could potentially change individual’s attitude towards seeking help for depression (Moyer-Gusé, 2008). A study on effective interventions to reduce mental-health-related stigma showed that narratives including social contact with equal status, inter-group cooperation and common goals between groups seem to be most effective features to disconfirm negative beliefs about mental illness, leading to behavior change (Thornicroft, et al., 2016). These features are also recommended to relevant researcher to explore and noted by health communication practitioners.
Conclusion
The study showed that although the narrative features suggested by the Entertainment Overcoming Resistance Model were not effective towards changing attitudes and strengthening help-seeking intention, there is potential that entertainment education can be an effective means to support mental health interventions. This study’s effort to evaluate the contribution of
involvement towards reducing resistance in selective avoidance and biased outcome expectancy has shown that variables in the experiment were significantly associated; Self-stigma was significantly associated to involvement, social-stigma and depression; Social-stigma was significantly associated to involvement, help-seeking intention and self-stigma; Help-seeking intention was significantly associated to social-stigma and depression ; and Involvement was
significantly associated to self-stigma, social-stigma and depression. Future research is advised to use different combinations of involving narrative features to test for effects for the
References
Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. (2004). Social cognitive theory for personal and social change by enabling media. In A. Singhal, M. J. Cody, E. M. Rogers, & M. Sabido (Eds.), Entertainment-Education and Social Change: History, Research, and Practice (pp. 75–96). Mahwah, NJ:
Botha, F. B., Shamblaw, A. L., & Dozois, D. J. A. (2016). Reducing the stigma of depression among Asian students. Journal of Cross-Cultural Psychology, 48(1), 113–131. doi: 10.1177/0022022116674598
Brijnath, B., Protheroe, J., Mahtani, K. R., & Antoniades, J. (2016). Do web-based depression literacy interventions improve the depression literacy of adult consumers? Results from a systematic review. Journal of Medical Internet Research, 18(6). doi: 10.2196/jmir.5463 Brown, J., Childers, K., & Waszak, C. (1990). Television and adolescent sexuality. Journal of
Adolescent Health Care, 11, 62–70.
Brown, C., Conner, K. O., Copeland, V. C., Grote, N., Beach, S., Battista, D., & Reynolds, C. F., III. (2010). Depression stigma, race, and treatment seeking behavior and attitudes.
Journal of Community Psychology, 38, 350–368. http://doi.org/bkwmtn
Buntrock, C., Ebert, D. D., Lehr, D., Smit, F., Riper, H., Berking, M., & Cuijpers, P. (2016). Effect of a Web-Based Guided Self-help Intervention for Prevention of Major Depression in Adults With Subthreshold Depression. Jama, 315(17), 1854. doi:
Busselle, R., & Bilandzic, H. (2009). Measuring narrative engagement. Media Psychology, 12(4), 321–347. doi: 10.1080/15213260903287259
Cohen, J. (2001). Defining identification: A theoretical look at the identification of audiences with media characters. Mass Communication & Society, 4, 245–264.
Corrigan, P. (2004). How stigma interferes with mental health care. American psychologist, 59(7), 614.
Corrigan, P. W., & Rao, D. (2012). On the self-stigma of mental illness: Stages, disclosure, and strategies for change. The Canadian Journal of Psychiatry, 57(8), 464–469. doi:
10.1177/070674371205700804
de Wit, J. B., Das, E., & Vet, R. (2008). What works best: Objective statistics or a personal testimonial? An assessment of the persuasive effects of different types of message evidence on risk perception. Health Psychology, 27, 110–115. doi:10.1037/0278-6133.27.1.110
Fishbein, M., & Cappella, J. N. (2006). The Role of Theory in Developing Effective Health Communications. Journal of Communication, 56. doi:
10.1111/j.1460-2466.2006.00280.x
Fu, C.-M., & Parahoo, K. (2009). Causes of depression: Perceptions among people recovering from depression. Journal of Advanced Nursing, 65(1), 101–109. doi: 10.1111/j.1365-2648.2008.04845.x
Gabriel, A., & Violato, C. (2010). The development and psychometric assessment of an instrument to measure attitudes towards depression and its treatments in patients suffering from non-psychotic depression. Journal of Affective Disorders, 124(3), 241–249. doi: 10.1016/j.jad.2009.11.009
Gebbers, T., De Wit, J. B., & Appel, M. (2017). Health Communication| Transportation Into Narrative Worlds and the Motivation to Change Health-Related Behavior. International Journal of Communication, 11, 21.
Gerrard, M., Gibbons, F. X., Benthin, A. C., & Hessling, R. M. (2003). A longitudinal study of the reciprocal nature of risk behaviors and cognitions in adolescents: What you do shapes what you think and vice versa. In P. Salovey & A. J. Rothman (Eds.), Social Psychology of Health: Key Readings in Social Psychology (pp. 21–46). New York, NY: Psychology Press.
