Hopeful narratives in cancer communication
A feeling of comfort in order to give cancer patients social support
Jikke van Dijk 11293950 Masters’ thesis
University of Amsterdam Graduate school of Communication Masters’ programme Persuasive Communication
Sanne Schinkel 8138 words 25.06.2020
Abstract
Background: A narrative is a type of information that is presented as a story with a
beginning, middle and end. In health communication, narratives seem effective in changing people’s behaviour with the moderating role of identification. Most of the research on the effectiveness of narratives is about a negatively framed message on attitude and behaviour. However, in order to decrease the general feeling of fear of cancer, that can be an obstacle in providing social support for cancer patients, a positively framed narrative is conducted in this experiment. This study focuses on the effects of a positively framed narrative (vs.
non-narrative) about lung cancer on the attitude towards cancer and fear of cancer and the role of identification by peer similarity and ethnic similarity.
Methods: The study compares the effect on attitude towards cancer and fear of cancer of both information types in a two (narrative vs. narrative) by two (ethnic similar vs. ethnic non-similar) by two (peer similar vs. peer non-non-similar) experiment. The experiment was conducted amongst 241 adolescents with an age between 18 and 25 years.
Results: The results showed no main effect of information type on attitude towards cancer and fear of cancer. Moreover, it showed no interaction effects. However, the overall attitude towards cancer was reasonably hopeful and fear of cancer was fairly low.
Conclusion: A positively framed message about cancer seems to result in a positive attitude towards cancer and low fear of cancer, among adolescents. Narrative and non-narrative information seem equally effective, suggesting that the claims of scholars about the greater effects of narratives should be looked at more closely. Policy makers should be aware of the target group of the information: narratives seem to work differently for adolescents.
Keywords: Narratives, Cancer communication, Identification, Perceived similarity, Health communication, Fear of cancer
Introduction
Cancer is one of the most common diseases worldwide and can occur in a lot of different forms (World Health Organization: WHO, 2019). In the Netherlands, one out of three people will be diagnosed with a form of cancer during their life (KWF, 2019). Skin and lung cancer are the most common cancers. Patients suffering from cancer feel a need for social support (Usta, 2012). According to Usta, social support consists of different aspects that result in a perception of received care in the eyes of a cancer patient. One important aspect is emotional support that is given by family members and peers. In addition, research has shown a strong positive association between social support and cancer progression. Social support has a positive effect on patients’ well-being, physical health and adjustment to cancer. This makes social support necessary for an effective cancer treatment.
Not only cancer patients experience a need of social support. Also adolescents, with family members who are diagnosed with cancer, experience a feeling of loneliness and a need for social support (Karlsson, Andersson, & Ahlström, 2013). It is important to get more information about how the social environment can provide social support. A study by Weiner (1980) found that the willingness to help is dependent on several factors. They found that the affective response on an incident is the most dominant predictor for people’s willingness to provide help in health care. This could mean that when people hear about a cancer diagnosis, the affective response predicts whether people would be able to provide help and social support.
Unfortunately, cancer is one of the most feared diseases (Clarke & Everest, 2006; Nelissen, Beullens, & Van den Bulck, 2015; Vrinten, McGregor, Heinrich, von Wagner, Waller, Wardle, & Black, 2017). Studies have shown that almost half of the population worldwide experience worried feelings about cancer (Vrinten et al., 2017). The disease is associated with death, lack of cleanliness, unpredictability and long and sickening treatment. ‘’Cancer fear’’ is understood as worry or anxiety towards the disease (Vrinten et al., 2017). In public health campaigns that address cancer, the focus is on prevention. Communication interventions are motivating people to go for a screening and detect cancer in an early stage. These interventions make use of fear appeals, in order to change people’s behaviour and prevent or detect a disease (Timmers & van der Wijst, 2007). For instance, anti-smoke campaigns, wherein the images and slogans on cigarette packages show the negative consequences of smoking, in order to induce fear and change people’s behaviour. Research has shown the negative influence of mass media on people’s perceptions, behaviour and fear
of cancer, since mass media are important sources of information about cancer (Nelissen, Beullens, & Van den Bulck, 2015; Clarke, & Everest, 2006). For instance, exposure to television seemed to result in more fear of cancer, because of the fear appeals in
advertisements (Nelissen, Beullens, & Van den Bulck, 2015). Cancer is often negatively portrayed in mass media. As a result, people experience a feeling of fear and stigmatize patients, which means that cancer patients become isolated from social life (Clarke, & Everest, 2006). And thus, the social support that cancer patients and their environment need comes at stake due to the feeling of fear.
However, it is important to make sure that cancer patients and their close environment can count on social support. Due to fear appeals in mass media, there is a general feeling of fear of cancer, suggesting that the social support for cancer patients cannot be guaranteed (Vrinten et al., 2017). Inducing fear can be effective in motivating people to go screening for instance, but when people become a patient of cancer itself, it is important that their social environment can provide the help that the patient needs. It is thus interesting to investigate whether that fear could also be decreased. If that fear could be decreased, the obstacle that fear could be in providing social support could be removed. In case someone’s social
environment is diagnosed with cancer, communication interventions should be developed to change the high fear feelings into an attitude with which people are able to provide social support.
Research has shown the effectiveness of narratives on changing beliefs in health communication (Dunlop, Wakefield, & Kashima, 2008; McQueen, Kreuter, Kalesan, & Alcaraz, 2011). A narrative refers to ‘’a representation of connected events and characters that has an identifiable structure, is bounded in space and time, and contains implicit or explicit messages about the topic being addressed’’ (Kreuter et al., 2007, p.222). A narrative
structured message is presented as a story with a beginning, middle and end. Rather than facts is the focus in narratives on characters (Green, 2006). This form of intervention can transport people and change their beliefs about diseases (Dunlop, Wakefield, & Kashima, 2008; McQueen, et al., 2011). Transportation is understood as absorption or flow and means that people are immersed in a story (Green, 2006). Research has shown that by listening to or reading personal stories from others, patients can take distance from their negative feelings towards cancer, which in result helps patients to cope with the negative feelings (Carlick, & Biley, 2004). This mechanism could also be applicable to the social environment of the patients. Research has already shown that narratives are effective in changing beliefs of cancer, because it overcomes counterarguments (Green, 2006). People are more absorbed in a
story and this makes them less able to come up with counterarguments. For instance, the effect of narratives among cancer patients itself; reading a story of breast cancer survivors gave meaning, proof for survival and made cancer patients more hopeful (Green, 2006).
