Feb 26, 2016

Interviewer: What's the best messaging strategy to get more people to be properly screened for colorectal cancer? That's next on The Scope.

Announcer: These are the conversations happening inside healthcare that are going to transform health care. The Health Care Insider is on The Scope.

Interviewer: Health care communicators should always be asking if our messaging is achieving the intended outcome whether that's getting somebody to go and get a screening or making some behavior change to prevent burn injuries or stuff like that. Jake Jensen is in the Department of Communication at University of Utah and he took a look at colorectal cancer screening and what type of messaging would be the most effective in getting people to go get their screening and then adhere to that screening schedule. Jake, what are some of the communication strategies that have been used to accomplish this goal in the past?

Jake: The first score of technique would be stories and the second category of techniques would be what we might refer to as targeting or tailoring. Targeting is when we design messages for a particular group of people. So if we want African American women to screen, we might have public service announcements or pamphlets that we create that are specific to that group.

Tailoring is where we design messages specifically for an individual. So you give us information about yourself and then we kick out materials for you. We see stories and we see targeting and tailoring techniques both being used to try to get people to screen.

Interviewer: So, to me it seems like the targeted, my gut would tell me that would be better because when you're talking directly to somebody you would be able to get the action you want, although it probably would be more expensive to create all those materials for all those different groups. What did you find?

Jake: Your instinct is exactly right. That's what I thought when I started this randomized control trial where I compared stories versus, in this case, tailored messages. I assumed that tailored messages would be more effective for the reasons you were just inferring. That as an audience member, I am always more interested in information when it seems directly relevant to me. So you would think that as material became more relevant that it would be more persuasive. And I had done research on tailoring communication before and discovered that tailored communication would be more effective than not tailoring a message, than giving people standard materials that are not customized to them at all.

So I did start off with the assumption that tailoring would probably win the day, but what we discovered was that stories were actually more effective than tailored communication, which is a very fascinating finding that we're now exploring in more detail.

Interviewer: How do you explain that?

Jake: Here is something about tailored communication that we're just starting to wrap our heads around and I think the next 20 to 30 years of tailored research is going to reveal some promising avenues, but as of right now, we've sort of entered into the second phase in this research. And in the second phase, we're more appreciative that when you customize or personalize information for an individual, that actually can be somewhat unattractive as a communicator because, first of all, they feel the hand of persuasion very strongly. So when someone uses information you just gave them to try to persuade you . . .

Interviewer: And it hits a little too close to home.

Jake: Yeah. First of all, it feels a little bit like outright manipulation and so a lot of the participants in our randomized control trial that were in the tailored condition, they were a little creeped out by it.

I could tell that they felt it was a violation of their personal space in a sense. "I gave you this information and now it feels like you're attacking me with it." Which does fit with other research we've had in terms of personalization and customization where we've noticed that it's prone to backlash, that people are very quick to like it, to sense our hand. And of course, once we became more sensitive to that, we started to realize that there was a lot of literature on physiological reactance where starting at age two, we start to develop our autonomy as people and we like to maintain our autonomy and that when communicators attempt to infringe upon our autonomy, we often will push them away.

I also think with stories, the reason that . . . so there are two different things here. Why did tailoring struggle in the randomized control trial? And we've explained that. And then, why do I think that stories were so strong? I think it's almost mere opposites. The thing that's wonderful about a story is even when it's trying to persuade you, you seem to get lost in it for a moment.

It's someone's story so it's not an argument, per se, it's a story about someone's experience. And so I might say, "Well, yeah, they're trying to get me to screen. I can tell that, but at some level, they're also telling me this person's story. That is their story." And so it shuts down our counter-arguing instinct.

One triggers it; the other shuts it down. And so perhaps, in hindsight, it's not surprising that one is very effective, the other, diminishing effectiveness at least across participants.

Interviewer: I feel like you've said two different things. I feel like you've said the research-targeted and non-targeted messages says targeting is better.

