Part One: Preface to Messages
Let’s briefly review McGuire’s Input/Output model  before we drill down specifically into Messages.
“Outputs,” more generally known as the Hierarchy of Effects (see Introduction Module), are key to our design of the evaluation of our health communication efforts. In marketing research and evaluation, we want to know how well our communication is getting out there, in terms of exposure to, interest in, and impact of the message. We will be discussing this in more detail in subsequent modules. But our primary task for the purposes of The Global Communication Project 2021 is to design and implement the “inputs.” Another way to present McGuire’s inputs is through a structure we probably learned in primary school. Inputs are the “who,” “how,” “what,” “to whom,” and “why” of communication .
The message is the “what” in terms of the basic description of the health, social, or other behaviors we hope the audience performs. Messages specifically comprise both the content and feel of the health communication message. Armed with insightful formative research, effective health communicators and social marketers are able to capture the essence of a health or social issue with words, images, and sounds that best represent their theme. The content of a message manifests its theme, and can be thought of as its light, whereas the colors, sounds, words, and images used to elicit emotion can be thought of as its heat. Together the heat and the light of the message are the subjects of the current module.
The audience, or “receivers,” are the “to whom”: in other words, the target population (e.g., individuals and families, neighborhoods and their associations, communities and civic groups, gatekeepers such as elected officials) we wish to reach. We rely on formative research conducted with members of the target audience or subject matter experts, not only during message development, but also for channel selection and audience segmentation. Audience segmentation is crucial to finding the balance between being effective and being efficient: although one size does not fit everyone, we can seldom afford to tailor messages to each individual in the audience. The process of segmentation determines the strategies required to address different health or social issues, language or cultural distinctions, age and other demographic variables, and receptivity to change for different subgroups. We will take a deeper dive into these issues in the Audience and Formative Research modules.
The sender is the "who" (or source) of health communication: a real person or an invented personality or character; an agency or office; or a group or movement to be associated with the origin of the message in order to optimize the audience’s reaction to it. Again, we devote entire modules to both Source and Channels.
The channel (or medium) is the “how” or the main method or media mix that we use to disseminate the message. Channels can include print, broadcast, display, social media and other web based communication, and the eternal base of all communication, face-to-face contact with the audience. Media mixes (using combinations of the above and other channels) and media delivery systems (for example, print and video presented interpersonally or through social media) present us with the opportunity to achieve effective use of channels.
Part Two: The Message
The core of any health communication effort is the message, and thus this “input” is our lead-off content module. Subsequent modules and the broader sections to which they belong derive from McGuire’s other “inputs” and “outputs.” But the development of health communication theory and application did not begin in the 1970s. In the 4th century BC, Aristotle wrote Rhetoric, which delineated the key dimensions of effective communication as telos, logos, ethos, pathos, and kairos.
“Telos” represents the ultimate purpose or 'destination' of a message.
"Logos" is the logical argument, or light, of the communication, presenting facts and logical deductions.
"Pathos," part of the heat, refers to the attempt to win the audience's sympathy by appealing to emotions.
"Ethos" establishes the credibility of the senders (i.e., sources) from the perspective of the audience, especially in terms of their moral caliber.
Finally, "kairos" refers to the timing (and placement) of a message that optimizes its impact. In this section we will emphasize logos and pathos, saving the other dimensions for later modules.
Again, the message is the “what” of communication. Communication messages tend to combine both logical and factual content with emotional and artistic expression. The factual content is the “light” (logos) of communication: It lays out specifically how individuals can improve their health or that of the community, or at least avoid or reduce the risk of unhealthy behavior. Factual content can be presented in a variety of forms but has to be adjusted to the cultural and economic context of the audience.
The emotional, artistic, and expressive aspects of a message comprise the “heat” (pathos) of the health communication piece. Messages often employ humor, sympathy or empathy, anger, anxiety, or even fear with respect to a specific health issue. Colors, sound, and other flairs may be added to contribute to a multisensory and more memorable audience experience with the message.
Messages' Four A's
The GCP 2021 authors examined hundreds of different types of messages and developed a 4-category scheme, hence labeled "Elders' four A's". To review, a message is a statement (explicit or implicit) that presents a key aspect of a communication’s destination, embodying the core strategy of targeting a specific audience. Messages should derive from key campaign objectives; without such objectives, messages may seem unclear to a target audience (and, eventually, to the sources themselves). These campaign objectives represent what the source, or sender of the message, wishes to do: 1) announce, 2) advise, 3) activate, and/or 4) advocate. (Note that messages can manifest more than one or even all of these objectives, but be careful; by doing so you may risk clarity!)