A lot of experiments have shown that narratives are effective in promoting certain behaviour, such as sun screening, smoking cessation or mammography (Lemal, & Van den Bulck, 2010; Shen, Sheer, & Li, 2015). Narratives that consist of a negative health message result in a more negative attitude towards the disease, and lead to a more positive attitude towards the recommended behaviour. One of the most important factors in this persuasion process of narratives is identification (Green, 2006; Murphy, Frank, Chatterjee, & Baezconde-Garbanati, 2013). If people identify with the character in the negatively framed narrative, they are transported into the story and take over the negative feelings such as fear.
The negative frame in the message influences the attitude towards cancer negatively (Dunlop, Wakefield, & Kashima, 2008). In result, the negative attitude and fear lead to behavioural change (e.g. screening). However, in order to provide social support when
patients are diagnosed with cancer, fear should not be induced, but decreased. A more hopeful attitude towards cancer could result in the ability to provide social support. Little research is done about the effects of positively framed narratives in health communication. According to previous research, the valence of the narrative message is taken over by the receiver. When the narrative is about a more positive message that provides hope, people might take over the more hopeful attitude towards cancer and lower degree of fear for cancer. It is important to find out if the attitude towards cancer could be changed and fear of cancer could be decreased through exposure to a more positively framed narrative.
A relevant form of cancer in this context is lung-cancer, since there are a lot of fear appeals that try to induce fear towards lung-cancer, suggesting is it one of the most feared cancer forms. It would be interesting to investigate the effect of a positively framed narrative about long cancer. Moreover, lung-cancer is one of the most common cancer forms. The cancer is positively associated with smoking (Trichopoulos, Kalandidi, Sparros, & Macmahon, 1981). Most habitual smokers start smoking when they are adolescents (Lipperman-Kreda, Paschall, & Grube, 2009). Anti-smoke campaigns are created to make adolescents more aware of the negative consequences of smoking (Smith, & Stutts, 2003). According to scientific research, frequent exposure to fear appeals lead to more fear towards lung cancer (Timmers, & van der Wijst, 2007). This could result in quitting smoking, but it could also be an obstacle for providing social support to their social environment diagnosed with cancer. In addition, adolescents are in the early stages of life, which means that they
might have less experience with diagnosed people than older people. The older people get, the more likely it is they get to know people with cancer. This means that if the feeling of fear of cancer could be decreased among adolescents, interventions could be effective to make sure they are ready for the experience with diagnosed people. It is thus important to find out if the feeling of fear of cancer could be decreased among adolescents. And according to scientific research, identification plays an important role in the effects of narratives, but also the role of identification is not clear yet in positively framed narratives.
This research adds to scientific research, because previous research hasn’t focused on the effects of positively framed narratives in cancer communication. Moreover, if positively framed narratives seem to work, it could be helpful in making sure cancer patients can count on social support, which is essential in the cancer progression. This study will focus on the following research question:
RQ: What is the effect of a positively framed narrative (vs. non-narrative) about lung-cancer on the attitude towards cancer and fear of cancer among adolescents and what is the role of identification?
Theoretical framework How do narratives work?
People are storytellers by nature (Fisher, 1984). Every day, they are exposed to stories in movies, novels, news articles and more. These narratives help people to understand the world. In health communication, narratives are effective strategies to change beliefs, attitudes and promote behaviour (Chen, 2016). Narratives seem to make health information more understandable and meaningful, which makes it easier for the audience to engage in the message and pay attention (Yoo, Kreuter, Lai & Fu, 2014). It is especially useful in
addressing issues that are personally relevant (Hinyard & Kreuter, 2007). When people need to cope with cancer related issues, the information about cancer becomes personally relevant and thus narratives seem to be an effective way to communicate information.
Two important mechanisms are important in the narrative effect: transportation and identification. Transportation is also understood as absorption or flow and means that people are immersed in a story. Moreover, it is associated with positive emotions towards the character and negative cognitive responses are decreased due to transportation (Green 2006). Because people are absorbed in the story, they are less likely to give counterarguments and individuals develop strong emotions for the characters in the narrative. As a consequence, the
attitude of the character in the narrative influences the beliefs of the receiver (Hinyard & Kreuter, 2007). Engagement and transportation into the narrative will lead to a more story-consistent attitude, suggesting that transportation is an important factor in creating a hopeful attitude towards cancer (Buselle, & Bilandzic, 2009).
Narratives vs. non-narratives
In research, narrative structured messages are often compared to non-narrative messages. Non-narrative messages are messages that are not packed in a story, but focus on statistical and factual information (Hinyard, & Kreuter, 2007). Narratives seem to be more effective in changing attitudes in health-related issues than non-narrative structures (Murphy, et al., 2013; Yoo, et al., 2014). However, scientific research has mainly focused on attitudes towards certain behaviour, instead of the attitude towards the disease. A study by Murphy, et al., (2013) compared the effects of narratives and non-narratives on attitudes towards a Pap test, that tests if people suffer from human papillomavirus (HPV) among participants with an age between 25 and 45 years old. The narrative condition consisted of a negatively framed movie, showing that everybody has a high risk of getting cervical cancer and that this disease could be prevented by doing a Pap test. In the non-narrative condition, participants were exposed to a more traditional video, including doctors and experts in a lab, recommending people doing a Pap test. Participants who were exposed to the narrative had a significantly more positive attitude towards the Pap test, compared to participants who were exposed to the non-narrative.