Green, M. C., & Brock, T. C. (2000). The role of transportation in the persuasiveness of public narratives. Journal of Personality and Social Psychology, 79, 701–721.
Hammer, J. H., & Spiker, D. A. (2018, April). Dimensionality, reliability, and predictive evidence of validity for three help-seeking intention instruments: ISCI, GHSQ, and MHSIS. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29672088
Issakainen, M. (2014). Young People Negotiating the Stigma Around their Depression. Young, 22(2), 171–184. doi: 10.1177/1103308814521624
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in depression care. Bulletin of the World Health Organization, 82, 858-866.
Knowles, E. S., & Linn, J. A. (2004). The importance of resistance to persuasion. In E. S. Knowles & J. A. Linn (Eds.), Resistance and Persuasion (pp. 3–11). Mahwah, NJ: Lawrence Erlbaum.
Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 509–515. doi: 10.3928/0048-5713-20020901-06
Mental disorders affect one in four people. (2013, July 29). Retrieved from https://www.who.int/whr/2001/media_centre/press_release/en/.
Milner, A., Witt, K., Burnside, L., Wilson, C., & Lamontagne, A. D. (2015). Contact & connect—an intervention to reduce depression stigma and symptoms in construction workers: protocol for a randomised controlled trial. BMC Public Health, 15(1). doi: 10.1186/s12889-015-2394-x
Moyer-Gusé, E. (2008). Toward a theory of entertainment persuasion: Explaining the persuasive effects of entertainment-education messages. Communication Theory, 18(3), 407-425. Rubin, A. M., & Step, M. M. (2000). Impact of motivation, attraction, and parasocial interaction.
Critical Studies in Mass Communication, 3, 184–199.
Papageorgiou, K., Vermeulen, K. M., Schroevers, M. J., Stiggelbout, A. M., Buskens, E., Krabbe, P. F. M., … Ranchor, A. V. (2015). Do individuals with and without depression value depression differently? And if so, why? Quality of Life Research, 24(11), 2565– 2575. doi: 10.1007/s11136-015-1018-3
Quinn. Z. (2003), Depression Quest. Retrieved from http://www.depressionquest.com/ Slater, M. D., & Rouner, D. (2002). Entertainment-education and elaboration likelihood:
Understanding the processing of narrative persuasion. Communication Theory, 12, 173–191.
Tannenbaum, M. B., Hepler, J., Zimmerman, R. S., Saul, L., Jacobs, S., Wilson, K., &
Albarracín, D. (2015). Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological Bulletin, 141(6), 1178.
Tay, J. L., Tay, Y. F., & Klainin-Yobas, P. (2018). Depression literacy levels. Archives of Psychiatric Nursing, 32(5), 757–763. doi: 10.1016/j.apnu.2018.04.007
Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., … Henderson, C. (2016). Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123–1132. doi:
10.1016/s0140-6736(15)00298-6
Wang, X., Peng, S., Li, H., & Peng, Y. (2015). How depression stigma affects attitude toward help seeking: the mediating effect of depression somatization. Social Behavior and Personality: an international journal, 43(6), 945-953.
Appendix Conditions
Out of the five conditions, 90 participants were exposed to the interactive scenario with an efficacious character (Condition A), 80 participants were exposed to the non-interactive scenario with an efficacious character (Condition B), 103 participants were exposed to the interactive scenario with a non-efficacious character (Condition C), 94 participants were exposed to the non-interactive scenario with a non-efficacious character (Condition D), and 149
participants in the control condition were only exposed to the questionnaires. Gender
268 participants identified as male, 348 participants identified as female, 5 identified as non-binary and 1 identified as other.
Race
For racial ancestry, the sample majority is Caucasian with 486 participants, 30 identified as African, 70 identified as East Asian, 23 identified as South Asian, 4 identified as Pacific Islander, 39 identified as mixed and 29 identified as others.
Sexual Orientation
In terms of sexual orientation, the majority identified as heterosexual with 486 participants, 54 identified as homosexual, 61 identified as bisexual, 6 identified as queer, 7 identified as other and 8 participants did not wish to disclose.
Residence
Most of the sample resided within North America with 498 participants, 30 in South America, 79 in Europe, 10 in Asia, 3 in Africa, and 2 in Australia.
The participant’s ages ranged from 19 to 78 years old (M=34.60, SD=11.88). Exposure Check
189 participants reported that they received an ending with the character feeling better after attending therapy session, 185 participants answered that the character felt worse because he did not go to work and 95 participants were unsure of the outcome.