Brief definitions of these actions are presented below.
The First A: Announce
Campaigns that announce involve a presentation that directs individuals as to where they can obtain services, buy a product, or (in the case of health fairs, for example) get more information about a specific health issue. Announcement messages can also direct the individual to watch or read other media, or attend an event, which will then provide them with additional information and motivation. See this promotion of an upcoming health fair for a good example of an announcement. Another is the Planned Parenthood website, which lists its clinics and telehealth options and describes its services.
The Second A: Advise
Campaigns that advise are characterized by factual statements regarding health behaviors, risk factors, medications, etc. Information objectives are fairly simple, knowledge-oriented factual statements informing the target audience about the positive and negative aspects of certain behaviors. Advising can help address the challenge of presenting new knowledge or clarifying misperceptions that people may have. Finally, this information may serve as a “booster shot,” reinforcing existing knowledge and reminding the target audience of certain issues. This highly useful example shows how to use Twitter for health care advice, including how best to disseminate curated or original information, the use of the right hashtags, why frequent communication is important, and ethical and legal guidelines. As most people spent far more time in their homes during the early part of the pandemic, health advising and coaching via social media helped to increase coping skills through meditation, yoga, and vigorous physical activity such as high-intensity interval training.
The Third A: Activate
Using both the heat and light of the message, campaigns that activate involve motivating or persuading the audience to attend to and act on the advice or other information presented. This is usually related to individual and small group behavior (to contrast with advocacy, described below). This example presents strategies for activation for confronting myths about vaccinations. This other livelier piece appeals to Argentines' patriotism and their love of soccer to convince the population to take COVID-19 control measures.
The Fourth A: Advocate
Advocacy promotes system-level change via documentaries, articles, movies, public demonstrations, or ads that embrace and promote a social or political point of view. For example, this video piece presents racial discrimination in the application of criminal law. From equal pay for women's soccer to protests for reproductive rights, 2022 gave us dozens of examples of advocacy for actions that were healthy or unhealthy, climate change-indifferent or environmentally protective, peaceful or violent, and unifying or dividing.
Campaigns with combined objectives are pieces that attempt to achieve two or more of the above objectives, as in this example from CDC.
Analysis Activity 2
In 1955, 14-year-old Emmett Till was visiting relatives in Mississippi when a murderous gang of white men became convinced he had flirted with a white woman, beat him savagely, and lynched him. His mother insisted on an open casket funeral, wanting the world to see the mutilated face of the young boy, the victim of others' hate. Examine this article from The New Yorker. Which of the 4 A's did this action address? Given the incredible level of gun violence in the USA, would showing the bodies of children and other victims be an effective means to realize gun control legislation?
Research Activity 1
Locate one example for each of the "4 A's" and one example of the combined objective.
Part Three: Motivating and Persuading in Messages
Whether the objective is to announce, advise, activate, or advocate, the message’s motivational and persuasive contents emphasize change in individual attitudes and group norms with respect to a certain health issue (e.g., behavior, social issues, barriers and challenges) while bringing the health issue to the forefront of the target audience’s collective mind. Specific examples of applying activation objectives often derive from fear appeal messages: attempting to arouse fear in the audience by demonstrating to individuals the scary aspects of engaging in a certain behavior and/or not doing something to mitigate the damage that that behavior can cause. Fear appeal messages usually involve a scary or threatening image to create the desired reaction and promote subsequent behavior change.
The Elaboration Likelihood Model (ELM), developed by Richard Petty and John Cacioppo, and Kim Witte’s Extended Parallel Processing Model (EPPM) provide excellent theoretical bases to analyze messages designed to motivate and persuade, especially those that appeal to fear. A problem with fear-based messaging, however, is that it may diverge from the original concept of “pathos” by causing maladaptive responses when an individual either does not find the image sufficiently threatening or, conversely, avoids the message if it is determined to be too threatening (for example, when its images are overly gruesome). To illustrate the former maladaptive response, The Partnership for a Drug-Free America’s campaign “This is Your Brain on Drugs” was criticized for engendering more curiosity than fear among teens in the target audience. With respect to this maladaptive response, if the message is sufficiently threatening, the individual may lack the “efficacy,” or confidence, to take actions that would eliminate the threat. In other words, the viewer might experience feelings of helplessness that may actually cause the individual to avoid the message altogether. Therefore, fear-based messages must be used with caution.