The results are in line with the finding of another study that investigated the effects of narratives on Facebook on the attitude towards testing for human papillomavirus (HPV) (Cuesta, Martínez, & Cuesta, 2017). The narrative video consisted of a vlog styled message, wherein a girl filmed herself while she was waiting for the results of her HPV test. She posted this on her Facebook profile. The non-narrative condition consisted of an animation video, showing a girl and wherein facts where given with a more formal-institutional tone. The results showed that the narrative resulted in a more positive attitude towards periodic medical check-ups and tests for HPV, compared to the non-narrative (Cuesta, Martínez, & Cuesta, 2017). Their research was done among Spanish adolescents with an age between 18 and 23 years old. However, the two conditions were completely different from each other and thus the results could be due to other factors than the information type.
In contrast, a study that on attitude towards alcohol and intention to drink found equal effects of narratives and non-narratives (Zebregs, van den Putte, de Graaf, Lammers &
Neijens, 2015). This study was done among adolescents with an age between 11 and 14 years old and repeated the measurements. The narrative form consisted of characters who discussed the negative consequences of alcohol, while the non-narrative consisted of a more factual text without characters.
Narratives also seem effective in evoking negative emotions as fear, sadness and anger (Yoo, et al., 2014). A narrative video that consisted of a negatively framed video about high risk of getting breast cancer and the importance of a mammogram, told by breast cancer survivors as personal stories resulted in more negative emotions compared to the non-narrative video. The non-non-narrative differed by giving the information in an expository form. The emotions in the message were taken over by the participants (Mage = 64). The narrative had a greater effect of taking over the emotions compared to the non-narrative condition.
Negatively framed narratives thus seem to result in negative emotions and attitude. Regarding positively framed narratives, it is not clear what the effects will be. A study that looked at the effect of a positively framed narrative found that narratives resulted in a more positive attitude towards cannabis use compared to the non-narrative (Sznitman, & Lewis, 2018). In the narrative, the disease HPV was explained, it was told that the treatment did not result in the desired help and that cannabis delivered the desired help. Then, all positive consequences of cannabis use were discussed. The narrative resulted in a more positive attitude towards cannabis use compared to the non-narrative, wherein the text was more informative instead of personal (Sznitman, & Lewis, 2018). However, not the attitude towards the disease itself was measured, but only the attitude towards the recommended behaviour. Moreover, the narrative wasn’t defined in detail, so it is not very clear how the non-narrative looked like.
In entertainment communication research about narratives, findings reveal that positively framed messages can affect the attitude towards the topic positively (Hoffner & Buchmann, 2005; Igartua, & Frutos, 2017). People with an age between 16 and 20 years old were exposed to a positively framed narrative in a television program about a minority group, or a program with the information more informative, not in a narrative structure. The narrative resulted in a more positive attitude about minority groups compared the non-narrative.
This means that narratives can work in both directions, depending on the valence of the message. Participants take over the emotions that are central in the narrative (Cuesta, Martínez, & Cuesta, 2017; Hinyard, & Kreuter, 2007; Igartua, & Frutos, 2017; Murphy, et al., 2013; Sznitman, & Lewis, 2018). Moreover, narratives seem to have greater effects than
non-narratives on attitudes and emotional responses (Yoo, et al., 2014). This leads to the first hypotheses:
H1a) A positively framed narrative will lead to a more hopeful attitude towards lung-cancer survival compared to a non-narrative message
H1b) A positively framed narrative will lead to less fear of lung-cancer compared to a non-narrative message
The role of identification
In addition to transportation, identification is an important factor in the underlying mechanism of narrative effects. Identification consists of different aspects: liking, similarity and empathy for instance (Green, 2006). A study by Hoeken, Kolthoff & Sanders (2016), manipulated identification and looked at the effects on evoking emotions and attitude change. Identification was defined by likability of the character. They found that people identified more with the likeable character compared to the less likeable character and that this evoked heavier emotions and a more positive attitude towards the issue. The narrative condition stressed out the emotions from the character, compared to a descriptive text in the non-narrative condition. However, both were stories, which makes this study different from other studies that operationalise non-narratives as more factual information. Identification turned out to be a moderator in the effects of narratives on evoking emotions and attitude.
Research has shown that perceived similarity with the narrative character is an important predictor of transportation and identification (Green, Brock & Kaufman, 2004). A study showed for instance that people whose social environment consisted of gay persons were more transported into a story about prejudice against homosexuals, because they identified themselves with the characters from the story who had friends that were gay
(Green, Brock & Kaufman, 2004). The extent to which people perceive the narrative character as similar to themselves influences the extent to which people identify themselves with the character. Perceived similarity with the character is thus an important determinant for
identification (Hoeken, Kolthoff, & Sanders, 2016; Hoffner & Buchmann, 2005; Moyer-Gusé & Nabi, 2010; Murphy, et al., 2013). Moreover, the more identification with the character in the narrative, the greater the persuasive effect will be and so the attitude change (Hoeken, Kolthoff, & Sanders, 2016; Moyer-Gusé, 2008). Identification seems necessary to let the narrative work. And through manipulating perceived similarity, the underlying mechanism of
narrative with identification and transportation will be activated to let the narrative have effect.
Similarity
Perceived similarity can be understood in different ways: physical attributes, situations or personality traits and demographic characteristics (Cuesta, Martínez, & Cuesta, 2017). Similar demographic characteristics can easily result in perceived similarity (Chen, Bell & Taylor, 2016). The more similarities the receiver perceives to have with the narrative character, the more the receiver perceives the character as similar, the more likely it is that identification with that character takes place and the receiver will accept the message (Hinyard, & Kreuter, 2007). This is explainable by the ‘homophily-literature’, that states that people are more likely to get in contact with people who have similar characteristics (Bol, van Weert, de Haes, Loos, & Smets, 2013). This could also be applicable to narratives, by suggesting that people are more likely to read the text with understanding when the main character feels similar to them.
