Nathan Walter
Sheila T. Murphy
Lauren B. Frank
Lourdes Baezconde-Garbanati
Publication Date
November 1, 2017

University of Southern California (Walter, Murphy, Baezconde-Garbanati); Portland State University (Frank)

"[H]ealth campaigns can be used to change beliefs and teach new behaviors, as long as they account for the fact that the audience's cultural background and social environment can either reinforce or attenuate persuasion."

This study examines health communication through storytelling by exploring the importance of cultural factors in the framework of narrative persuasion. A key argument in favour of the use of narrative approaches to health promotion has been the ability to hone in on cultural groups through stories that resonate with specific audiences. However, there has been a dearth of research into the role played by audiences' acculturation in the interpretation and adoption of narrative-consistent beliefs. To help contribute to the literature on this topic, this study asked a random sample of 186 Mexican American females of various levels of acculturation to watch either a narrative designed to increase human papillomavirus (HPV) vaccine uptake or an equivalent nonnarrative film.

The context: There are barriers to HPV uptake for Latino adolescents in addition to lack of recommendations by physicians, including lower levels of acculturation; for instance, Luque et al. (2010) reported that, compared with Anglo-American women, less acculturated Latinas were unlikely to be aware of HPV and the HPV vaccine - which is seen as an effective and safe prevention strategy for invasive cervical cancer.

The researchers explain what they mean by narratives and persuasion - in short, if stories depict characters who engage in activities that prevent diseases (e.g., character who gets the HPV vaccination), viewers may come to believe that those activities are more prevalent and generally viewed as beneficial, creating a shift in perceived social norms. Traditionally, descriptive norms (perceptions of how others are actually behaving) and injunctive norms (behaviours that are perceived as being approved by others) were expected to be influenced by actual others, but it has been established that fictional stories may encourage shifts in normative beliefs as well. The researchers proceed to lay the basis for their hypothesis that acculturation - a process of learning and adoption that takes place as people are exposed to a nonnative culture - plays a role in narrative persuasion. One point they make here is that the literature suggests that culturally grounded narratives are a natural choice for identifying and shaping health messages for less acculturated audiences, because they reflect the underlying values and norms of the culture within an approachable context.

In characterising a key difference between Hispanic cultures and the United States (US) mainstream culture, the literature describes the former as being more collectivist (with community, family, and cultural traditions more salient for less acculturated Latinos) and US culture operating predominately on the individualism side of the continuum. Previous research has documented that, because the family and community contexts are much more dominant for Latinos, peer norms are highly salient and easily enforced. Thus, it has been suggested that health communication meant to reach Latinos should attend to collectivist concerns, such as behaving in accord with acceptable social norms.

The experimental material consisted of two versions of an 11-minute film (see below) designed to highlight key facts and misconceptions about the detection (Pap tests) and prevention (HPV vaccine) of cervical cancer. The narrative, Tamale Lesson, portrays a Mexican American family amidst the preparations for their youngest daughter's quinceañera, or 15th birthday. The interactions among four women (designed to model different perspectives toward HPV detection and prevention) unfold a cervical-cancer-related plot, wherein Lupita (the oldest daughter) shares her recent abnormal Pap test results, which sparks a conversation with her younger sister, her mother, and her mother's friend. Although the nonnarrative stimulus (click here to watch) is similar in the key facts contained and in the length and quality of the video, it is set in a laboratory and features health providers and patients who discuss key facts associated with cervical cancer detection and prevention. Before participants were exposed to the stimuli, the study used 12 focus groups to verify that both films resonated with those from a Mexican American culture. Much of the dialogue in the films was taken directly from the barriers reported by women in those focus groups.

Ages of the 186 participants ranged from 27 to 47 years, with an average of 40 years. Intentions to vaccinate adolescent daughter/son served as the two-outcome (dependent) variables. Descriptive social norms were assessed with two 10-point Likert scale items, on which respondents were asked to imagine 10 women like themselves with a 13-year-old daughter/son and then to estimate how many would have their daughters/sons vaccinated against HPV. To measure HPV-vaccination-related injunctive social norms, participants were asked to assess the extent to which they were confident that various important referents (e.g., mother, female relatives, female friends) would approve of their vaccinating their daughter/son. These items were also measured on a 10-point Likert scale. Level of acculturation (the moderator variable) was assessed with 6 items on a 4-point scale, adapted from Marín and Gamba's (1996) acculturation scale.

In short, the researchers found that, while message format failed to exert a direct effect on vaccination norms and behavioural intent, participants' level of acculturation played an important role in the processing of the message. Namely, when treating acculturation as a moderator, consistent effects emerged for less acculturated Latinas on various research outcomes, including descriptive and injunctive norms regarding HPV vaccine uptake.

As the researchers explain the findings: "when we are dealing with less acculturated participants, normative beliefs emerge as a relevant outcome of narrative persuasion. Specifically, as indicated by the moderation analysis, compared with acculturated Latinas, their less acculturated counterparts tend to experience a shift in descriptive and injunctive norms when exposed to the HPV vaccination message in a format of a narrative. This finding coincides with previous literature showing that health-related decision making for less acculturated Latinas is often family based and community oriented....Thus, for less acculturated individuals, information regarding the prevalence of health-related behaviors and their social approval is perhaps more salient. Conversely, the results for acculturated individuals closely mimic persuasion patterns associated with U.S. mainstream culture, where exposure to a narrative will not necessarily shape normative perceptions. In concert with previous analyses of cultural barriers to health-related decision making, these results suggest that information regarding the audience's level of acculturation could contribute to the validity of narrative persuasion mechanisms."

In conclusion: "the link between acculturation and normative cues may explain why educational strategies intended to reach less acculturated individuals through factual information have too often failed....The current results suggest that culturally sensitive narratives that offer information in the context of social norms are, perhaps, especially suitable vehicles for engaging less acculturated populations."


International Journal of Communication 11(2017), 4946-4964. Image credit: University of Southern California

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