McGUIRE 1984 Public communication as a strategy for inducing health promoting behavioral change

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PREVENTIVE MEDICINE 13, 299-319 (1984) 
SPECIAL ARTICLE 
Public Communication as a Strategy for Inducing Health- 
Promoting Behavioral Change’ 
WILLIAM J. MCGUIRE 
Department of Psychology, Yale University, IIA Yale Station, New Haven, Connecticut 06520 
INTRODUCTION 
Recent biomedical and epidemiological research has identified some major 
health problems and some promising solutions to them. This article describes 
how social and behavioral science research can bring these biomedical and epi- 
demiological advances more fully to bear on improving the health status of the 
American public by using either of two strategies for reducing health risks. The 
first involves engineering the public’s behaviors toward health maintenance by 
making structural changes in the institutional arrangements of society, e.g., ban- 
ning certain products, legislating their specification, taxing their use, restricting 
their sales. Disciplines such as political science, organizational psychology, and 
economics can contribute to this institutional approach, for example, by studies 
on the legislative and regulatory processes that led to the ban on cigarette ad- 
vertising on television or by taxation studies on the price elasticity of cigarette 
smoking behavior (21). The second strategy involves convincing individuals to 
exercise personal responsibility for their health by altering their lifestyles in more 
healthful directions, such as using mass media and other communication channels 
to inform the public about dangers, motivate them to reduce risks, or train them 
in skills that enable them to adopt more healthful lifestyles. 
Some health problems, such as reducing environmental noise or water pollu- 
tion, call mainly for the institutional approach. Others, such as obesity or acci- 
dent-risking carelessness, call for the second, individual approach. There are 
other health risks amenable to both approaches: cigarette smoking and alcohol 
abuse are discouraged both by the government’s imposition of high taxes, restric- 
tions on sales, and other deterrents, as well as by educational campaigns to 
increase school children’s motivation and ability to resist pressures to begin cig- 
arette smoking or alcohol abuse. The next section discusses briefly the institu- 
tional class of strategies whose implementation entails manipulating society’s 
elites and governmental and private institutions. The following three sections will 
discuss in more detail techniques for the second strategy, persuading individuals 
to take more effective responsibility for maintaining their own health. 
’ The writing of this article was substantially aided by Grant MH32588 from the National Institutes 
of Mental Health, Interpersonal Processes and Problems Section (BR-5). 
299 
0091-7435/84 $3.00 
Copyright 0 1984 by Academic Press, Inc. 
AI1 tights of reproduction in any form reserved. 
300 WILLIAM J. MC GUIRE 
INSTITUTIONAL STRATEGIES FOR PROMOTING HEALTHFUL LIFESTYLES 
In reviewing institutional strategies for improving public health, I shall first cite 
punitive options available mainly to governmental agencies and then positive 
inducements usable by both public and private institutions. 
Governmental Punitive Strategies 
Governments can reduce health risks by imposing design specifications on man- 
ufacturers; for instance, car manufacturers are required to install seat belts 
(though they are used by fewer than 20% of U.S. car occupants and a slightly 
larger minority in the Federal Republic of Germany), head supports, safety 
steering wheels, etc. (though not yet air bags). Toy and lawn mower manufac- 
turers are forbidden to market items with certain dangerous features, and some 
clothing, furniture, and building materials must be flame-retardant. Governments 
can even impose safety behavior on the individual member of the public, as in 
the case of requiring motorcyclists to wear helmets and (in some countries) car 
riders to fasten seat belts. 
The government can reduce health risks in dangerous environments by regu- 
lating practices such as toxic waste disposal. Occupational injuries can be reduced 
both by legislating worksite modification and by requiring injury-reducing be- 
havior by the individual worker, such as the wearing of hard hats, goggles, or 
other protective equipment. 
Banning health-threatening behaviors and products is another governmental 
option used in the “noble experiment” of the 1920s by the U.S. Federal Govem- 
ment in prohibiting alcohol and currently by most European and American gov- 
ernments in banning the use of drugs like heroin, cocaine, and marijuana and in 
prohibiting automobile driving by those who have consumed a specified amount 
of alcohol shortly before driving. Of course, legislating is one thing, but enforcing 
is something else. (Glendower says in Henry IV, “I can call spirits from the vasty 
deep.” We, however, must ask with Hotspur, “But will they come when you do 
call for them?“) Governments may prohibit driving while intoxicated, but the 
annual occurrence of over 25,000 alcohol-related highway deaths in the United 
States raises the question of whether proscription legislation provides adequately 
for detection and discouragement through fines, license suspension, jail terms, 
and other penalties. 
A fourth punitive option available to the government is to require health-pro- 
moting behaviors as a condition for the receipt of services. For example, New 
York City has long required that all school children obtain a specified set of 
inoculations, but compliance fell off until a state ukase forbade attendance by 
any child who could not present evidence of having received the required inoc- 
ulations, thus motivating negligent parents to have their children immunized lest 
academic baby sitting services be lost and motivating local governments to facil- 
itate obtaining the inoculations lest they suffer reduced per capita state support 
due to the enforced absence of uninoculated children. The state may also mandate 
health examinations and the correction of detected health problems as a condition 
for obtaining working papers, entering governmental employment, holding food- 
handling jobs, etc. 