Ethnic similarity
Taking a closer look to cancer communication and attitude towards cancer, similarity in ethnic background seems to be important. Scientific research has shown that different ethnic groups have different beliefs about lung-cancer treatments (Jonnalagadda et al., 2012). Also, according to the study by Murpy et al., (2013) people identify more with characters that have the same ethnic background, which is in line with other research that highlights the importance of perceived similarity. Their research among people with an age between 25- and 45-years old shows that ethnic similarity can play an important role in the persuasiveness of narratives (Murphy et al., 2013). The narrative condition consisted of a video with characters with a different ethnic background, talking about getting HPV. The non-narrative condition consisted of a video with local doctors and experts, talking about getting HPV. The narrative resulted more in a story-consistent attitude and ethnic similarity turned out to be a moderator (Murphy et al., 2013).
More research focused on the role of ethnic similarity in the effects of narratives. A study by Van den Hende, Dahl, Schoormans, & Snelders, (2012) showed that people with an age between 55 and 80 years old identified the most with the character that had the same ethnic background and that this influenced the evaluation of a product positively, which could be understood as a positive product attitude. This means that ethnic similarity again had a moderating role in the narrative effect on attitude.
Ethnic similarity thus seems to strengthen the narrative effect. According to this scientific research, the expectation is:
H2a) The narrative effect on attitude about cancer will be stronger for people with ethnic similarity with the main character
H2b) The narrative effect on fear of cancer will be stronger for people with ethnic similarity with the main character
The role of peers in narrative effects
Especially among adolescents, similarity with an information source seems to play an important role in the creation of an attitude. Adolescents’ behaviour and attitude is often very similar to that of their friends (Brechwald, & Prinstein, 2011). According to the homophily theory, this can be explained by youths’ tendencies to affiliate with friends who already have similar attitudes and behaviour: they choose their own friends based on similarity in attitude or behaviour. Peers are defined as ‘belonging to the same societal group, based on age, grade or status’ (Reitz, Zimmermann, Hutteman, Specht, & Neyer, 2014). Adolescents’ attitude seems to be highly influenced by their peers. Research has already shown the great influence of peers on adolescents’ behaviour, due to so called ‘’social norms’’ (Paek, 2009). Exposure to mass media messages including peers led to engagement in risky behaviour, because adolescents created the perception that many peers do. For instance, students’ intention to smoke seems to be influenced by their perception about what their peers think they should do (Paek, 2009). Thus, the opinion of peers seems highly important for adolescents. Therefore, peers seem very influential in changing adolescents’ attitude and fear feelings. This study also revealed a difference in the influence between close peers or distant peers, wherein close peers can influence others’ behaviour even greater (Paek, 2009).
In narratives, the role of peers is not clear yet. Age seems to play an important role in the effects of narratives (Bol, et al., 2013). The study by Bol, et al., looked at the effects of narratives in online health information and took into account age congruence, by
manipulating the character’s age. Participants were divided into groups: older or younger than 65 years old. They found that recall was higher if people were exposed to a message with a character that was congruent to their age. Moreover, they found that recall was the highest in a narrative condition (compared to a non-narrative condition) with a character that was congruent in age. People could identify themselves more with the character that had the same age, which is also an important character of peers.
However, a peer is not only based on age, but also on grade and status and is defined as belonging to the same societal group (Reitz, et al., 2014). This means more similarities, which could be favourable for identification in the narrative effect. Since research already showed that peers could influence adolescent’s attitude, it could be effective to combine this with narratives. This leads to the hypotheses:
H3a) The narrative effect on attitude about cancer will be stronger for people with peer similarity
H3b) The narrative effect on fear of cancer will be stronger for people with peer similarity
The more people feel themselves similar to the narrative character, the more persuasive the message will be (Green, 2006; Hoeken, Kolthoff, & Sanders, 2016). It is unclear whether it is effective to combine ethnic- and peer similarity in order to strengthen the narrative effect. The following research question is conducted to investigate this:
What is the effect of ethnic similarity and peer similarity on the effect of narratives on attitude towards cancer and fear of cancer?
Method Sample
For reasons of feasibility, a snowball sample was employed in order to recruit participants for this experiment. Via online social networking (Instagram, Facebook,
YouTube, Whatsapp and Surveycircle) people were asked to participate in the experiment and to share the post with link to the questionnaire. Since this experiment focused on adolescents, people needed to have an age between 18 and 25 years old. In scientific research, this
generation born between 1995 and 2000 is called generation Z, always socially connected through Internet, smartphones and tablets (Chaney, Touzani, & Ben Slimane, 2017). This makes social media an appropriate way to reach them. No other traits were demanded from the participants.
In total, 391 individuals participated in the experiment. However, when checking for missing values, 143 individuals had to be excluded from the experiment, since they didn’t finish the survey or quitted after exposure to the material. Moreover, seven other participants were excluded, because they didn’t meet the age criteria. In total, this study counts 241
participants (33.2% males, 66.8% females) who completed the survey. Their age was ranged between 18-25 years old (M = 21.83, SD = 1.7) and 75.5 % of the participants had an HBO certificate or higher as highest level of education. In addition, 10.8% of works in the health care sector, 52.3% knew someone having cancer and 87.6% knew someone who has had cancer close to them.
Design and procedure
A 2 (narrative vs. non-narrative message) x2 (Peer vs. non-peer similarity) x2 (ethnic vs. non-ethnic similarity) between subject design with fear of cancer and attitude towards cancer as dependent variables was conducted via an online experiment in Qualtrics (See Appendix B for the questionnaire). The questionnaire started with an informed consent that participants had to agree with for continuing the survey. Then, participants were asked about their demographic characteristics, such as age, gender and highest level of education. In total, there were eight conditions, to which people were randomly assigned. After exposure,
participants were asked about their attitude towards cancer and fear of cancer. Then, identification with the main character, transportation into the story and perceived similarity with the main character were measured. The questionnaire ended with questions about the manipulation check, credibility, social environment with cancer and job in the healthcare sector.
