Mental contrasting with implementation intentions as a technique for media-mediated persuasive health communication

ABSTRACT

Mental Contrasting with Implementation Intentions (MCII) is a self-regulation strategy that combines the strategies mental contrasting (MC) in which individualscontrast a desired future with the current reality with the strategy of forming implementation intentions (II), which involves making concrete if-then plans (implementation intentions, II) to overcome the obstacles standing in the way of the desired future. Numerous studies across behavioral domains have demonstrated the effectiveness of this strategy in supporting people to adopt health-promoting behaviors or changing unhealthy behaviors. However, research on MCII has so far neglected the applicability of the concept in media-mediated persuasive health communication. This conceptual review aims to demonstrate and examine the potentials and effects of MCII as a technique to tailor media-mediated persuasive health messages and their dissemination through different media channels. In doing so, it draws on existing models of health behavior change, especially individuals’ threat and coping appraisals. Potential effects of MCII on these cognitive factors are discussed, and practical implications for health message design are outlined.

KEYWORDS:

• Persuasive health communication
• self-regulation
• goal achievement
• mental contrasting with implementation intentions
• health behavior change
• narrative health messages

Introduction

To achieve health-related goals (e.g., staying in shape, losing weight, quitting smoking, practicing safe sex, or going to cancer screenings), an individual must be capable of successfully setting and sticking to goals and regulating his or her behaviors. As research on self-regulation and goal attainment shows, people often have difficulties in adhering to healthy behaviors, practicing self-care activities, and abandoning problematic behaviors (Adriaanse et al., 2010; Allan et al., 2016; Oettingen et al., 2010a; Oettingen et al., 2001). Underlying causes for these struggles are that health-promotional actions are often unpleasant (e.g., taking blood, vaccinations, prostate examination) and strenuous (e.g., physical activity). Moreover, people can have existing habits that are difficult to break as they might be accompanied by a short-term forfeiture of pleasurable experiences (e.g., reducing the consumption of foods high in sugar, fat, and salt, as well as abstaining from tobacco, alcohol, and drugs). Thus, enacting health promoting actions requires self-control, which is limited and requires effectively dealing with temptations, impulses, and overcoming habits.

In addition to direct expert-patientinterventions to address these obstacles, one widely used means to help people achieve goals of health promotion and disease prevention is through media-mediated persuasive health communication. This approach relies on the diffusion of information through different media outlets (e.g., posters, social media postings, and public service announcements) and its assumed effectiveness. This kind of strategic communication aims to stimulate, develop, stabilize, or change individuals’ health-related knowledge, attitude, or behavior (Nabi, 2015; Petty & Briñol, 2008).

Given the importance of media-mediated persuasive health messages to trigger and maintain individuals’ efforts in reaching their health goals, it is surprising that persuasive healt hcommunication has not taken greater advantage of findings from motivational psychology. More precisely, motivational psychology has demonstrated the importance of getting people to (1) commit to and strive for change (motivational phase; Oettingen, 2012) and (2) enacting their intentions (volitional, phase; Sheeran, 2002) on how to increase goal commitment (motivational phase) or which strategies can be helpful in translating goal commitment into action (volitional phase). In this regard, research onMental Contrasting with Implementation Intentions (MCII)—a self-regulation meta-cognitive strategy where individuals first contrast the desired future with the current reality (mental contrasting; MC) and subsequently supplement this imagery by concrete if-then plans (implementation intentions, II)—combines two very effective self-regulation strategies that address both of these aspects. Thereby, it could informthe content of persuasive media-mediated communicationto support the attainment of health-related objectives (Oettingen & Gollwitzer, 2010, 2018).

The goal of this conceptual review is to discuss the potential and possibilities to use and integrate MCII in media-mediated persuasive health messages. This is done by shedding light on commonalities between this meta-cognitive strategy and conventional strategies in persuasive health communication. Moreover, this article points out and discusses ways to create and apply compelling narratives for messages that rely on this technique and the advantages of following the process of goal pursuit, that is, goal commitment, goal striving, and goal achievement.

Promoting goal achievement

To successfully pursue a goal, individuals need to address two crucial challenges effectively: (a) define and set themselves a personal goal that is desirable and achievable and (b) have the motivation and ability to implement their chosen goal through adequate actions. The application of MC (especially assisting with goal setting and goal striving) and II (especially assisting with overcoming difficult obstacles and attaining goals) can support the mastery of these challenges (Oettingen & Gollwitzer, 2010).

Setting and striving for goals: mental contrasting

From a motivational-psychological perspective, a critical prerequisite to achieving goals is committing to them. This commitment can be defined as ‘[…] a strong sense of determination, the willingness to invest effort, and impatient striving toward goal implementation’ (Oettingen et al., 2001, p. 738). Consequently, individuals need to comply with a set objective to achieve a goal that is desirable.¹ If, for example, a person wants to achieve health-related goals, he or she needs to invest a considerable amount of personal time and effort (e.g., sticking to a healthy diet or exercising regularly) as well as suppress impulsive, habitual, and addictive behaviors (e.g., smoking, sex without protection, drug use). People also must overcome individual barriers (e.g., physical, psychological, or social), concerns (e.g., doubts about the effectiveness of a treatment or medication), or fears concerning prevention (e.g., results from screenings or self-examination procedures) and treatment (e.g., procedures, pain, quality of life afterward, and getting out of one's comfort zone). Especially in health communication contexts, individuals need to restrain their urges to respond to uncomfortable or challenging information with reactance, avoidance, or denial. Such reactions occur in particular if the information provided is non-compliant with a person's habits, beliefs, values, or attitudes (Brehm, 1966; Dillard & Shen, 2005). It is thus necessary to provide individuals with support in identifying self-regulation strategies that enable them to stick to and eventually achieve the goal, despite all the possible impediments.