INDUCING BEHAVIORAL CHANGE 301 
The government’s power to tax can also be used as a tool to channel behavior 
in healthful directions. “Sin” taxes on alcohol and cigarettes make use of the 
demonstrated price elasticity in these substances of abuse: Federal Trade Com- 
mission analyses indicate that for every 1% rise in cigarette prices, cigarette sales 
fall by 0.8%, due to smokers’ smoking fewer cigarettes rather than to a reduction 
in the number of smokers (21). 
Government can also reduce health risks by impeding access to health-threat- 
ening products. Total proscription has been tried as in the 1920s U.S. prohibition 
of alcohol and the current banning of heroin, cocaine, and marijuana. This method 
does reduce, but does not eliminate, abuse of these substances, and it incurs 
other costs. Less drastic measures by governments have attempted to reduce 
alcohol consumption by restricting the hours, places, and amounts in which al- 
cohol can be sold, the age at which purchases may be made, etc. In recent years 
many European and American governments have prohibited the advertising of 
cigarettes on the electronic media, although time-series analyses have failed to 
demonstrate that this banning has reduced the number of smokers or the number 
of cigarettes consumed per smoker (5). 
A rapidly growing form of government regulation mandates that products be 
labeled with regard to risks and benefits (20). This approach requires disclosing 
to the public the nutritional and “additive” ingredients of foods, the possible side 
effects of medications, etc., and leaves it to the individual to decide whether the 
benefits are worththe risks. Such an approach is in tune with current elitist 
beliefs that risk management should be achieved by informing the individual 
of risks and benefits and leaving it to him/her to make a decision based on his/ 
her personal value system. This current laissez-faire philosophy contrasts with 
the more authoritarian banning approach popular during the 1960s when the Es- 
tablishment consensus favored government-imposed solutions as manifested in 
the DuLaney clause prohibition of the sale of foods containing a substance found 
in any concentration to cause cancer in any animal. 
Another way the government can protect public health is by legal regulation of 
health services by licensing medical and paramedical personnel, inspecting hos- 
pitals, certifying medical schools, monitoring pharmaceutical manufacturing, or 
requiring evidence of effectiveness and safety before allowing the marketing of 
new drugs. 
Punitive Strategies by Nongovernmental Institutions 
Modern governments typically attempt to monopolize coercion and the power 
to inflict punishment, but a variety of “activist” private organizations recently 
have been using economic and other punitive sanctions available to the private 
sector to reduce health risks. For example, organizations opposed to the adver- 
tising of “junk” food on Saturday morning children’s television shows have used 
public pressure campaigns against network officials, boycotts against advertisers, 
and demands for FTC and FCC regulation. Similar campaigns against television 
violence have been launched in the hope of reducing the level of life- and health- 
threatening criminal aggression in society. Private coercion has also been exerted 
by mobilizing public-service attorneys to bring class-action suits against environ- 
mental polluters or manufacturers of dangerous items, hoping that private in- 
302 WILLIAM J. MC GUIRE 
dustry can be induced by fear of costly litigation and settlements to increase 
safety precautions in the design and manufacture of their products. 
Private agencies may protect public health also by professional or industry self- 
regulation and -policing, as when physicians’ associations require a certain level 
of continuing education to certify the competence of their members, when hos- 
pitals routinely do pathology tests or otherwise check the performance of indi- 
vidual practitioners, or when manufacturers in an industry adopt a product safety 
code and inspection procedures to enforce it. 
Supportive Strategies by Governmental and Nongovernmental Institutions 
Institutional approaches may use the carrot as well as the stick. While most of 
the punitive procedures just described for promoting public health are government 
monopolies, positive inducements have often been used by private as well as 
governmental institutions. Research support is a positive institutional contribu- 
tion to health maintenance whose level has increased greatly in the United States 
and Europe during the last 20 years but still represents only 2% of all expenditures 
for health; even with so highly studied a condition as cardiovascular disease, the 
annual research budget is only 1% of the yearly cost of cardiovascular diseases 
to the U.S. economy. Private agencies have traditionally contributed research 
support, but increases in governmental funding in recent decades have turned 
some private health foundations into fund-absorbing rather than fund-generating 
institutions. Social science research relevant to the research option for health 
maintenance includes the still inconclusive econometric research on the cost/ 
benefit ratio of biomedical research (lo), organizational psychology studies of 
how the structure and conditions of biomedical research institutes enhance their 
productivity (1), and cognitive and social psychological experiments on factors 
promoting creativity in the individual scientist (3, 4, 29, 30). 
Public and private institutions can also improve the supply of trained health 
personnel by funding medical schools and students, by developing curricula for 
training medical and paramedical personnel, by improving certifying examinations 
to evaluate both the training institutions and the individuals they admit, or by 
training the general population in risk-reducing skills, such as training in CPR and 
lifeguarding, or training special subpopulations in relevant skills (for example, 
restaurant workers in recognizing choking symptoms and executing the Heimlich 
maneuver). Cost/benefit analyses of these various programs are needed, although 
such analyses are admittedly difficult. 