Materials
For this experiment, eight conditions were manipulated. The independent variable is the information type, with two conditions: narrative versus non-narrative message (See Appendix A for the conditions). In the study, both conditions were introduced by asking people to imagine opening a newspaper where they would be exposed to the text. This
introduction is chosen, since this study investigates whether fear of cancer could be decreased in general. The narrative and non-narrative conditions had an equal amount of words: 311 words, in line with the average amount of words in a newspaper between 255 words and 411 words (Meijers, 2017). The narrative condition consisted of a narrative in the first-person perspective about someone’s mother who was diagnosed with lung-cancer. First the topic was introduced, then the progression was discussed, and the story ended by saying that the
situation now is stable. This form meets the criteria to be a narrative with a beginning, plot and an end. In addition, the main character used emotions in the narrative and an informal language style. The message was positively framed, by focusing on the positive outcomes of
the treatment and their hope to make lung cancer a chronic disease. The non-narrative condition consisted of an informative text, told by a doctor about the new developments in long-cancer treatments. The message was – similar to the narrative condition - positively framed, by focusing on the doctors’ hope for making lung-cancer a chronic disease. However, only facts were discussed instead of personal emotions. The main character was a doctor, instead of someone whose mother was suffering from cancer (in the narrative condition).
Moreover, the conditions were further manipulated to measure the effects of the two moderators: peer similarity and ethnic similarity. The name, age and pictures of the character differed between the conditions. By searching in Google images, pictures were found of the main characters in the stimuli.
Peer similarity was manipulated by presenting different main characters in both texts. The peer condition consisted of a young girl with an age of 23 years old. She was described as a student and a picture was presented below the text. The non-peer condition consisted of an older woman with an age of 54 years old. She was described as mother of two kids and a picture of her was presented under the text. Since the non-narrative condition was about a doctor, all the people in the non-narrative conditions were wearing a doctors’ coat, whereas the people in the narrative conditions were wearing normal clothes.
Different skin colours of the people on the picture and different names with different country of origin were used to manipulate ethnic similarity. In the ethnic similar condition, the main character was a white girl, called Elise Bakker. This name is chosen, because it is a typical Dutch name. The other condition, the non-ethnic similar condition, consisted of a main character with a darker skin colour. She was called Dalila Smith who moved from South Africa to Amsterdam. The rest of the text was similar.
Pilot test
A pilot test was conducted, to check if the manipulations worked. A total of 16 participants were exposed to the survey with the information texts. The narrative resulted in more transportation into the story (M = 3.61, SD = .75), compared to the non-narrative (M = 3.20, SD = 0.93), t (15.34) = -1.02, p = .324, 95%CI [-1.26, .44] (bootstrap). Moreover, the peer condition resulted more in perceived peer similarity (M = 4.00, SD = .82), than the non-peer condition (M = 1.75, SD = .71), t (15.86) = -6.26, p = .560, 95%CI [-3.01, -1.49] (bootstrap). Also, ethnic similar condition resulted more in perceived ethnic similarity (M = 3.50, SD = .68) than the non-ethnic similar condition (M = 2.50, SD = 1.11), t (15.15) = -2.51,
p = .10, 95%CI [-1.97, -.16] (bootstrap). This means that information type, peer similarity and
ethnic similarity were successfully manipulated.
In addition, one sentence was added in the survey: ‘‘the main character in the text is the person who is speaking’’ to make clear who was meant by the main character. Also, a question about working in the health sector was added. Since one item of the scale for fear of cancer turned out to be unclear it has been changed into: ‘’Cancer is more frightening than a heart attack instead of heart disease.
Measures
Dependent variables
Attitude about cancer
Seven items measured attitude towards cancer, based on the study by Lamanna (2004). The items were positively framed, in order to measure a hopeful attitude (e.g. ‘’People who have had cancer can live a positive life’’). Lamanna (2004) described the factor with the seven items as belief or control of independence during the cancer. Participants could score on a 5-point scale ranging from (1) totally disagree till (5) totally agree. A factor analysis showed three components with an Eigenvalue higher than one. The first component consisted of four items and could be described as ‘’positivity in life after cancer’’, component 2
consisted of two items and could be described as ‘’medicine for cancer’’ and the third component consisted of one item and could be described as ‘’difference between cancer patients an no cancer patients’’. The first factor is chosen, because of the strongest correlation and it measured positive outcomes of having cancer, the highest relevance with a hopeful attitude. The final scale attitude towards cancer thus consisted of four items with just acceptable reliability (Eigenvalue = 2.00, explained variance = 50.00%, α = .63).
Fear of cancer
Fear of cancer was measured with all six items based on the study by Lamanna (2004). Different statements about cancer were presented, with a 5-point scale ranging from (1) totally disagree till (5) totally agree. A factor analysis showed two components with an Eigenvalue higher than 1. One item had a factor loading lower than .3: ‘’cancer is more frightening than a heart attack’’. Therefore, this item was removed from the scale. The scale fear of cancer is thus built with five items, (e.g. ‘’I feel afraid of getting cancer’’). Now, the scale showed one factor and sufficient reliability (Eigenvalue = 2.65, explained variance = 53.01%, α = .78).
Manipulation check
Transportation
Transportation was measured with nine items of the scale by Green & Brock (2000), (e.g. ‘’I wanted to know how the story ended’’). Two items were excluded, because those seemed inappropriate. People could score on a 5-point scale with a range from (1) totally disagree till (5) totally agree. Three items were recoded because of reversed formulation. A factor analysis showed that the items load on two factors. However, the scree plot showed one dimension and taken the sufficient reliability all the items were included in the scale
transportation (α = .77). An independent sampled t-test showed that people in the narrative condition were significantly more transported into the story (M = 3.17, SD = .56), compared to people in the non-narrative condition (M = 2.86, SD = .54), t (239) = -4,43, p < 0.001, CI 95% [-.45, -.17]. The narrative thus seems be successfully manipulated.
Perceived ethnic similarity
Three items measured perceived ethnic similarity, based on the study by McCroskey, Richmond, & Daly (1975), (e.g. ‘’the main characters’ cultural background is similar to my cultural background’’). People could score on a 5-point scale, ranging from (1) totally
disagree till (5) totally agree. Factor analysis showed that the items load on one factor with an adequate reliability (Eigenvalue = 2.09, explained variance = 69.67%, α = .78). An
independent sampled t-test showed that people in the ethnic similar condition perceived the main character significantly more ethnic similar to themselves (M = 2, 86, SD = .69),
compared to people in the ethnic non-similar condition (M = 1.82, SD = .63), t (239) = -12,23,
p < 0,001, 95%CI [-1.21, -.87]. This means that ethnic similarity was successfully
manipulated.