Against the background of these challenges, researchers have proposed and investigated the MC technique as one effective self-regulatory imagery strategy that supports goal commitment, goal striving, and goal achievement. The concept draws on assumptions and findings of Fantasy Realization Theory (Oettingen, 1996, 1999) and proposes three modes of self-regulatory thought (see Oettingen, 1996; Oettingen et al., 2001; Oettingen & Gollwitzer, 2018):

1. Indulging signifies fantasizing about a desired positive future without considering obstacles of the present reality that could stand in the way of realizing this vision. These pleasant images (fantasies) about future events appearing in an individual's stream of thought are a good start for behavior change. However, staying in this stage of enjoying the future as if it has already been achieved (without accounting for past performance or personal capabilities and the probability of their occurrence) can be problematic and result in failure to act. For example, people who desire to lose weight might imagine their desired future and picture themselves wearing their old favorite trousers again. Without coming back to the present reality, merely indulging in the fantasy of wearing the smaller jeans leads people to enjoy this desirable future already without inciting a necessity to act or a sense of urgency. In other words, it leads people to enjoy the future as if they have already achieved the desired outcome. Indeed, empirical studies have found that indulging ‘saps’ energy by reducing physiological energy, as indicated by lower systolic blood pressure (Kappes & Oettingen, 2011; Sevincer & Oettingen, 2015). In addition, people who were instructed to indulge in their desired future were found to be generally unsuccessful in making any changes that might impact weight loss (Oettingen & Wadden, 1991).

2. Dwelling signifies reflecting on negative aspects of the present reality that stand in the way of realizing the desired future. When an individual is dwelling, problems and aspects that lead to dissatisfaction are cognitively accentuated, thereby dominating the individual's stream of thought. Such one-sided elaborations fail to clarify the direction in which to act. Consequently, people that only dwell without first getting a sense of direction by picturing a desired future get mentally entangled in ruminations. For example, people desiring to lose weight might contemplate their restrictions for physical activity or the lack of time to integrate exercises into their packed daily routine. Dwelling then does not lead to action because—without the future thought—it does not provide a clear direction to act. The resulting lack of goal commitment eventually hinders or even prevents the realization of a set goal (Kappes & Oettingen, 2014).

3. Mental contrasting (MC) combines indulging and dwelling by integrating mental imagery of thinking about the future (see 1) and then elaborating on obstacles in the present reality that stand in the way of achieving the fantasy (see 2) into one imagery process (Oettingen, 1996, 2012). In concrete terms, that means: ‘[…] juxtaposing one's fantasies about the future with obstacles from one's present reality that get in the way of realizing that future’ (Sheeran et al., 2013, p. 803; based on Oettingen et al., 2001). In doing so, both aspects become cognitively accessible, and associative links between the obstacle and the behavior are established, activating expectancy-dependent goal commitment. In contrast to indulging and dwelling, MC constitutes a self-regulation imagery tool that promotes and maintains behavioral change towards wish fulfillment in case of sufficiently high expectations of success. Basing actions on expectations is smart, as people only put effort into the goals that have a chance of being a success while disengaging when expectations of success are low, even though sometimes this is not an option, e.g., when people must self-manage a chronic disease (Adriaanse et al., 2013). MC is theorized to promote goal attainment through an additional allocation of motivational resources that increase the available energy for addressing challenging situations and obstacles (Oettingen et al., 2009), as indexed by self-report (Oettingen et al., 2001), systolic blood pressure (Kappes & Oettingen, 2011; Kappes et al., 2013; Oettingen, 2012; Oettingen et al., 2009), and magnetoencephalography (Achtziger et al., 2009). In sum, MC is most effective for resource conservation, as individuals are more likely to invest cognitive and physiological effort or energy in endeavors where the obstacle to behavior change seems surmountable.

Research on these three modes of self-regulatory thought has validated that MC is more effective in creating expectancy-dependent goal commitments than indulging and dwelling. Concerning health-related behaviors, a recent meta-analysis found MC to be an effective strategy for health behavior change in the short term (Cross & Sheffield, 2019). Even though an overall evaluation is still missing, individual studies demonstrated that effects could last for up to two years (Stadler et al., 2009, 2010).

Attaining goals: implementation intentions

As a specific way of cognitive processing, MC can provide guidance and support to solve the task of setting a desirable goal and striving for it. However, while goal setting is an essential task for behavioral change, the self-regulation of implementation (goal striving) is a second crucial task for goal attainment (i.e., health behavioral change; Oettingen & Gollwitzer, 2018). As Gollwitzer (1999) stated, ‘Successful goal attainment requires that problems associated with getting started and persisting until the goal is reached are effectively solved’ (p. 493). For individuals to get started or stay on track, they need to recognize and seize opportunities to overcome any reluctance to act (Duckworth et al., 2011), which can be promoted through implementation intentions (II).

Typically, II are conceptualized as concrete if-then plans that are formed in support of overall goal intentions. Such plans should ideally be simple, concrete, and measurable, as they provide people with start-up support to act and help them stay focused and goal-oriented during goal striving—especially when they face temptations or other obstacles. That is why, in addition to abstract and unspecific goals (e.g., ‘I need to lose X pounds of weight’), II provide a script of when, where, and how to act in the face of arising obstacles (e.g., ‘If I feel the urge to eat chocolate, then I will get an apple out of the basket of fresh fruit’; Gollwitzer, 1999). Such scripts help to choose and enact a goal-oriented response in an anticipated situation so that a suitable response automatically gets elicited when needed.

Research has shown that people who actively utilize II strategies have a higher chance of achieving their set goals in the end (Vilà et al., 2017) as they act earlier (instant habits), stick to their plans more reliably, and stay on track—even in inconvenient times or situations (Gollwitzer & Brandstätter, 1997; Oettingen et al., 2000). This even applies when the execution of an action seems to be unpleasant (Orbell et al., 1997) or frightening (Sheeran & Orbell, 2000)—such as participating in preventative health check-ups or undergoing other health procedures (Orbell et al., 1997) or when competing with existing habits (Adriaanse & Verhoeven, 2018). Finally, having II available is particularly valuable when intended behaviors are likely to be abandoned, such as when other goals are of higher priority (Sheeran & Orbell, 1999).

Forming II is familiar to people, as research has found that individual self-regulation already includes this practice and gets intuitively and regularly applied in everyday situations (Gollwitzer & Brandstätter, 1997). Thus, encouraging people to develop and use II through media-mediated interventions promises to be effective. Moreover, II are teachable at scale, such as to improve people's performance related to their goals (academic tasks: Bayer & Gollwitzer, 2007) or to abandon unhealthy habits (eating: Verplanken & Faes, 1999). A recently published study also shows the applicability of II for mediated messages about dental hygiene (Davies et al., 2017).