Jake: Yeah

Interviewer: But yet between targeted messages and story, now targeted messages seem creepy. So how do targeted messages beat out regular messages, then?

Jake: Research has shown in meta-analytic studies, which is where you synthesize a whole bunch of studies, I like to say you take a whole bunch of studies and what is the average? What they've shown is that tailored messages are significantly . . . it's a small effect, but significantly more effective than non-tailored messages. Standard of care where everybody gets the same message. It's not customized to you at all. It's a small effect, but it's there.

Now, the reason I think it's more effective than standard of care, a standard of care message typically is a pamphlet that is very generic. "Colorectal is a major threat. People should get screened Here are the basic demographics of who should get screened, when you should start, who is at higher risk."

Tailored information, relative to that, at least, adds something to it. Well, it's a little more relevant so when the comparison is that kind of generic pamphlet, tailoring seems to be more effective. Although even there, we find studies . . . one of the reasons the effect size is kind of small or the difference is kind of small is even there, we see some backlash. Sometimes the tailored message does not beat the standard of care. It does, across all the studies, it does, but there are individual studies where it doesn't.

But once you compare tailored communication to some other strategy, not just standard of care, the other strategy at least of this trial, is indicative of what we see in the future. The other strategy destroys it, basically. Stories were far more effective and they were so much easier to create. The tailored messaging strategy is very time-consuming. First, you have to collect all this information on the participants and then you have to develop a system that can develop personalized messages for them. Then you have to deliver those messages to them.

So there are a lot of steps in it and a lot of cost in it. And the idea was even though that's true, it would be so much more effective that it would be worth it. But, yeah, stories were more effective and not to say the stories aren't challenging in and of themselves too. Collecting stories can be time-consuming, but, on the other hand, you don't have to develop a system. We're actually then re-delivering that information back to the . . . it takes their information and turns it into a message . If I just have a story, I can give it to people.

To hit the nail right on the head, we also had a condition in this trial where people received tailored stories. So they received a story and the story was tailored to their personal demographics and the barriers they had said were major barriers to screening for them. They received essentially a double dose, tailoring and story. And you might think if both of these are effective, then potentially, that condition would be most effective.

Interviewer: I'm sitting here thinking, "That's got to be it."

Jake: But it wasn't. Tailored stories are not more effective than stories in general. This is a mistake we make in health communication all the time and I want to make sure that people hear this because this is, in a sense, going to sound contradictory to everything they think they've been taught. We want to believe that it really matters that our messages depict characters and people that are of the same demographic group that we are trying to reach.

Interviewer: Like I need to have that picture of that person on my cover of my pamphlet.

Jake: That's right. The evidence isn't that strong in favor of that. And I want to . . . right now, there are listeners who are going, "I can think of a study where that worked." Yeah, you can think of individual studies where that works but here is the point I want to hammer into your head: That's not how people always think of themselves.

So when I'm thinking about whether or not I want to screen for colorectal cancer, my first thought process isn't necessarily, "Well, how is it that I as a Hispanic woman need to go in and screen? What are the barriers I face as a Hispanic woman?" I might think of something other than demographics as an initial barrier. I might think, "I just don't have the time to go do it," and that is the major barrier that I face. That is a thing that seems to . . . if you can tell me a story about somebody overcoming a time barrier, it doesn't matter . . .

Interviewer: Because that's universal.

Jake: Right. That's the barrier I face. So, we're allowing, as communicators, simplistic ways of understanding humans to dominate our communications strategy when what the evidence seems to keep telling us is when we tell a story that really hits the barrier right on the head that really captures the experience that people have, the details of the story can vary and the story still resonates with people. One of the things where I really became conscious of this is I did a lot of early work in Hammond, Indiana and in east Chicago, which there are a lot of low-income neighborhoods in those two communities. And so I was working predominantly with low-income individuals and very diverse populations.