Perceived peer similarity
One item measured perceived peer similarity (e.g. ‘’the main character’s life situation is similar to my life situation’’). An independent sampled t-test, showed that people in the peer condition, perceived the main character significantly more as a peer (M = 3.18, SD = 1.14), compared to people in the non-peer condition (M = 1.93, SD = .99), t (234.10) = -9.05,
p < 0.001, 95%CI [ -1.51, -.97). This means that peer similarity was successfully manipulated. Attention to the text
In order to check whether people read the text carefully regarding the manipulations, people were asked to choose the name and ethnic background of the main character. A Chi-square analysis showed that participants noticed the correct main character’s ethnic
noticed the correct main character’s name, χ2 (1) = 7.08, p = .400, (table 1 and 2). It means
that the ethnic difference is noticed, and people read the text carefully.
Table 1
Scores on country of origin in the conditions
Condition
Country Ethnic similar condition (n = 116) Ethnic not similar condition (n = 125)
South African 17 109
Dutch 99 16
Table 2
Scores on name of the main character in the conditions
Condition
Name Ethnic similar condition (n = 116) Ethnic non similar condition (n = 125)
Dalila 110 16
Elise 15 161
Control variables
Identification
Identification is measured with a scale by Cohen (2001). Some items of the original scale were not applicable, so a total of eight items measured the variable identification, (e.g. ‘‘while reading the text, I felt like I was part of the story’’). People could score with a range from (1) totally disagree till (5) totally agree. A factor analysis showed that the items load on one factor with good reliability (Eigenvalue = 3.93, explained variance = 49.06%, α = .85). A One-way Anova analysis showed that participants in the narrative condition identified
themselves significantly more with the main character (M = 3.22, SD = .61) than participants in the non-narrative condition (M = 2.91, SD = .65), F (1, 239) = 14.83, p < .001. Moreover, identification didn’t correlate with fear of cancer, but significantly correlated with attitude towards cancer, r (240) = .28, p < .001. The more identification, the more hopeful the attitude towards cancer. This correlation is weak, but it still means that this variable will be a
Perceived similarity
Perceived similarity was measured by a scale based on a study by McCroskey, Richmond, & Daly (1975). A total of seven items were chosen, because those were
applicable. However, three items were not included, because those three items were used in measuring the moderator ethnic similarity. People could score with a range from (1) totally disagree till (5) totally agree. A factor analysis showed two components with an Eigenvalue above 1. The first component could be described as ‘’ behaviour similarity’’ and the second factor could be described as ‘’appearance’’. The second factor consisted of two items. These items were excluded from the scale, because they didn’t correlate with the other items. The scale perceived similarity is made of five items (e.g. ‘’the main character is similar to me in her social economic status’’) and showed a good reliability (Eigenvalue = 3.06, explained variance = 61.21%, α = .84). One-way Anova showed that people in the narrative – non peer – ethnic similar condition scored the highest on perceived similarity (M = 3.46, SD = .57) and people in the narrative – peer – ethnic non similar condition scored the lowest on credibility (M = 3.16, SD = .62), but this is not significant, F (7, 240) = .78, p = .603. This means that there were no differences in perceived similarity between the conditions. A Bivariate Correlation analysis revealed no correlation with the dependent variables.
Credibility
The credibility of the manipulations was measured by one item (e.g. ‘’the text I just read is representative for the reality.’’). People could score on a 5-point scale with a range from (1) totally disagree till (5) totally agree. One-way Anova showed that people
experienced all conditions equally credible, F (7, 240) = .89, p = .516. This means that there were no differences in perception of credibility between the conditions. A Baviarate
Correlation analysis showed no correlation with fear of cancer, but a weak positive correlation with attitude towards cancer, r (240) = .13, p = .043. The more credible, the more hopeful the attitude towards cancer. This means that this variable will be a covariate in the analysis.
Randomization check
Gender
The Chi-square analysis showed that the allocation of females and males was successful, χ2 (7) = 7.34, p = .394. A bivariate Correlation analysis showed no correlation
with attitude towards cancer, but a weak negative correlation with fear of cancer, so it will be a covariate in the analysis, r (240) = -.14, p = .024. Woman hold more fear of cancer
Working in the health sector
Another Chi-square analysis with working in the health sector as dependent variable and condition as independent variable showed that the allocation was successful, χ2 (7) =
5.03, p = .657. Moreover, the Bivariate Correlation analysis shows no significant correlation with the dependent variables.
Social environment with cancer
A Chi-square analysis with knowing someone in your social environment who has cancer as dependent variable and condition as independent variable showed that the allocation to the conditions was successful, χ2 (14) = 14.39, p = .421. Moreover, a Bivariate Correlation
analysis showed a weak negative correlation between social environment with cancer and fear of cancer, r (240) = -.13, p = .041. The more people with cancer in the social environment, the less hopeful attitude towards cancer and the less fear of cancer.
Age
A One-Way Anova analysis showed that participants’ mean age did not significantly differ between the conditions, F (7, 233) = 1.05, p = .398. A Bivariate Correlation analysis showed a weak negative correlation between age and attitude towards cancer, r (240) = -.18, p = .005. This means that the older people get, the more negative their attitude towards cancer will be. Age will be a covariate in the analysis.
Results Main analyses
In order to test the hypotheses and research question, two Univeriate ANCOVA analyses were conducted. The first Univariate ANCOVA analysis had attitude towards cancer as dependent variable, information type, peer similarity and ethnic similarity as independent variables and age, identification and credibility as covariates. The second Univariate
ANCOVA had fear of cancer as dependent variable, information type, peer similarity and ethnic similarity as independent variables and social environment and gender as covariates.