Mental contrasting with implementation intentions

Even though MC already helps people to overcome obstacles to reach behavioral goals, II can provide further support, especially if people are struggling with obstacles, as they address different aspects of goal striving (motivational and volitional phase). In turn, the combination of MC and II as self-regulation meta-cognitive strategy—as opposed to a separate utilization—is theorized to perform better in fostering goal attainment such as behavioral change:

‘MC of feasible wishes strengthens the non-conscious associative links between reality and instrumental means, and explicitly forming II strengthens this association even further. MC, in turn, enables the effects of II in two ways: (1) MC of feasible wishes fosters goal commitment and energization, and goal commitment is a prerequisite for implementation intentions to be effective (Sheeran et al., 2005); and (2) in MC, the idiosyncratic critical situations and means to pursue the desired future are specified, so that these can be used to specify the if-then components of a given II’ (Oettingen & Gollwitzer, 2018, p. 424).

The effectiveness of combining MC with II for various behaviors has been broadly reviewed and empirically tested (Adriaanse et al., 2010). Therefore, its potential to promote the pursuit of goals is undisputed (for an overview, see Oettingen & Gollwitzer, 2018). A recent meta-analysis pointed out that adding II to MC can additionally promote health behavioral change, even though the lack of sufficient empirical studies prevents a clear conclusion from being drawn (Cross & Sheffield, 2019).

Specifically, existing empirical evidence for the beneficial effects of MC or a combination of MC with II for health behavior change covers a variety of different topics targeting both health promotion (implementation behaviors; i.e., things people should do more) and disease prevention (de-implementation behaviors; i.e., things people should refrain or abstain from). With respect to promoting healthy behaviors, research has already looked at improving diabetes self-care (Adriaanse et al., 2013), increase in physical capacity among chronic pain patients (Christiansen et al., 2010), increase of fruit and vegetable intake (Stadler et al., 2010), or physical activity (observed stair use: Kappes et al., 2012b; self-reported levels of physical activity: Marquardt et al., 2017; Sheeran et al., 2013; Stadler et al., 2009; jogging: Sailer et al., 2015). Concerning de-implementation of target behaviors, the effectiveness of MC as well as MCII has been investigated against the background of reducing unhealthy nutrition (unhealthy snack intake: Adriaanse et al., 2013; consumption of high-calorie foods: Johannessen et al., 2012), reducing alcohol intake (Wittleder et al., 2019), or ceasing smoking (Mutter et al., 2020; Oettingen et al., 2010a).

It is surprising that MCII and its integration into health campaigns have not yet received attention in media-mediated persuasive health communication. Even though there are some larger-scale health-promotional studies (Sheeran et al., 2013; Stadler et al., 2009, 2010), they did not consider explicitly tailoring media-mediated messages, such as (mass) media campaigns or entertainment-education formats. This is unfortunate, as considering MCII seems to offer potential to improve their effectiveness. Therefore, after elaborating, the following sections discuss the innovative idea and possibilities to integrate MCII into media mediated persuasive health communication, i.e., communicative actions in health promotion and disease prevention.

Media-mediated persuasive health communication

Persuasive attempts through media-mediated channels are generally characterized as ‘any influence on beliefs, attitudes, or actions brought about by a narrative message through processes associated with narrative comprehension or engagement’ (Bilandzic & Busselle, 2013, pp. 201–202). Examples from persuasive health communication include a variety of forms and modes of delivery such as health campaigns or public service announcements (PSAs); teaching materials; informative content like statistics, news, or research reports; as well as entertaining materials such as serious games, documentaries, TV shows, and drama series(Rice & Atkin, 2012), henceforth termed media-mediated communication. Regardless of the type of the communicative vessel, audience members are usually confronted with messages that include at least a basic form of narrative: ‘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 (health) topic being addressed’ (Kreuter et al., 2007, p. 22). In contrast, non-narratives rely on brief rhetorical statements or isolated factual information (i.e., straightforward claims or statistical evidence). Communication research has widely shown that narrative messages have advantages in effectively persuading people. For example, they take effect by disguising persuasive attempts, increasing parasocial relationships with characters, or augmenting liking and identification with a central character (Bilandzic & Busselle, 2013; Cin et al., 2004; de Wit et al., 2008; Kreuter et al., 2010; Niederdeppe et al., 2011). Narratives can foster information processing while reducing reactance, resistance, or counterarguing toward the persuasive message (Moyer-Gusé, 2008; Moyer-Gusé & Nabi, 2010). That is why narratives are ‘a promising set of tools for motivating and supporting health-behavior change’ (Hinyard & Kreuter, 2007, p. 789).

Regarding the persuasive potential of narratives, it is crucial to consider different ways of how a story can be told. One stylistic device attracting much scientific attention is the specific use of emotional cues in a persuasive message to charge them in an emotionally negative, neutral, or positive way (Diefenbach et al., 2008; Kok et al., 2017; Nabi, 2015; Nabi et al., 2017; Tannenbaum et al., 2015). These possibilities of emotionally framing health information are sometimes combined within one narrative (e.g., a TV spot) or are strategically presented step by step over a long-run intervention (e.g., billboard campaigns comprising several motifs), thereby offering different opportunities but also challenging message designers.

By evoking negative emotional experiences (e.g., through fear or disgust appeals that emphasize the threat), health communication expertstry to provoke behavioral change through triggering avoidance motivations (Kok et al., 2017). Such a way of designing a message relies on the idea that an individual's motivational deficit to act can be overcome by raising threat perceptions over a threshold to make him or her want to avoid potential negative consequences (Elliot, 2006; Elliot & Covington, 2001) while suggesting possible ways to address the threat (Witte, 1992).

Alternatively, the rather austere presentation of facts (e.g., statistics or expert opinions) mainly aims to enable informed and responsible health decisions (Brown et al., 2006; Freimuth et al., 1990; Joosten et al., 2008). Such an evidence-based approach presupposes that behavior is the result of rational thinking. Also, those strategies often focus on triggering the perception of threat and risk by explicitly pointing them out and evoking an associated emotional response. However, in contrast to the first approach, which often strategically omits or holds back certain information to achieve a persuasive goal, this kind of communication aims to provide unbiased and complete information.