Governmental and private agencies can enhance public health by supporting 
programs to provide nutritious school lunches and free clinics, dispatching hy- 
pertension detection units to communities deficient in ordinary medical facilities, 
or establishing blood or organ donor programs, etc. Treatment facilities can be 
made more available by organizational action to provide Medicare, Medicaid, and 
the various health insurance programs, although economic developments may 
now call rather for large organizations to switch to self-insurance in order to bring 
medical costs under more adequate control. 
A final type of institutional program for health promotion is the carrying out 
of research and demonstration programs, such as regional arthritis centers spon- 
INDUCING BEHAVIORAL CHANGE 303 
sored by the National Institutes of Health, the Multiple Risk Factor Intervention 
Trial, and programs within private corporations for detecting hypertension, re- 
ducing occupational health hazards, or treating alcoholism. 
This list of punitive and supportive strategies by which governmental and pri- 
vate institutions can contribute to the maintenance of public health could be 
expanded considerably. However, the 14 categories mentioned here must suffice, 
since the focus of this paper is on alternate strategies for promoting health and 
reducing risk through education and persuasion campaigns aimed directly at the 
general public or at subpopulations especially at risk to induce them to adopt 
more healthful lifestyles. The alternative mass communication approach to health 
maintenance will be discussed at greater length in the next three sections. 
DEVELOPING SOCIAL INFLUENCE CAMPAIGNS TO ENHANCE 
PUBLIC HEALTH 
Public communication campaigns to induce people to adopt more healthful 
lifestyles have had only modest success. Eliminating from consideration the many 
campaigns that have not been adequately evaluated, there remain numerous dis- 
couraging studies where appropriate evaluations revealed no appreciable health 
gains from substantial communication campaigns. There are, however, a few 
careful studies which have yielded encouraging preliminary results, the Stanford 
Three-Cities Project (12) and the North Karelia program in Finland (23, although 
the benefits of these programs have yet to be evaluated against their costs. I have 
analyzed elsewhere (14) why public communication campaigns are likely to have 
limited effectiveness. For example, their impact on the desired health behavior 
depends on their eliciting a whole chain of responses, such as being exposed to 
the health communication, attending to it, becoming involved in it, compre- 
hending its contents, agreeing with what it says, acquiring the skills necessary 
for compliance, retaining these over time, and acting on the basis of them, etc; 
each of these responses has a low probability of being elicited, so the ultimate 
payoff in behavior compliance will be the very small product of a series of prob- 
abilities. In the face of such obstacles, for communication campaigns to be cost- 
effective they should be designed more insightfully than has usually been the case 
in past campaigns, perhaps following the seven-step procedure briefly describedhere for constructing an adequate health-promoting communication campaign. 
Step 1: Reviewing the Realities 
The first step is a review of the realities described by biomedical and epide- 
miological research in order to identify the problems most suitable for a com- 
munication campaign to enhance the public health. This review involves assigning 
priorities to possible targets using three sets of criteria: (a) identification of serious 
health problems; (b) selection of the subset for which effective solutions are 
known; and (c) focusing further on solutions best achievable through persuasive 
communication. Such criteria suggest, for example, that were one tempted to 
mount a mass media campaign urging the addition of a missing nutrient to the 
diet, a serious question arises as to whether this is a high-priority 
304 WILLIAM J. MC GUIRE 
problem area in the general population or in a special subgroup (such as pregnant 
teenagers) for whom there may be some specific nutritional deficiency problem. 
In this latter case, it may be more efficient to find communication channels that 
can best reach the small at-risk group than to mount a general campaign. Or, 
given that the health of some segment of the population (say, Type-A personali- 
ties) suffers from their poor handling of stress a question arises as to whether 
cost-effective techniques exist for improving the handling of stress. Where there 
is a solution with clear health benefits, such as reduction of cigarette smoking, 
the question arises of whether a mass media campaign is an effective way of 
getting smokers to quit, since quitting requires skill acquisition, social support 
systems, etc., not easily provided by mass media. Hence a smoking-reduction 
health campaign might better be aimed at prevention than at cure. Moreover, 
since few people begin smoking after adolescence, a prevention campaign should 
probably be channeled to youths through school programs rather than the mass 
media. 
The first two criteria, identifying serious medical problems and problems for 
which feasible solutions are available, call mainly for biomedical and epidemio- 
logical expertise. Given the social science. focus of this article, these shall be 
discussed only briefly relative to the third, more psychological criterion, of how 
effective a mass persuasion campaign would be for implementing the solution. 
The first criterion, assigning priorities on the basis of the seriousness of the health 
problem at hand, calls for the assignment of weights to health-reducing conditions 
in proportion to the number of people they effect and the extent to which the 
condition impairs functioning and causes suffering and other costs to both the 
afflicted person and society. Careful problem-identification undertakings of this 
sort have been carried out by the biomedical and public health establishments in 
recent years, and convenient priority targets have been published by the U.S. 
Department of Health and Human Services (31, 32). 
Such thoughtfully developed hit lists of priority targets for public health pro- 
motion campaigns are valuable but would be more useful still if three selectional 
improvements were introduced: an increased emphasis to morbidity relative 
to mortality costs, to life loss relative to lives lost, and to initial causes rather 
than proximal links in the causal chain leading to illness and death. Each of the 
three correctives is illustrated below. 