The first hypotheses tested the main effect of information type on attitude towards cancer and fear of cancer. The results showed that people in the non-narrative condition had a slightly more positive attitude towards cancer (M = 3.98, SD = .05) compared to people in the narrative condition (M = 3.87, SD = .05), while the opposite was expected. This the effect is very weak and not significant F (1, 240) = 2.71, p = .101, eta2 < .01. The results further
showed that people in the non-narrative condition experienced equal fear of cancer (M = 3.16,
.14, p = .701, eta2 < .01. This means that there seems to be no effect of information type on
attitude towards cancer and fear of cancer. Hypothesis 1b is also not supported.
Moderation effects
Ethnic similarity
The ANCOVA also tested the interaction effect of information type and ethnic similarity and showed that people in the non-narrative, ethnic non-similar condition scored the highest on attitude towards cancer (M = 4.01, SD = .06), and people in the narrative, ethnic non-similar condition scored the lowest on attitude towards cancer, (M = 3.86, SD = .06), F (1, 240) = .27, p = .607, eta2 < .01. This means people in the non-narrative, ethnic
similar condition had the most positive attitude towards cancer and people in the narrative, ethnic non-similar condition had the most negative attitude towards cancer. Hypothesis 2a is not supported, there is no interaction effect of information type and ethnic similarity on attitude towards cancer.
The other model with fear of cancer as dependent variable, with information type and ethnic similarity on fear of cancer shows that people in the narrative, ethnic similar condition scored the lowest on fear of cancer (M = 3.05, SD = .10), and people in the non-narrative, non-ethnic similar condition scored the highest on fear of cancer (M = 3.23, SD = .10), but this weak effect wasn’t significant, F (1, 236) = .01, p = .928, eta2 < .01. This means that
hypothesis 2b is rejected. However, the results go in the direction stated in the hypothesis, because ethnic similarity with the main character in the text resulted in less fear towards cancer. But the mean differences are very small.
Peer
The ANCOVA also tested the interaction effect of information type and peer similarity on attitude towards cancer and fear of cancer.
People in the non-narrative, non-peer condition scored the highest on attitude towards cancer, (M = 4.03, SD =.07), and people in the non-narrative, peer condition scored the lowest on attitude towards cancer, (M = 3.86, SD =.06), not significant, F (1, 240) = .84, p = .359, eta2 < .01. This means that hypothesis 3a is not supported.
Also, no interaction effect of information type and peer similarity on fear of cancer was found. The results showed that people in the narrative, non-peer condition scored the lowest on fear of cancer (M = 3.10, SD =.10) and people in the non-narrative, no peer condition scored the highest on fear of cancer, (M = 3.18, SD =.10). This effect is not
significant, F (1, 236) = .11, p = .742, eta2 < .01. The experience of fear of cancer is almost
equal in the different conditions. This means that hypothesis 3b is not supported.
Three-way interaction effect
To answer the research question whether information type, ethnic similarity and peer similarity have an effect on attitude towards cancer and fear for cancer, the ANCOVA looked at the three-way interaction effect. The results show no significant interaction effect of
information type, peer similarity and ethnic similarity on attitude towards cancer, F (1, 240) = .06, p = .801, eta2 < .01. Participants in the non-narrative – non-peer – ethnic similar
condition had the most positive attitude towards cancer (M = 4.09, SD = .09), whereas participants in the narrative – non-peer – ethnic non-similar condition had the most negative attitude towards cancer (M = 3.78, SD = .08). The results also showed no significant
interaction effect of information type, peer similarity and ethnic similarity on fear of cancer, F
(1, 236) = 1.39, p = .240, eta2 < .01. People in the narrative – peer – ethnic similar condition
scored the lowest on fear of cancer (M = 3.02, SD = .14) and people in the non-narrative – non-peer – non-ethnic similar scored the highest on fear of cancer (M = 3.31, SD = .15). The mean scores are still small, and the effect is very weak. There are no three-way interactions.
Covariates
Identification had a significant but weak effect on attitude towards cancer, F (1, 240) = 17.99, p < .001, eta2 .07. Age also had a significant but weak effect on attitude towards
cancer, F (1, 240) = 9.01, p = .003, eta2 .03. Gender had a significant weak effect on fear of
cancer, F (1, 236) = 4.24, p = .041, eta2 .02. Social environment with cancer also had a
significant weak effect on fear of cancer, F (1, 236) = 2.73, p = .032, eta2 = .02.
Conclusion and discussion
An experiment in which 241 people participated investigated the effect of information type (narrative vs. non-narrative) with a positively framed message about lung-cancer on the attitude towards cancer and fear of cancer among adolescents. Also, the role of peer similarity and ethnic similarity is analysed in order to check for moderating effects of identification. The results indicate small, negligible differences between narratives and non-narratives on attitude towards cancer and fear of cancer. In addition, no two-way interactions were found. The attitude towards cancer and fear for cancer was almost equal in the different conditions. All the hypotheses were therefore not supported. However, four co-variates revealed to have effect on the dependent variables. For future research, it would be interesting to investigate
the role of identification and age on attitude towards cancer and the role of gender and social environment on fear of cancer.
The results show no main effects of information type on the attitude towards cancer and fear of cancer. The differences between conditions were very small and the effect size was very weak. This means that both dependent variables are not affected differently by exposure to a positively framed narrative about cancer compared to a non-narrative structured message about cancer. Moreover, in both conditions people scored reasonably high on attitude towards cancer and low on fear of cancer. This means that all participants had a fairly hopeful attitude towards cancer and were not very afraid of cancer. These findings are not in line with previous scientific research about narrative effects, that showed a greater effect of narratives on attitude and fear (Cuesta, Martínez, & Cuesta, 2017; Hinyard, & Kreuter, 2007; Igartua, & Frutos, 2017; Murphy, et al., 2013; Sznitman, & Lewis, 2018; Yoo, et al., 2014).