The EPPM specifically looks at four key factors that can predict the likely outcome of health promotion pieces that involve fear appeals: 1) “self-efficacy” (the confidence individuals have that they can perform the tasks needed to control the risk), 2) “response efficacy” (the perception the individual has that the action will control the risk), 3) “susceptibility” (the vulnerability individuals feel as to how likely the threat is to impact them), and 4) “severity” (the perception the individual has of the magnitude of the threat). When individuals perceive the severity and susceptibility of the threat to be high and also believe they are competent to take action, they will control the danger of the threat. If, on the other hand, the individuals do NOT believe they can control the risk, even if severity and susceptibility are high, they will take steps to control the fear instead.
Fear is not the only emotion used in persuasive health messages. Other emotions can also be invoked that will help individuals remember a specific message, recall the facts, and perhaps provide reinforcement to change behavior. Humor (as used in these condom ads), sympathy, excitement, and other positive emotions can also create an association that may help an individual remember the importance of the behavior change. To illustrate the potential of emotional appeals, contrast the 'heat' of the some of these condom ads, all of which have the same general 'light'.
Analysis Activity 3
Compare the following two graphic pieces with respect to fear appeals and potential self-efficacy and response efficacy responses to the messages.
Emotions can be evoked not only as a result of the specific subject matter of the message, but also by images, sounds, and other elements that have both an emotional and physical impact on an individual. For example, concordant and discordant musical notes and colors may contribute to a message oriented toward fear and anxiety on one hand, or harmony and sympathy on the other. As “Verge” lays out well, individual colors may convey different feelings, though the approach and response to this may vary culture to culture. As musical chords mix different notes to create distinct feelings for different compositions, combinations of colors also vary as a function of the light or heat of a message.
Research Activity 2
Listen to a variety of these sounds. With respect to five of the sounds, give a one sentence description of five distinct feelings they convey. Then, develop a message to pair with each of the five sounds. For example, “Sound X conveys sympathy and could be used in a spot to increase food bank donations.”
Motivating and Persuading: What to do and what NOT to do
A variety of methods can be used to improve the audience’s reception of messages designed to motivate and persuade. First, serious health issues cannot be treated too lightly, but at the same time, the consequence of not taking an action should not be exaggerated. For example, credibility can be lost if people are shown dying from a fairly minor or obscure illness; the message must make a realistic connection between a problem and its consequence.
Part Four: Social Marketing: A Different Slant on Message Objectives
Of major importance to the field of health communication is Philip Kotler’s “social marketing” framework, developed with his colleagues 50 years ago. Health communication has a mixed ancestry: while its roots are in psychology (social-cognitive psychology and behaviorism), its other ancestor is business and economics (primarily, microeconomics and “behavioral economics”). Kotler took a business marketing model and applied it to community efforts for health and social change. Building on the work of others in the business world who developed the concept of the “marketing mix” Kotler describes “4 Ps”: Product, Price, Place, and Promotion. This alliterative framework overlaps to some extent with that of McGuire, but specifically details what aspects of the messages content should be included, especially in terms of:
The “Price” of a new behavior (not just monetary, but with respect to personal effort and other resources required, and perceived benefits and costs of changing the behavior);
How best to describe “Product” (e.g., the behavior change itself, the social or environmental change that one attempts to achieve);
The channels by which to send the message that should be used in terms of “Place” (kairos: where and when a message can best reach someone in terms of a channel or program, and in what stage of life, time of day, season of the year, etc.). An example of 'place' comes from a community food pantry in which both of your editors volunteer. Roughly 250 individuals representing immigrant and refugee households visit this pantry each week, in which they proceed through 3 aisles to pick up dry goods, and fresh vegetables and fruit donated by Trader Joe's and Smart & Final food markets. It was noticed that the 250 weekly guests declined most of the dry goods but wanted most or all of the fresh produce, even though the dry goods aisle offered nutritious items such as beans, pasta, and cans of tuna. To test why, the pantry's directors rearranged the aisle so that the fresh produce was offered in the first aisle, followed later by the dry goods. And indeed, no longer worried that they would miss out on the fresh produce for having taken time looking at the dry goods, the guests began to choose most or all of the dry goods from the second and third aisles as well.