I once had a participant tell me something that really stuck in my head till this day. I was saying, "We're trying to come up with a strategy that is going to help," in this case, it was Hispanic women, "help Hispanic women come in and start doing some preventive health with some of the free clinic services in the community." And she says back to me, "Well, you need a strategy to help poor people. That's what you need." And I thought she kind of threw it right back in my face.

I was attempting as an outsider to say, "Here is how I view you and so I will communicate with you in this way that I view you." And she was sort of saying, "Well, okay. We're poor."

Interviewer: That's the thing.

Jake: That's the thing. It's a money thing. So that's what you need to understand and that's what your messages need to understand. So what I would say to communicators is to start from a position of saying, "What really matters to the target populations we're trying to reach?" And if that's demographic information, if you have good reason to believe that's demographic information, great. But what this study, in my sense, really taps into is if there's an experience you want to describe that is having an experience of having a colonoscopy and what's that's like to go through and how to overcome various barriers, then let that be your message.

And don't worry so much as some of the other details because you're never going to arrive at a situation where your message is perfectly tailored to each individual and, in fact, our study suggests that even if you do that might not be desirable. What you want is a good story, what you want is a story that captures the experience that is essential to overcoming the barriers.

Interviewer: I think we already have the answer, but as I wrap this up, what would you to say to somebody who has a job of increasing adherence and screening with colorectal cancer?

Jake: Look for great stories.

Interviewer: That overcome the barrier that you're trying to overcome.

Jake: Yeah. Stories about people overcoming the barriers. And another point that should be made is we often use cancer survivors in our communication, especially when cancer outcomes are the goal. We want people to have a mammogram and we'll depict breast cancer survivors. We want people to have a colonoscopy and we'll depict colorectal cancer survivors. We rely on the survivor community for a lot of our narratives. And it's wonderful that we do because they tell great stories. They have all the drama that you would want of a story. It's a person that survived.

But let me suggest an alternative path. If your goal is to speak to people that are non-adherent, who are not currently screening, then survivor narratives may be effective, but they may also miss the mark because what we want are stories that resonate. So what if I had stories, and that's what I used in this case, what if we had stories about people that were struggling to screen but then found a way to do it? They were struggling with the barriers that your population faces and they have managed to overcome those barriers to screen if that's the outcome. That better connects with the actual challenge I'm facing. My challenge isn't, "Can I survive colorectal cancer?" My challenge is, "Can I screen?"

Interviewer: So overcome the nearest challenge to whatever the goal is.

Jake: We overshoot the mark with some of our stories. And so that's not to say don't use survivor narratives. I wouldn't want people to hear this and think I'm saying, "Oh, never use survivor narratives." Survivor narratives can be so powerful and effective in so many different ways. And I love what the survivor community has done in terms of telling their stories. So I would never want to silence them.

But what I would add is I would love to see us start integrating, overcoming barrier narratives, people that are struggling to do the behavior narratives. If that's what you want, then those are the kind of stories that if I'm listening, I say, "Well, it's true, but how would I find time to do this?" Now, a story about somebody who actually finds the time to do it.

It also forces you to think, by the way. You're not going to get out of this without thinking for a minute. When you have to find stories and tell stories about people really overcoming barriers, suddenly you realize sometimes you're not doing something you need to do to make that barrier go away. When it comes to cancer screening, sometimes when you try to craft a story about someone finding the time, you realize the system isn't really very time-friendly. It's hard to find the time and that might lead to change within your system. So beware of the fact that your own stories, fictional or not, sometime reveal cracks in the armor, system-level changes that you need to do.

Interviewer: Very enlightening. I think we've learned stories that are universal to people that overcome the problem are one strategy, anyway, that we should use for . . . would you say for all health care communication?

Jake: Well, I think there's pretty good evidence that it works with colorectal cancer screening so the idea in general seems to be a logical strategy for a large number of areas and there's tons of narrative research or stories-based on research that's examining it in different areas. So I would say it's an attractive strategy that I would love to see people try across a number of domains.

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