Mortality is probably overemphasized relative to morbidity, considering that a 
less selfish and sentimental appraisal suggests that prolonged and serious mor- 
bidity tends to impose more diffused but, in the aggregate, higher total human 
cost than does mortality. When a dreadful automobile accident kills one young 
man and permanently incapacitates another, both losses are catastrophic. The 
person killed suffers loss of life, his relatives and friends suffer emotional and 
material losses, and society suffers loss of 40 or more years of the worker’s 
economic and other contributions. The “totally” disabled person still has life, 
though its quality may be reduced due to pain and frustration; the emotional 
anguish of his-friends and relatives may be less intense but will be of much longer 
duration; and society, beside losing 40 years of economic contribution, may incur 
additional extraordinary costs of maintaining the sufferer materially and medi- 
cally. 
INDUCING BEHAVIORAL CHANGE 305 
It is reasonable to emphasize cardiovascular disease and cancer as priority 
health problems, since they are the leading underlying causes of death. Our preoc- 
cupation, however, with these mortal ills should not be allowed to distract atten- 
tion from less common, but earlier-occurring, causes of death like accidents, 
suicides, and homicides, which tend to strike their victims at the outset of their 
productive lives. Nor should we overlook conditions like cigarette smoking and 
alcoholism, which contribute diffusely if only indirectly to both mortality and 
morbidity. Alcoholics may be a long time dying but they live diminished lives and 
diminish the lives of others, and when they go they may take others with them 
(e.g., the involvement of alcohol in 25,000 highway deaths and thousands of 
homicides each year). Nor should preocccupation with death deny due priority 
as targets for public health campaigns to chronic diseases like asthma, arthritis, 
and the sexually transmitted diseases that cause much misery even though they 
lack the macabre glamour of appearing among the top 10 “Leading Causes of 
Death.” 
A second needed corrective is to give more weight to life loss relative to lives 
lost in apportioning priorities among competing targets for preventive medicine 
campaigns. This correction entails taking into account the age at which the var- 
ious potential health threats inflict mortality or morbidity costs on their victims. 
For example, cardiovascular disease and cancer cause many deaths, but they 
tend to strike victims at advanced ages when their life expectancies and likely 
further contributions to society are relatively small. Fewer lives are lost in acci- 
dents, suicides, and homicides, but these deaths tend to occur quite early in the 
victim’s productive life, resulting in the loss of considerable life expectancy to 
the victim and considerable services expected by society. Among people in their 
twenties, accidents cause 10 times as many deaths as cancer and 100 times more 
than cardiovascular diseases. Suicides and homicides also vastly outweigh car- 
diovascular and cancer deaths among these young people. Selecting targets more 
on the basis of life loss than lives lost by taking age of occurrence into account 
would considerably alter priorities among public health campaign targets. 
A third corrective is to give more weight to the earlier links in the chain of 
events terminating in death. While it is useful to conduct research on terminal 
diseases, an even greater improvement in public health might come from inducing 
people to adopt more healthful lifestyles in childhood, such as not starting to 
smoke. For example, Cohen and Lee (2) calculated how much life loss could be 
prevented by the achievement of various health goals. If all heart diseases were 
prevented, they found that life expectancy (at birth) would increase by 6 years, 
slightly less than would be gained by stopping males from smoking cigarettes. By 
eliminating all cancer, life expectancy could be lengthened by 3 years as compared 
with the 4 years that could be added by achieving normal weight among those 
30% overweight. But the really formidable statistical health threat is being un- 
married; married men live 10 years longer and married women 4 years longer 
than their single counterparts. So to make a solid contribution to life expectancy, 
one has only to eliminateheart diseases or cancer; to make a still bigger contri- 
bution, one should eliminate cigarette smoking or obesity; but to make a really 
giant leap forward, one should go after the big one and open a marriage bureau. 
306 WILLIAM J. MC GUIRE 
Naturally, one should not interpret such epidemiological statistics too naively: 
the relationship between being unmarried and having a shorter life expectancy is 
probably due in part to both being coeffects of preexisting physical conditions. 
Still the lifestyle associated with the unmarried state is probably itself a contrib- 
utor to the lo-year-shorter lifespan of single men, suggesting an issue even more 
basic than sex and the single man: death and the single man. 
It is appropriate that biomedical and epidemiological researchers take the lead 
in this first step of reviewing the realities to select priority targets for health- 
promoting campaigns. However, the social, behavioral, and communication sci- 
entists on the team can make contributions even on these first two technical 
criteria, because their very distance supplies a needed objectivity. Physicians and 
health researchers tend to have long professional involvement with specific dis- 
ease entities or with certain treatment approaches; for example, the arthritis spe- 
cialist may appropriately be preoccupied by the prevalent use of quack treatments 
of the elderly or the internist may have become obsessed by the need for early 
detection or better treatment compliance by hyptertensives or the epidemiologist 
may be narrowly worried about the recent increase in smoking among teenaged 
females. There is also the habitual orientation of physicians and other biomedical 
researchers toward medical rather than behavioral or lifestyle interventions. Such 
specialized expertise of the team’s health professionals may require their exer- 
cising heroic virtue to attain objectivity in identifying priority targets, an objec- 
tivity painlessly bestowed on the social, behavioral, and communication re- 
searchers by their very ignorance. 