Regardless of the approach to message design, persuasive attempts are confronted with a universal challenge: People often resist persuasive attempts, which manifests in reactance reactions such as denial, downplay, or avoidance of information (Brehm, 1966; Dillard & Shen, 2005; Knowles & Linn, 2004). Such responses are triggered because persuasive health messages often focus on a potential loss or present information that sparks dissonance in the audience. Moreover, at an individual level, the effects of both strategies often fail to materialize because of existing hindrances such as withdrawal effects (e.g., smokers), ingrained habits, reactance, counterarguments, lack of perceived self-efficacy, lack of suitable coping strategies, unwanted outcomes (e.g., sideeffects from a medication), as well as adverse outcomes (e.g., findings from a cancer screening; Ruiter et al., 2014; Shen & Dillard, 2014; Tannenbaum et al., 2015). Hence, the implementation of health-promotional behaviors requires individuals to leave their comfort zone and change their current behaviors. Examples that can cause these dilemmas include eating foods high in salt, sugar, and fat; smoking; or drinking alcohol (de Cock et al., 2016; Tapper et al., 2015). Eventually, such negative reactions from audiences can significantly limit the potential effectiveness of a message.

To avert such problems, some communicators use a positive approach to message design (Mitchell Turner, 2012; Monahan, 1995). These kinds of messages rely on mechanisms rooted inpositive psychology (Fredrickson, 2001, 2013; Fredrickson & Branigan, 2005; Pressman & Cohen, 2005). To induce positive affect, the messages contain distinct positive emotional cues (e.g., appeals to pride, happiness, humor), entertaining content (e.g., plot designs or production techniques; Anikina & Yakimenko, 2015), or uplifting and empowering communication (e.g., ‘You can do it!’ rationale). This approach aims at motivating people and helping them to overcome existing hindrances by strengthening their efficacy beliefs or reshaping the inhibiting threat perceptions. Fostering (self-) efficacy perceptions can, in turn, trigger approach motivations that finally lead to adaptive behavioral change (for an overview: Elliot, 2006; Elliot & Covington, 2001; Sherman et al., 2006).

The result of these cognitive, emotional, or motivational impediments is that media-mediated communicative efforts often miss their pre-set objectives and fail to change key target factors effectively. Even if persuasive attempts succeed in initiating a change of attitudes or intentions, those beneficial effects often do not translate into actual behavior. One explanation for media-mediated persuasive health messages lacking effectiveness is that despite all the positive and motivating support, temptations, and additional obstacles in everyday life, as well as ingrained habits, render communicative efforts ineffective. Research on the intention-behavior gap repeatedly demonstrates this challenge (R. E. Rhodes & de Bruijn, 2013; Sheeran, 2002). Underlying message narratives hardly, insufficiently, or too simplistically integrate information on existing or potentially emerging obstacles and how to overcome them as they focus on conveying information about the level of risk associated with a particular health threat as well as strengthening people's belief in their ability to succeed in avoiding that risk by means of behavioral change (Leventhal, 1970, 1971; Rogers, 1975; Witte, 1992). Moreover, such interventions aim to make people think about why an alternative future is better, without coming back to the present reality. This lack of clarity in media-mediated messages is surprising, as providing individuals with effective cues to action to overcome barriers to health behavior change is a central objective of persuasive health communication.

Harnessing MCII for media-mediated persuasive health communication

As demonstrated above, a vast amount of empirical research in motivational psychology supports this observation and has shown that directing individuals to contrast the mental imagery of the desired future with the imagery of their current and personal (‘What is it in you that is standing in the way of your desired future?’) obstacles (Mental Contrasting; MC) can energize people how to resolve this and guide them to invest their energies efficiently for goal attainment (e.g., Kappes et al., 2012a; Oettingen et al., 2009; Oettingen et al., 2010a). Such empirical findings suggest that media-mediated intervention design should incorporate components that directly point towards obstacles and barriers to behavior change or that prompt the recipient to consider and pinpoint the obstacles that are standing in their way.

Moreover, health messages regularly fail to address the fact that intention or goal-commitment in and of itself is frequently insufficient to engender a change in behavior. That is, it is a highly well-known finding that there is a gap between intentions and behavior, which has been found to be moderated by implementation intentions (Sheeran, 2002). Implementation intentions (if-then) were designed as a self-regulation strategy to overcome these problems and promote the translation of intentions and behavior (Gollwitzer, 1993, 1999). II plans encourage people to identify a relevant cue (e.g., ‘If I have the choice to walk the stairs or use the elevator … ’) and link it to a goal-oriented behavior (e.g., ‘ … then I will take the stairs’). II link a specific context cue to a specific behavioral response using an if-then format. By linking a situational cue to a specific action, a cognitive association is formed. As a result, when encountering the situation, the behavior is executed relatively automatically and is no longer derailed by a lack of cognitive resources. Hence, promoting the formation of such if-then plans in persuasive media-mediated health communication interventions can contribute to goal attainment by bridging the intention-behavior gap (Gollwitzer, 1999).

Concerning health behavior, MCII has—to the authors’ knowledge—so far only been investigated in non-media-mediated health interventional settings. Studies have either investigated self-administering the technique or following instructions from an interventionist or a researcher. Cross and Sheffield (2019) have provided an excellent meta-analytic summary of MCII as a self-regulatory strategy for health behavior change. Building on this existing work regarding the effectiveness of MCII for a variety of different behaviors (for an additional overview, also see Oettingen & Cachia, 2016), the following section reviews the benefits and utility of applying this well-established self-regulatory technique (Oettingen & Gollwitzer, 2010, 2018) as a useful narrative structure for mediated persuasive health communication. The following sections demonstrate that it is very promising to extend the scope of MCII to (mass) media channels by investigatingits’ potentials for health promotion and disease prevention through persuasive health messages.