Since previous research mainly focused on negatively framed messages, this study suggests that the information type (narrative vs. non-narrative) has a different effect when the message is positively framed. This study suggests that a positively framed message about cancer itself results in a hopeful attitude towards cancer and low fear of cancer. It would be interesting to investigate this by replicating this study and add a pre-measurement in which the attitude towards cancer and fear of cancer would be measured before exposure to the stimuli. However, the results might also be a consequence of the sample in this study. Other research that showed different effects of narratives and non-narratives mainly focused on older people. An explanation for this result could be that narratives do not work among adolescents in general. The study by Zebregs, et al., (2015) also focused on adolescents and also found equal effects of narratives and non-narratives on the attitude about alcohol.
Therefore, it could be the case that adolescents might respond differently on narratives. Since adolescents grew up with the rise of the Internet and social media, they might be used to listening to stories through podcasts, video’s and social media posts, while older people aren’t that familiar with stories and are more influenced. It would be interesting to investigate this by replicating this study among older people instead of adolescents. The result might then be that narrative indeed lead to a more hopeful attitude and lower fear compared to the non-narrative.
Also, a lot of people quitted the survey after exposure to the material, suggesting that people who quitted the survey after they have read the text have higher fear of cancer. The overall means of the people who finished the survey showed a fairly hopeful attitude towards cancer and little fear of cancer. This is explainable if the sample consisted of people who had
for instance positive experience with cancer patients in their social environment, since results also revealed that most of the participants knew someone suffering from cancer in their social environment. However, in that case the sample is not representative for the whole population adolescents. Expected is that if those participants didn’t quit the survey, the overall means would have been less positive.
Also, the role of peer similarity and ethnic similarity was investigated, because scientific research suggested an important role of identification on the effects of narratives. This research shows that people in the narrative condition identify themselves more with the main character compared to people in the non-narrative condition. However, there was no difference in perceived similarity between groups. This means that although there were differences in perceived peer similarity and in perceived ethnic similarity, there was no difference in a total perceived similarity. This could mean that only peer similarity and ethnic similarity is not enough for adolescents to create the feeling of being similar to the character in general. Since 2000, the society has become more multicultural (Verkuyten, & Thijs, 2002). Adolescents have grown up with people from different countries. Therefore, it could be that ethnic similarity isn’t crucial in the effects of narratives among adolescents, because ethnic background isn’t a very important characteristic in the eyes of adolescents. In addition, previous research indicated that close peers have a greater influence compared to distant peers (Paek, 2009). Since participants didn’t know the main character in the story, the main
character might have felt as a very distant peer. For future research, it would be interesting to investigate the role of close peers in this context, that might have a more story-consistent effect.
However, this experiment suggests that a positively framed message about cancer can be presented in either a narrative or non-narrative in order to create a hopeful attitude and low fear for cancer. It seems like only a positively framed message about cancer itself can cause a hopeful attitude towards cancer and little fear of cancer. This could mean that in order to assure social support for cancer patients, patients’ social environment should be exposed to a positively framed message about cancer. It doesn’t matter whether this message is presented in a narrative or non-narrative form.
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Appendices Appendix A Conditions
Narrative, peer similar, ethnic similar
Narrative, non-peer, ethnic similar
Non-narrative, peer similar, ethnic similar
Non-narrative, non-peer, ethnic similar
Appendix B
Questionnaire (retrieved from Qualtrics)
Info:
Beste deelnemer,
Hierbij wil ik je uitnodigen om deel te nemen aan een onderzoek dat wordt uitgevoerd onder verantwoordelijkheid van de Universiteit van Amsterdam. Voordat het onderzoek begint, is het belangrijk dat je op de hoogte bent van de procedure die in dit onderzoek wordt gevolgd. Lees daarom onderstaande tekst zorgvuldig door.
Aan de hand van dit onderzoek wordt in kaart gebracht hoe wordt gereageerd op informatie over de ziekte kanker. Je zult een artikel lezen over de ziekte en daarna een aantal vragen beantwoorden. Aan dit onderzoek kunnen uitsluitend jong volwassenen en adolescenten van 18 jaar en ouder meewerken. In totaal duurt dit onderzoek
ongeveer 10 minuten. Er zijn geen goede of foute antwoorden. Ik zou je willen vragen de vragenlijst op een rustige plek in te vullen, zodat je je zo goed mogelijk kunt
concentreren.
Omdat dit onderzoek wordt uitgevoerd onder verantwoordelijkheid van de Universiteit van Amsterdam, heb je de garantie dat:
1) je anonimiteit wordt gewaarborgd en dat jouw antwoorden of gegevens onder geen enkele voorwaarde aan derden worden verstrekt, tenzij je hiervoor van tevoren
uitdrukkelijke toestemming hebt verleend.
2) je kunt zonder opgaaf van redenen weigeren mee te doen aan het onderzoek of uw deelname voortijdig afbreken. Ook kun je binnen 24 uur na deelname uw toestemming intrekken voor het gebruik van jouw antwoorden of gegevens voor het onderzoek. 3) je deelname aan het onderzoek neemt geen risico’s of ongemakken met zich mee. De onderzoeker zal je niet opzettelijk misleiden.
4) uiterlijk vijf maanden na afronding van het onderzoek kan ik je een
onderzoeksrapport leveren waarin de algemene resultaten van het onderzoek worden toegelicht.
Voor meer informatie over het onderzoek en de uitnodiging tot deelname kun je altijd contact opnemen met Jikke van Dijk (jikke.van.dijk@student.uva.nl). Ik hoop dat ik je hiermee voldoende geïnformeerd te hebben en bij voorbaat hartelijk bedankt voor je deelname.
Met vriendelijke groet, Jikke van Dijk
Consent:
Stimuli:
Attitude towards cancer:
Identification:
Control:
Debriefing:
Beste deelnemer, Hier eindigt de survey.
Aan de hand van dit onderzoek kan in kaart worden gebracht welke manier van het geven van informatie over de ziekte kanker ervoor zorgt dat de angst voor de ziekte kanker verlaagd wordt.
Ik wil je vriendelijk bedanken voor jouw deelname!
Respondenten die via Surveycircle deze vragenlijst hebben ingevuld: UYHN-EBJ3-A8XA-DTCG