Social scientists can make a more obvious contribution to this initial step of 
realistic assignment of priorities when it comes to applying the third criterion: 
judging how feasible it is to use a communication lifestyle change approach to 
implement the available solution to the serious health problem. Applying this 
criterion involves analyzing lifestyles associated with the health threat, then iden- 
tifying changes that could reduce the risk, suggesting ways in which desired 
modifications could be effected, and judging the feasibility of mass media or other 
communication campaigns for economically achieving these lifestyle changes with 
a minimum of undesirable side effects. In this undertaking, one considers several 
principles. Can the change be induced simply by providing information, or must 
motivation also be supplied, the former being more achievable by mass com- 
munication than the latter? To what extent does compliance require skill acqui- 
sition and social support, thus lessening the suitability of a mass communication 
solution? Does the “psychographic profile” of the at-risk subpopulation include 
a specific pattern of media exposure, thus making the target group efficiently 
reachable by a mass media campaign? 
Step 2: Axiological Analysis 
Once a hit list of health problems has been assembled and given priorities on 
the basis of the three reality criteria just discussed, the problems should be sub- 
jected to an ethical appraisal which may alter the priority ordering of the targets 
or even lead to dropping one or more of them. Such value analyses should con- 
INDUCING BEHAVIORAL CHANGE 307 
sider the campaign’s costs as well as benefits, its indirect unintended effects as 
well as its intended direct effects, its general psychological as well as its specific 
physiological effects, and its effects on society as well as on the target individual. 
For example, before urging people to alter their lifestyles by engaging in jogging, 
tennis, or other vigorous exercise, one should consider not only the health ben- 
efits to the physically unconditioned (e.g., weight loss, greater endurance, im- 
proved muscle tone) but also the possible health costs in knee injuries, foot 
disorders, even dog bites. Also, one should consider subtle, indirect effects, in- 
cluding benefits such as improving the person’s general feeling of well-being or 
providing opportunities for pleasant social interactions, and indirect costs such 
as guilt feelings if the jogging leaves less time for one’s family and work. Effects 
on society must also be considered; for example, before we slow down the “Type- 
A” people we should consider the resulting cost to society in lessening the con- 
tributions of its most productive workers. One has also to consider that the effects 
of communication campaigns seldom can be fine-tuned or monitored, which could 
result, say, in a campaign to induce more physically active lifestyles becoming 
all too successful if jogging is taken up by people who should not engage in heavy 
exercise or adopted too suddenly or too vigorously by others. 
Carrying out of a value analysis calls for imagination, perspicacity, and objec- 
tivity in identifying effects-both costs and benefits, direct and indirect, indi- 
vidual and social. Once an inclusive list of the campaign’s possible effects is 
generated, each effect could be evaluated in terms of the probability and mag- 
nitude of its conduciveness to a wide range of values such as those in Rokeach’s 
(27) or Murray’s (22) lists. 
In ordering the steps in constructing health-enhancing campaigns I have intro- 
duced ethical examination early, but one should also return to it subsequently as 
the campaign construction continues. It is important to consider the ethical as- 
pects early on, before becoming so involved in the campaign that it becomes 
personally and socially awkward to raise ethical issues. At one time, I participated 
in a campaign to induce people to be diagnosed for hypertension, the asympto- 
matic nature of which was communicated by the slogan “Only your doctor can 
tell.” I worried that this heavy emphasis on the necessity of going to a physician 
might interfere with concurrent efforts to promote hypertension detection by 
stationing paramedics trained and equipped for initial hypertension screening at 
public places in depressed areas of the city poorly served by formal medical 
facilities. An early value analysis allows detection of possible problems before 
emotional investment constricts one’s sensitivity to difficulties and while slight 
modifications may still allow the problem to be averted with little lost time or 
embarrassment. When a moral issue arises only after the campaign construction 
has progressed considerably, it may leave one with the painful choice among 
working out laborious and disruptive campaign alterations, wasteful and embar- 
rassing withdrawal from the campaign, or half-hearted and stressful continuation 
in an enterprise about which one has ambivalence. Hence, an early value analysis 
of the campaign’s goals is desirable. However, one should not, after this initial 
appraisal, put these ethical considerations aside, but rather should return to the 
ethical evaluation of both the means and ends that are adopted intermittently as 
the campaign develops. 
308 WILLIAM J. MC GUIRE 
Step 3: Surveying the Sociocultural Situation 
The purpose of this third step in designing a health-maintenance campaign is 
to study those at-risk in their natural environment in order to identify situational 
circumstances that instigate and maintain health-threatening lifestyles. Through 
this study, points and directions in which social influence effectively can be ex- 
erted to redirect behavior into risk-reducing channels can be detected.In this 
way, the campaign objectives can be further specified with regard to what lifestyle 
changes should be urged on the target population. 
If Step 1 was concerned with biomedical and epidemiological facts and the Step 
2 value analysis emphasized philosophical, religious, and ethical perspectives, 
the third step calls for anthropological and ecological skills (namely situational 
inventories, participant observation, use of informants, psychographic profiles, 
etc.). If, for example, a campaign were to focus on smoking prevention, one might 
study the junior high school culture in which most smoking begins by interviewing 
informants such as school teachers, principals, and coaches, and even-if the 
language difftculty can be overcome -the children themselves, perhaps in this 
latter case using peer leaders and “focus group” techniques. 