Health message processing and behavior change

One prominent framework used to describe and investigate the processing and effects of mediated persuasive health appeals (i.e., fear appeals) is the Extended Parallel Process Model (EPPM), proposed by Witte (1992; see also: Earl & Albarracín, 2007; Mongeau, 1998; Peters et al., 2013; Ruiter et al., 2014; Tannenbaum et al., 2015). The model identifies four features of a message that shape an individual's processing of threatening communication: severity, susceptibility, self-efficacy, and response efficacy. Whereas severity and susceptibility affect the perception of threat and trigger an emotional response (i.e., fear), self-efficacy and response efficacy contribute to the appraisal of coping possibilities. Following the assumptions of the EPPM, the ratio of perceived threat to perceived efficacy determines if persuasive messages achieve their goal. It is generally assumed that a certain level of perceived threat perception is a prerequisite for message processing. If this condition is met, high levels of perceived efficacy will lead to danger control (i.e., acceptance of a message's propositions and subsequent adaptive responses), while low levels of perceived efficacy will result in fear control (i.e., reactance, followed by defensive responses). Adaptive and defensive responses indicate positive and negative changes in attitude, intention, and behavior to internalize the presented information or exert the suggested health-related behavior (Witte, 1992).

Research shows that although presenting threatening information is suitable to emphasize the relevance of a topic, efficacy cues and their effect on an individual's perceptions of efficacy contribute more to adaptive responses (Ort & Fahr, 2018, 2020). Thus, despite the ubiquitous subtext conveyed in persuasive health communication that individuals are ‘at-risk’ of getting sick or losing health, people's coping appraisal is of vital importance for beneficial health-promotional outcomes. Moreover, although a certain level of threat perception is essential for message processing and effectiveness—especially concerning attention and awareness—threatening cues also increase the chances of avoidance or reactance, which further impair message processing and ultimately diminish the chances to achieve desired outcomes (Earl & Albarracín, 2007; Mongeau, 1998; Peters et al., 2013; Ruiter et al., 2014; Tannenbaum et al., 2015; Witte & Allen, 2000). On a related note, research on self-affirmation and optimism support these findings. Several studies have demonstrated that positive beliefs and experiences, which can be promoted by efficacy information, function as a self-regulatory resource for people confronted with health threats (Reed & Aspinwall, 1998) and can improve attention and recall of threatening information (Aspinwall & Brunhart, 1996).

Against the background of the EPPM and its components, MCII provides excellent potential on how to appropriately guide people's thoughts about threats and promote their coping appraisals, thereby effectively fostering sustainable health behavior (change). Specifically, MCII offers concrete steps that individuals should mentally traverse in succession to achieve their health-related goals. Given its potential, the possibilities and consequences of applying MCII as a type of narrative structure for message design, particularly for media-mediated persuasive health communication, require further elaboration.

MCII and models of health behavior change

Conventional approaches in persuasive health communication often follow a fear appeal logic and apply a narrative pattern of boosting threat perceptions before offering efficacy cues. However, this strategy is potentially demotivating, especially if messages start with intense and ‘destructive’ threat cues (Dillard et al., 2017; Shen, 2017). In comparison, MCII follows a different rationale. In MC, individuals first envision an important and desired future, which is then followed by an imagery of potential personal obstacles that could inhibit goal achievement (Oettingen et al., 2001). From a lay perspective, applying this strategy might seem counterintuitive at first. This is because in addition to other social, emotional, and cognitive barriers to health behavior change, which are under frequent discussion (Beehler et al., 2014; Nagelhout et al., 2017; Schwarzer, 2008), the imagery of obstacles to reaching a goal after having envisioned a goal potentially catalyzes threat perceptions and might nullify its motivational momentum. Consequently, people would need to fight even harder to overcome those impediments. However, and in contrast to traditional fear appeal strategies, the fact that obstacles follow a previously established goal puts them in the right perspective and makes them meaningful instead of demotivating. By using positive outcomes of health-promotional actions as a starting point, heightened threat perceptions resulting from elaboration on obstacles are more comfortable for individuals to handle. Given sufficient self-efficacy perceptions towards a surmountable obstacle, elaborating on the latter empowers people to direct and sustain their energy in a meaningful way. This, in turn, increases their chances of realizing their desired future (Oettingen & Cachia, 2016). This is also why MC messages—in comparison to the mere application of indulging or dwelling (Oettingen & Mayer, 2002)—increase the chances for (health) behavioral change (Cross & Sheffield, 2019; Oettingen et al., 2001).

Through the application of a persuasive health message that includes an MC narrative, potential impediments become salient and give individuals the chance to anticipate the hardships they might face on their way to goal achievement. Eventually, this process functions as mental preparation for such circumstances, reduces dissonance effects, and encourages the achievement of the pre-defined goal (Oettingen et al., 2001; Oettingen & Gollwitzer, 2010). As persuasive health messages regularly challenge individuals’ existing behavior, thereby confronting them with incongruent information (negative feedback; Kappes et al., 2012a), MC can be an additional booster for their effectiveness by decreasing defensive reactions such as reactance or avoidance (Dillard & Shen, 2005).

Although it might be necessary to target individuals’ threat perceptions to raise awareness about a potential health risk, theory and empirical evidence from persuasive health communication research, as well as the EPPM, suggest that coping appraisals are of even greater importance (Aspinwall & Brunhart, 1996; Reed & Aspinwall, 1998; Ort & Fahr, 2018; Witte, 1992). Models investigating health-behavior change indeed demonstrate that individuals’ perceptions about their ability to respond to a threat (self-efficacy) and the effectiveness of actions (response efficacy, outcome expectations) need to exceed a certain threshold for interventions to be effective and ultimately determine the outcome of message processing (i.e., adaptive or maladaptive behavior: Leventhal, 1970, 1971; Rogers, 1975; Witte, 1992). Thus, it is advisable to include coping-related information in persuasive health messages that helps individuals achieve the communicated goal (e.g., Noar et al., 2015; Peters et al., 2013; Ruiter et al., 2014; Tannenbaum et al., 2015). These findings provide an additional link between research in persuasive health communication and MCII, as both lines of research demand integration of concrete information that promotes guidance on the route to goal achievement.