The overall “Promotion” (which is often referred to in social marketing as “media mix:” what best mix of media to use to initiate and sustain a campaign). Promotion often will emphasize the heat of a message, such as the sexual humor in this commercial piece promoting a fresh food brand. Also,
Some have added a fifth “P”, referring to “Position.” This indicates the specific comparison we can make or can be inferred between our product and that of another on the market (e.g., the advantages of getting iron and protein from legumes and quinoa rather than red meat). An example of position comes from the aforementioned food pantry, which initially offered only room temperature boxed milk. When fresh, chilled milk was added to the selection menu, it was assumed that most guests would prefer that. But one volunteer who had lived in Sub-Saharan Africa and Asia noted that many of the guests come from regions of the world in which refrigeration is absent or unreliable; hence, boxed products are considered safer. Subsequently, the boxed and fresh milk were displayed next to each other, with a substantial proportion of the consumers selecting the much less expensive boxed alternative.
Kotler’s and related work have had a substantial impact not only on the specific discipline of health and social communication. Behavioral economists have extended this focus and that of B. F. Skinner's operant psychology to the broader domain of consumer behavior, manifested in concepts such as Gladwell’s The Tipping Point and Thaler and Sunstein’s Nudge. The latter work especially demonstrates how health behavior change can be optimized through environmental, economic, and policy changes that alter Kotler’s 5 P’s, especially price and place.
Research Activity 3
Locate and examine two additional health and social communication pieces briefly, one using McGuire’s framework, and one using Kotler’s perspective. Which perspective do you think provides a clearer and more useful explanatory model, and why?
Tip: Remember the 4 types of message objectives (announce, advise, activate, and advocate) in McGuire’s psychology-based “input-output” model, and align these categories with Kotler’s business-based “5 Ps” outlined above.
Part Five: Branding
“Branding” is the process of pairing an image, slogan, or other stimulus with a product or practice until the two have become synonymous in the mind of the audience. The concept of branding derives from the discipline of marketing, with many successful efforts (e.g., Coca-Cola, Marlborough, Mercedes-Benz, Nike, Apple) as well as unsuccessful and wasteful failures. Successful branding can “build relationships between consumers and products” or services that are being marketed. Lerman, Morais and Luna (2017) provide a very useful definition of a brand as a:
“ …product or service that is distinguished by and marketed on the basis of a distinctive and enduring personality. A brand has greater value with any non-branded product with identical functional attributes because the brand carries with it a unique properties such as technical performance, a specific emotional connection with its customers, or any number of beliefs and ideas that it’s makers through advertising publicity and other means attempt to convince the target customers to associate with it."
Audiences eventually become familiar with a product and are reminded of it by seeing the image or hearing a slogan representing that product. Please note, however, that branding does not last forever: review how Frito-Lay has undone its own Doritos brand given the rejection by Gen-Z consumers of traditional marketing efforts.
One of the best examples of branding in health communication is represented by the long-standing condom promotion and HIV prevention program in Germany, “Macht’s mit: Gib AIDS keine Chance.” Note that this was initially primarily delivered through billboards and posters; now its creators have a very impressive web presence as well. Their success has led them to tackle numerous other health and social issues.
Part Five: Entertainment-Education
Pioneered by Miguel Sabido in Mexico City, “Entertainment-Education” (E-E) is defined either as education done in an entertaining style, or entertainment with an educational message built in. The following in a short primer about this important method; for more detail, please see the full Entertainment-Education Module. Two examples of education as entertainment are: 1) the “Soul City” TV/Radio series that emphasized sexual health and later, more broadly, social justice, produced in southern Africa; and 2) the American PBS program “Sesame Street” that targets preschoolers. Examples of E-E that are primarily designed to entertain but also include messages important health or social messages are popular songs about social issues (e.g., Bob Dylan’s advocacy song/epic poem about the falsely accused boxer Ruben Carter, titled “Hurricane," Jay-Z's "99 problems" which details racial profiling by law enforcement), streaming series (e.g., "Dopesick" based on the role Purdue Pharma played in the oxycontin scandal), and movies (e.g., those that focus on the power of the tobacco industry, either from a dramatic or comedic tone).
E-E often involves the identification and incorporation of media professionals, artists, and/or celebrities in health communication; however, successful examples produced by amateurs are increasingly common.