If one is endeavoring to promote seat-belt use or hypertension detection, one 
might interview those who have and those who have not adopted the risk-reducing 
practice and identify factors that have induced or discouraged taking the desirable 
step. Also, one could serve as a nonparticipant observer from a highway toll 
booth, recording seat-belt usage as a function of the demographics of driver and 
passengers, type of car, time of day, weather conditions, etc. Alternatively, one 
could use the “psychographic” approaches of consumer researchers to segment 
the population into subgroups varying in risk and analyze the characteristics, 
lifestyles, and especially the media-consumption habits of high-risk segments, in 
order to ascertain the optimal themes to stress and the most cost-effective media 
mix to reach subpopulations most in need. 
At the end of Step 3, one should have identified situational circumstances that 
increase the target health risk and critical choice points at which social pressure 
exerted through a communication campaign could promote alternate health be- 
haviors at minimal cost to an individual’s preferred lifestyle. 
Step 4: Mapping the Mental Matrix 
The previous step of surveying the sociocultural situation called for viewing 
the person at risk from the outside to identify critical health-relevant aspects of 
his/her ecological situation. This fourth step is complementary in that it calls for 
intra- rather than interpersonal analysis, getting “inside the person’s head” to 
see how he/she conceptualizes the health threats that the campaign is designed 
to reduce. Hence, this step calls for using clinical or cognitive psychologists’ 
techniques for mapping mental structures that determine how the person at risk 
selectively perceives the situation and that direct his or her behavior into health- 
threatening or health-maintaining channels. 
In this fourth step, one ascertains the kinds of information and misinformation 
people in the target group have about health dangers, the availability of risk- 
INDUCING BEHAVIORAL CHANGE 309 
reducing alternatives, and the connnection between their own lifestyles and these 
health problems and solutions. Besides mapping these (mis)informational struc- 
tures that direct perception and behavior, one must also ascertain the relevant 
dynamic aspects of the individual’s personality, that is, the motivations and values 
that propel the person’s behavior into health-threatening channels and which 
could provide impetus for diverting the behavior into risk-reducing paths. 
A variety of psychological techniques can be used for mapping these directive 
and dynamic psychological orientations relevant to health-risk behavior. 
Leventhal et al. (8) and Pennebaker (24) demonstrate clinical and cognitive 
psychological techniques by which one can determine the individual’s implicit 
theories of biology, of health, and of medical and surgical treatment, revealing 
that even well-educated persons can have amazingly distorted views of anatomy 
and physiology, the meaning of symptoms, and perceptions regarding how treat- 
ments work. One can use critical-incident analysis or projective techniques to 
ascertain the thoughts and motives that precipitate at-risk individuals to obtain a 
hypertension or cancer diagnosis or to stop smoking. One may find (in violation 
of commonsense expectations) that cosmetic needs are more powerful than health 
needs for improving dental hygiene or that altruistic appeals to people’s respon- 
sibility as parents may be more effective than appeals to preserve their own life 
and health for getting adults to cease smoking. Also useful is the expected-values, 
instrumentality x evaluation technique of presenting people at risk with a list of 
values and having them rate the appeal of each and the extent to which they see 
the health-relevant behaviors as conducive to or interfering with the attainment 
of each value. Such an analysis might reveal, for example, that a campaign 
against dangerous driving or drug abuse by young males that stresses the high 
risk involved in such behavior might backfire in that perceived riskiness can 
enhance the machismo appeal of the dangerous practices for this demographic 
group. Even humanistic techniques can be useful, as illustrated by Sontag’s (28) 
revealing analysis of the depiction of tuberculosis and cancer in literature as 
indicative of the very different ways these two diseases are perceived by their 
victims and potential victims. 
Step 5: Teasing out the Target Themes 
Steps 3 and 4 are divergent, information-generating operations that tend to 
inundate the campaign designers with a wealth of considerations as regards the 
external situational aspects of the problem (Step 3) and its internal psychological 
embeddedness (Step 4), leaving them ready and even eager for Step 5: narrowing 
down the possibilities. This step calls for the campaign designer’s convergent 
decision making to tease out a few basic themes and subpopulations on which a 
social influence campaign can focus from among the many situational and dis- 
positional possibilities generated in Steps 3 and 4. 
Selection of the most promising target themes can be guided by a number of 
social and behavioral science principles. Most drastically, the Step 5 analysis may 
reveal such formidable embeddedness of the health-threatening behavior as to 
indicate that one should forego this second, individual-change strategy and revert 
to one of the institutional-change strategies considered in the initial section of 
310 WILLIAM J. MC GUIRE 
this chapter. For example, Steps 3 and 4 may reveal so many situational and 
dispositional difficulties in inducing automobile passengers voluntarily to use seat 
belts that it will appear as cost-effective to switch to the institutional approach 
of requiring automobile manufacturers to install automatic impact-inflating pro- 
tective airbags. 