Conventional persuasive health-promotional messages often mention very broad, general, or even abstract efficacy-related information (e.g., ‘condoms are effective to protect you from contracting sexually transmitted diseases’) or behavioral prompts (e.g., ‘use condoms’). Such prompts can increase expectations of success or strengthen efficacy beliefs and are crucial for message success. In line with the theory about MC and Motivational Intensity Theory (Brehm & Self, 1989), individuals are more likely to mobilize forces when success seems possible and justified. However, media audiences are often required to find their own strategy to tackle behavior change and reach their goals instead of being shown concrete possibilities. This problem-centered way of communication puts additional strain on individuals, as they need to investigate goal-relevant information, acquire skills, and select behavioral options that fit their situation. Thereby, communicative actions often miss out on a crucial opportunity to prompt behavioral responses. To overcome these limitations, message narratives could make use of the benefits of II to strengthen the associative link between obstacle and behavior.

While MC assists peopleto processa risk in a realistic and goal-oriented way that emphasizes the relevance of taking action, II more strongly relates to coping appraisals. When successfully implemented, II can make use of the already-positive momentum resulting from MC and further strengthen the previously established mental connections. As a consequence, II can not only help to increase the chance of adaptive responses (i.e., danger control processes) but alsoact as a buffer to prevent excessive threat perceptions without de-emphasizing the relevance of a health risk. By strengthening the connection between the obstacle and instrumental behavior, II increase the chances of overcoming otherwise critical situations (Oettingen & Gollwitzer, 2010).

Integrating MCII in mediated persuasive health messages: a practical example

Building on the previous explanations, we will attempt to exemplarily transfer the MCII sequence to media-mediated (persuasive) health information. In doing so, the following elaborations build on an important and recurring challenge encountered by experts working in health promotion and disease prevention: Convincing smokers to reduce or abandon their tobacco consumption. While the possibility to teach MCII as part of an intervention is further discussed in the next section, the presented example draws on the mode of communication usually encountered in media-mediated persuasive health communication, such as mass media PSAs. Within such interventions, the audience is confronted with prespecified messages and behavioral cues.

First, a potential MC part of an MCII communication strategy for media-mediated messages needs to establish or reinforce the mental connections between the goal and the obstacles. Successful MC media narratives, therefore, require a clear goal and emphasize the necessity to act. A campaign against smoking could start by showing smokers a positive outcome of reducing or quitting tobacco consumption (such as positive physical, mental, and social consequences) while making them aware of negative aspects that get in the way of realizing that future. Activating both modes of thought has the potential to attenuate and promote threat perceptions concurrently. While addressing obstacles (e.g., the need to smoke a cigarette after dinner or during a break at work) alone might demotivate people, the goal-oriented gateway makes the information efficacious without putting people in a state of shock, hence preventing fear control processes. In this sense, including and addressing possible obstacles in the message seems crucial, as the raised awareness may function as a proxy that provides additional motivation for subsequent behaviors.

Like the MC component, message narratives could make use of the benefits of II in two ways. First, as outlined in the following section, they might encourage the audience to come up with their own ‘if-then’ plans on how to reach their individually identified goal and surmount the corresponding obstacles. Second, following the conventional example of persuasive media-mediated messages presented here and relating back to the addressed obstacles in the MC part, the II component of a message could illustrate specific if-then plans that are suitable to overcome the obstacle above. Compared to conventional and rather unspecific behavioral recommendations (e.g., ‘You should quit smoking’), this way of tailoring persuasive messages might be advantageous, as it enables people to execute corresponding actions (e.g., ‘If I feel the urge to smoke a cigarette after dinner or during abreak, I will go for a 5-minute walk around the block instead’). By strengthening the connection between the obstacle, the instrumental behavior, and their positive influence on coping appraisals, II should increase the chances of adaptive responses (i.e., danger control processes). In case such impediments arise, cognitive structures should then get activated and enable appropriate responsive actions, which increases the chances of overcoming otherwise critical situations (see also the existing literature on MC and MCII on smoking reduction, e.g., Mutter et al., 2020; Oettingen et al., 2010b).

Potentials, limits, and other helpful considerations for MCII-inspired media-mediated health message design

Whereas research demonstrates the overall health-promotional effects of MC and the combination with II (for an overview, see: Cross & Sheffield, 2019),² corresponding elements often do not get addressed in mediated persuasive health communication. Instead, such messagesfocus on making a risk or threat salient to their audience and (in the best-case scenario) showing them ways to reduce the threat or simply giving short behavioral recommendations (Peters et al., 2013; Witte, 1992). One factor in this equation is that many media outlets pose various practical or design-related constraints (e.g., space on a poster or flyer, character or time limitations on social media, and screen timefor PSAs). The exclusion or mere implicit suggestion of motivationally relevant information, such as concrete goals, leaves the audience alone with detection, deduction, and interpretation. Moreover, obstacles are often not addressed at allin persuasive media-mediated communication, and acquiring information on how to overcome hindrances requires further effort and motivation from audiences; the latter includes seeking information for additional materials (e.g., websites, discussion boards, flyers) or engaging in interpersonal communication (e.g., with physicians, experts, family members, and friends). This endeavor can be especially challenging, not only for sensible, embarrassing, or stigmatizing topics like sexual health (Wilton, 2000).

In addition, messages that neglect clear II options risk being perceived as vague or incomplete, which represents another barrier impairing the effectiveness of persuasive health-promotional actions. From a disseminator's perspective, such as experts working in health promotion and prevention, this not only means a loss in message effectiveness but also a loss of control. Due to the lack of sufficient orientation, the audience has too much flexibility for interpreting the message content and is left alone to acquire complementary knowledge through external resources. To overcome and avoid these shortcomings, the following sections present various suggestions on how MCII could potentially inform health message design.

Even though integrating MCII as a strategic narrative in persuasive mediated health communication does not fundamentally alter the process of creating and designing messages, communication experts should ideally account for all components (i.e., goals, obstacles,as well as relevant and feasible if-then plans). As these components are at the heart of MCII and determine their effectiveness, a thorough pre-investigation of necessary information, such as essential and possibly arising obstacles in the target group, is crucial before designing the message. Furthermore, it is essential to select and incorporate appropriate if-then options based on their fit with the envisioned target group and their suitability for the outlet channel of the message (e.g., TV, print, social media, YouTube). Such theoretically based and target-group oriented groundwork facilitates the design of a MCII narrative and matching slogans. For example, an excessive elaboration on obstacles might diminish message effectiveness in a target group that is already well aware of all the existing hindrances. In contrast, a message for individuals who lack awareness needs to emphasizethe obstacles. Thus, public health actors can expect to achieve their persuasive goals by carefully identifying the target group's background and selecting suitable message content for the MCII narrative.