More often, it will be possible to design a communication campaign to reduce 
the health risk, using such social science principles as the fact that it is easier to 
provide information than motivation through the mass media. For example, nu- 
trition messages to reduce sodium intake could be better devoted to providing 
information on the use of herbs instead of salt to make food tasty rather than 
trying to convince people that unsalted foods taste just as good. Mass media can 
more effectively communicate “what” than “how.” Since skill training by mass 
media is difficult, the nutrition messages might better concentrate on urging the 
family shopper to read the salt content on food labels rather than on training the 
family cook to prepare gourmet meals without salt. In general, the message should 
devote less time to arguing the seriousness of the danger than the efficacy and 
availability of ways to cope with it. All too often health campaigns focus dispro- 
portionately on the danger rather than the solution, as when valuable message 
time is wasted stressingthe dangers of hypertension, tetanus, cancer, etc., as if 
the public had to be talked out of a favorable leaning toward those conditions. 
Rather, the message should stress the efficacy of taking risk-reducing steps and 
especially should provide explicit instructions on how the person can avail her/ 
himself of relatively simple modes of risk reduction. A campaign to lower sodium 
consumption should emphasize simple expedients (such as the one-to-one sub- 
stitution of less dangerous spices for salt while cooking rather than the teaching 
of intricate new recipes). A campaign urging at-risk subpopulations to be im- 
munized against tetanus or diagnosed for hypertension or cancer should provide 
very concrete directions to easily accessible sites and to simple institutional ar- 
rangements for complying; rather than arguing for the need of such immunizations 
or diagnoses (9). 
When it does become necessary for a health campaign to induce motivation as 
well as provide information, a useful principle is that it is easier to manipulate 
perceived instrumentality than to change subjective value. For example, people 
at noisy work sites can be induced to wear protective ear coverings more effec- 
tively by giving periodic hearing tests that demonstrate to noncomplying workers 
their progressive hearing loss than by trying to make hearing loss seem more 
terrible or the wearing of ear protectors less unpleasant (34). Motivational appeals 
should also concentrate on values that are important to the people at risk rather 
than on those the campaign designers think should be important. While the health 
professional may want to urge dental hygiene or avoidance of sunburn for their 
yield in improving health, people at risk may be more influenced by appeals 
stressing their yield in improving physical attractiveness and popularity. This 
principle can also enmesh a campaign designer in moral dilemmas, such as 
whether to take advantage of religious guilt feelings to reduce alcohol or cigarette 
abuse within cultures with strong religious proscriptions against such substances, 
such as in Islamic or Mormon areas. 
INDUCING BEHAVIORAL CHANGE 311 
This fifth step entails not only teasing out the target themes but also defining 
subpopulations particularly at risk and identifying their media consumption habits 
in order to develop an optimal media mix for getting the health message to them. 
Toward this end, marketing and advertising techniques like psychographics and 
market segmentation are useful. 
Step 5 is completed when one has chosen a few particularly promising themes 
for emphasis and identified particularly high-risk subpopulations at whom the 
campaign should be directed. For example, if one’s objective is to decrease reck- 
less and drunken driving in teenage males, one might decide to avoid the riskiness 
theme because it might backfire for the “macho” population in favor of stressing 
the “masculinity” of “taking charge” and taking responsibility for the well-being 
of one’s passengers. For this target group, it might be more efficient to transmit 
spots not so much on popular television shows with large but diffused Nielsen 
ratings, but rather on late night, hard-rock radio stations having low general 
Arbitron ratings but high saturation for this particular group. 
Step 6: Constructing the Communication 
Having identified the themes to be stressed and the target subpopulations to 
be reached, health campaign designers can turn to the sixth step: constructing 
the communication. It is so obviously a central undertaking that it tends to be 
overemphasized to the neglect of the other steps in the campaign design. Too 
often communication experts or social and behavioral scientists are utilized only 
at this step to construct a communication that will produce maximum impact on 
the public’s health-related information, attitudes, and behavior. While it is true 
that the special expertise of the communication and social science people on the 
team is, indeed, most directly relevant to this sixth step, they have the respon- 
sibility and the capacity to contribute to the other steps as well. 
Communication specialists interested in this sixth step fall into two groups- 
one artistic, the other scientific. Each can make quite different contributions to 
the campaign, so inputs should be sought from both groups. The artistic special- 
ists include writers, directors, and production people from the media who know 
many rules of thumb (some of which deserve to be true but are not). (One such 
rule is to photograph political candidates and/or health communicators full face, 
at eye level, to enhance their impact and audience approval (23)). The second 
group of communication specialists consists of social and behavioral scientists 
who use empirically tested theoretical analyses to identify which aspects of the 
communication situation can be manipulated to enhance impact. The professional 
writers, directors, camera people, etc., in each medium know more than do the 
scientists, while the latter, besides knowing a few additional non-overlapping 
things, are much more aware than are the artists of which of these “known” 
things are true and which are not. The artists and the scientists complement one 
another on the health campaign team, although the focus of this article is nec- 
essarily the latter. 
A vast body of scientific research has been done on how communication vari- 
ables can be manipulated to maximize informational, attitudinal, or behavioral 
impact. Over 1,000 published studies on this topic are abstracted annually in 
312 WILLIAM J. MC GUIRE 
Psychological Abstracts. Lipstein and McGuire (11) were able to compile a bib- 
liography of 7,000 recent persuasion studies, each with an abstract and indexed 
according to the input and output communication variables it involved. The last 
two sections of this article will illustrate how this research bears on the construc- 
tion of communications to guide and motivate people toward electing more 
healthful lifestyles. First, however, the seventh step, that of evaluation, must be 
described. 