Of course, MCII as a self-regulatory strategy implies that obstacles and suitable plansare highly idiosyncratic. Consequently, applying this strategy in a (mass) media-mediated environment is challenging because it would necessitatenumeroushighly customized messages. This might impede their applicabilityin mass media, as individualization in classic media campaigns (which is discussed under the term tailoring or against the background of stage models; Kreuter & Wray, 2003; Parcel et al., 1987; Schiavo, 2013) is complex and cost-intensive. However, recent trends in the digitalized media landscape facilitate the implementation of MCIIstrategies. In particular, the fact that MCII is a tool and structure that can be filled with individualized content and combined with methods of targeting (i.e., the use of digital channels and advanced methods in audience research to single out relevant audience members) offers great potential (Birnbaum et al., 2017; Chou et al., 2012). As stated above, this requires detailed knowledge and an a priori investigation of the intended target group before designing and launching campaigns.

On a related note, modern digital audiences increasingly reject traditional static and non-interactive persuasive messages in favor of more engaging communicative settings that offer possibilities to exchange information, receive feedback, collaborate, or create and share content (e.g., via social media, blogs, and discussion boards). Work in the context of ‘co-creation’ investigates such shifts in preferences, usage, and the need for mediated health communication to adapt to this dynamic (Nambisan & Nambisan, 2009; van den Heerik et al., 2017). Accounting for this trend shifts the balance of power in message creation toward the audience and liberalizes communication. Even though communicators risk losing control over the specifics of the content that people generate in such settings, co-creation offers new possibilities to design messages of health promotion and disease prevention, which perfectly aligns with the idea of MCII as a tool and structure that can be filled with individualized content. This approach to message design could help develop highly relevant and individualized MCII scenarios for different audiences (i.e., tailored wishes, outcomes, obstacles, and plans). A possible opportunity is to set creative and engaging challenges for the audience to create and share their own MCII story via their social networks (e.g., by posts or using a specific hashtag). An initiative that followed a comparable approach and attracted much attention was the ‘waterbucket challenge’ that aimed to promote awareness of amyotrophic lateral sclerosis (Ohlheiser, 2016) and asked people to create and share their own stories. Beyond this, campaign planners could collect the results, adapt them to their needs, and disseminate the modified messages via media channels and other outlets of their choice.

On a related note, the ultimate ‘gold standard’ for integrating MCII in media-mediated persuasive health communication is to communicate highly individualized and tailored information. Therefore, the potential of digital and interactive media communication—in addition to the conventional one-to-many solutions provided by mass communication channels—calls for further attention. Prominent examples are smartphone apps as health-promotional tools for mental and physical health, well-being, or the treatment of chronic conditions such as diabetes and cardiovascular disease (Abroms et al., 2012). Since a device is usually tied to one person, such apps allow the highest personalization through media channels and can support individuals in the development of goals and strategies. Furthermore, because apps can directly collect additional information about the user, they strengthen possibilities for the individualization of communication and support through messages. Direct queries (self-reports) not only can shed insights into users’ preferences and prior knowledge about a topic but can also provide essential information about their individual goals or perceived obstacles that can subsequently be used as content to tailor MCII interventions. Moreover, different tracking techniques (e.g., physiological data, geo-tracking, diaries, and experience samplings) help to evaluate users’ past and current behavior, progress, obstacles, and compliance with recommendations. Based on the collected information, communication can then be adapted to individuals’ situational needs and provide them with immediate feedback or tailored plans to overcome their most elusive obstacle. To fulfill this gold standard, it is crucial for health experts and campaigners to closely investigate if and how recent innovations, such as digital media and social media, provide them with the possibilities and necessary capacities to achieve this goal (Borrelli & Ritterband, 2015).

Content-wise, MCII messages need to integrate multiple connected aspects.³ Adapting to these requirements in creating a narrative takes up comparably more space than conventional measures such as fear appeals. In this sense, longer media formats, such as movies, drama series, documentaries, or other longer text-based media content, seem to be an ideal form of conveying an MCII narrative. Multifaceted stories that are also entertaining and relatable (Bilandzic & Busselle, 2013) offer extensive creative possibilities for narratives about wishes or goals, obstacles, and II.

Regarding short or static media formats, such as posters or short audiovisual materials, it might be very challenging or even impossible to integrate and address every component of MCII. That is why it is necessary to discuss the possibility of a partial integration of single MCII steps for settings that lack sufficient length, space, or viewing time (e.g., cigarette packaging, posters). There might be situations in which individuals are already aware of their goal and the hindrances they have to face because they are already highly involved in and knowledgeable about the health topic. Such circumstances would, for example, allow the message creators to focus primarily on II.

Although it might seem possible to solely address II without MC, this or any other modification of MCII (i.e., omitting steps or changing the order) may risk decreasing its effectiveness (Cross & Sheffield, 2019; Oettingen, 2012). First, people need to be willing to spontaneously acknowledge and face the obstacle in such situations. As studies demonstrate that only a fraction of people spontaneously engages in MC (e.g., Sevincer & Oettingen, 2013). If omitting MC, communicators would need to confirm in advance—for example, by means of audience research—that individuals in a target group already have (or can quickly develop) an understanding of the wished-for future and the corresponding obstacle. Dynamic stage models of (health) behavior change, such as the Precaution Adoption Process Model (Weinstein & Sandman, 1992) or the Transtheoretical Model (Prochaska & DiClemente, 1983), might offer important insights to determine if and when people are more likely to engage in these processes. This calls for additional empirical attention.

However, as MC and II both affect behavior change directly by processes that are outside of people's awareness, i.e., by affecting the associative link between future and obstacle and the non-conscious detection of obstacles (MC) or by linking the situation (e.g., an obstacle) with goal-directed behavior (II). Given awareness about existing obstacles, research on mediated communication utilizing MCII could investigate, if solely presenting II is a reasonable and effective strategy. Especially for settings in which time or space is scarce. Beyond this direct effect and subconscious effect, it is possible that IIs already include the associated obstacle, such as in, ‘If I am offered a cigarette [obstacle and‘if’ part of the plan], then I will decline it and feel proud [‘then’ part of the plan].’ Compared toconventional broad and unspecific behavioral suggestions, II provide a specific goal-directed response instead of a simple call to ‘Say no to cigarettes!’. Such messages, even if missing information about personal obstacles, can boost efficacy perceptions and avoid the adverse effects of strong fear appeals. Thereby, they work in line with the requirements of the EPPM for effective communication.

Besides the limitation in space or length, another challenge faced by message designers involves interventions that aim to get people to change their unhealthy behavior (e.g., smoking cessation). As messages addressing such topics frequently question current unhealthy/inadequate behaviors, they are prone to spark defensive reactions as people try to defend their sense of self-worth (Steele, 1988). A potential solution for such situations and media formats that do not allow longer narratives would be the integration of self-affirming II that not only include specific plans but also boost people's self-worth by including statements like ‘thinking about the things I value about myself’ and ‘remembering things that I have succeeded in’ (Armitage et al., 2011). Promoting people's self-worth before confronting them with a critical message can improve adaptive responses toward the message, as it has been found to be an effective means to overcome negative feelings such as threat or anxiety resulting from a message encounter (alcohol consumption: Armitage et al., 2011; Armitage & Arden, 2016; Armitage et al., 2014; dietary salt intake: Bradbury et al., 2016).

Irrespective of how MCII can be adapted and applied in media-mediated communication, its effectiveness as a communication strategy depends on additional factors. For example and as elaborated above, an individual's expectation of success (comparable to efficacy perceptions) needs to exceed a certain threshold to influence motivation (i.e., goal commitment) positively. On the one hand, if expectations of success are high, individuals become active, which makes goal achievement more likely. On the other hand, MC with low expectations fosters people to actively disengage from unfeasible projects and engage in feasible projects, thus preserving energy and other resources. Such circumstances make public health care's promotional efforts useless. From an individual perspective, though, both ways can be functional by either providing a sense of accomplishment or saving resources. Thus, as with models of health behavior, communication practitioners face the central task of sustaining individuals’ expectations of success (efficacy perceptions).

Other additional factors that might influence the crafting of MCII-oriented messages include transportability (Cin et al., 2004) and personal relevance or involvement (Cin et al., 2004; Shen et al., 2015). Therefore, one considerable challenge for research lies in investigating those and other possible mediating or moderating factors and interdependencies. Efforts in these directions will help to provide additional knowledge on when, for whom, and under what conditions MCII might work best as a persuasive strategy in comparison to other approaches. The preceding discussion illustrates that although MCII is an innovative and promising approach for persuasive health communication, it certainly is not a panacea or should be seen as a miracle strategy.

Another possibility for the practical use of MCII in persuasive media-mediated health messages follows an entirely different logic. As repeatedly demonstrated, MCII is teachable as part of an intervention (e.g., Oettingen et al., 2010a). A website, https://woopmylife.org, as well as a mobile phone application, WOOP app, created by Gabriele Oettingen, provides a fruitful resource to understand how MCII, also referred to as Wish, Outcome, Obstacle, Plan (WOOP technique), can be used and taught for everyday situations and in health messages. Following this autonomous logic, one could foster health behavior change via MCII by persuasive health messages simply asking the viewers the four questions entailed in WOOP (‘What is your dearest, feasible wish; best outcome; inner obstacle; and [if one wants to add IIs] form an if … obstacle, then I will … behavior to overcome obstacle’ plan). In addition to this, media messages can show the audience how to harness and apply MCII in their everyday life. Instead of confronting people with pre-set content (e.g., specific goals, obstacles, and plans), this would enable them to develop idiosyncratic solutions that suit their needs in a specific situation. A media-mediated intervention would then consist of information about MCII that informs and enables people to generate their own health-related wishes, outcomes, obstacles, and plans. Possibilities to follow this path include teaching MCII in general and tailoring the content on how to self-apply the technique for specific topics, such as tobacco consumption, healthy eating, or exercising. Such a self-tailored approach could empower people to apply MCII to other topics and situations, which might minimize the necessary efforts for other communicative actions in the long run.

Conclusion

MCII provides a theoretically and empirically based constructive and effective narrative structure to address central and frequent difficulties encountered in persuasive health communication, such as reactance reactions or avoidance of the presented information. The strategy helps to provide individuals with a motivational momentum to act via communicated recommendations. Thus, applying MCII as a strategy for persuasive media-mediated health communication can contribute to an increase in the predictive power of persuasive outcomes. As much work in health communication already focuses on perceptions of threat and efficacy, MCII accounts for a variety of related factors that can offer a broader perspective and practical guidance in what combinations of informational cues can be the most effective. This review discussed the numerous possibilities to use MCII as a narrative strategy for media-mediated communication and its benefits for the effectiveness of messages to influence health behaviors. In doing so, MCII ties in with earlier efforts to integrate self-regulation strategies into behavioral models (e.g., II and the Theory of Planned Behavior; Orbell et al., 1997). Beyond these practical benefits for persuasive health communication, MCII can further our understanding of persuasion processes within other domains, such as conventional advertising, change communication, or risk communication in general. The discussed ties to central factors in current models of health behavior provide a possible framework for future research.

Acknowledgement

We thank Prof. Dr. Marieke Adriaanse (Leiden University, Dept. of Health, Medical, and Neuropsychology) for her professional advice during the last revision of the manuscript. She contributed valuable suggestions that certainly added significant value to this work.

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No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes

1 Desirability refers to an individual's cumulated beliefs about the pleasant quality of potential short-term and long-term outcomes resulting from attaining a set goal (Heckhausen, 1977). Consequently, a basic requirement for goal attainment is that it gets evaluated as desirable.

2 Cross and Sheffield (2019) stated that more empirical data are needed to determine if supplementing mental contrasting with implementation intentions substantially improves intervention effectiveness.

3 These aspects can include establishing a goal, elaborating on at least one obstacle, and pointing toward specific plans to overcome it.