Step 7: Evaluating the Effectiveness 
Discussion of the evaluation step has been left until last in recognition of the 
obligation that one incurs in designing any undertaking as complicated and im- 
portant as a health campaign to conduct an end point appraisal of its ultimate 
effectiveness. The design of the campaign ideally should allow this final evalua- 
tion to provide not only an overall appraisal of impact, but also specific measures 
of the effectiveness of separate input aspects with respect to the intended outputs. 
More important than serving as a report card on the given campaign, this final 
evaluation can provide important guidance for future health-promoting cam- 
paigns . 
In addition to an end-point evaluation, a campaign should incorporate ongoing 
evaluations to aid the designers in choosing alternatives and in detecting and 
strengthening weak points as the campaign is developed. Such ongoing checks 
may be as simple as getting a diverse set of experts (including, perhaps, a “devil’s 
advocate”) to evaluate the team’s decisions. For example, as soon as the health 
campaign team carries out Step 1 by deciding which health risks and solutions 
will be emphasized, it might deliberately submit its decision to certain biomedical 
researchers, epidemiologists, or communication specialists known to advocate 
alternative health targets or to downrate the chosen ones; again, the cam- 
paign designers may check their own Step 2 ethical analysis by submitting 
their plan to concerned persons in other professional fields who have in the past 
voiced criticism regarding the morality of similar campaigns. Criticism obtained 
from such unsympathetic external reviewers would not necessarily result in the 
abandonmentof the proposed work, but it might induce some adjustment that 
would meet the objection. 
Another mode of ongoing internal evaluation is to use multiple methods in 
carrying out the various steps and ascertaining whether the same decisions are 
indicated by the different approaches. For example, the Step 3 analysis of the 
sociocultural situation underlying the health-threatening lifestyle might be pur- 
sued by both questionnaire and observational methods, each supplying supple- 
mentary information and providing mutual cross-validation; or the Step 4 mapping 
of health-relevant perceptual and motivational psychological domains can be’done 
by both structured and unstructured instruments. In the ongoing evaluation it 
may even be cost-effective to introduce miniature experiments; for example, in 
the sixth, communication constructing step, various copy-testing procedures may 
be employed with rough or final forms of the proposed communications to de- 
termine the best of several plausible alternatives before investing heavily in pro- 
ducing and disseminating the material. While the end point evaluation primarily 
INDUCING BEHAVIORAL CHANGE 313 
benefits later campaign efforts, these ongoing evaluations serve to improve the 
particular campaign itself. 
Obviously, a thorough implementation of each of the seven steps outlined here 
would constitute a formidable task, calling for prodigious efforts and an intimi- 
dating range of skills, since few individuals would feel competent to serve as 
biomedical scientist, epidemiologist, moralist, cultural anthropologist, cognitive 
psychologist, clinical psychologist, media expert, attitude-change maven, and 
evaluation technician, among others. That the task is so difficult is no excuse 
either to despair or to do a sloppy job; rather it is an impetus to try harder. 
Resources are not infinite and compromises must be made, so some steps may 
be neglected relative to others in a given campaign. Recognition of the whole 
spectrum of needs allows these sacrifices to be chosen rationally. The wide range 
of needed expertise makes it desirable that a health promotion campaign be a 
team effort. Still, while the team approach allows the adding together of a wide 
range of talent and special knowledge, it multiplies rather than divides the re- 
sponsibility, so that each team member should not only take the lead in steps 
particularly relevant to her/his expertise, but should also contribute actively to 
each of the other steps by making suggestions, expressing reservations, and 
choosing among alternatives rather than leaving these other steps to the expertise 
of the more relevant specialists. 
USE OF THE COMMUNICATION/PERSUASION MATRIX IN CONSTRUCTING 
PERSUASIVE CAMPAIGNS 
The previous section as well as the two that follow are “how to” sections 
describing ways of producing an education-persuasion communication campaign 
to promote more healthful lifestyles by inducing the members of the public to 
take more responsibility for reducing their own health risks. The focus within 
these last three sections becomes progressively narrower. The preceding section 
outlined an overall seven-step procedure for designing a health-promoting per- 
suasion campaign. In the present section we focus on the crucial sixth step of 
constructing persuasive communications out of the available input variables. The 
final section is more narrowly focused on the various motivational themes that 
can be used as part of the message appeals in the communication. 
The communication/persuasion matrix approach to designing public health 
communications involves first using an available checklist of communication 
input resources to construct an effective campaign, and then using an output 
checklist to tick off how effectively each of the dependent variables (the steps 
involved in being persuaded) is likely to be evoked by the various inputs. These 
two sides of the process (i.e., input and output) can be viewed as a matrix, whose 
“input” column headings are supplied by the independent variables that can be 
manipulated in the health communication, and whose “output” row headings are 
furnished by the dependent variable effect steps needed for changing lifestyle in 
the more healthful direction. Into each cell of this matrix one can enter the 
relationship between its column input factor to its row output step, as indicated 
by theory and empirical research. 
314 WILLIAM J. MC GUIRE 
TABLE 1 
COMMUNICATION INPUT VARIABLES 
I. Source (communicator) variables 
A. Credibility 
1. Expertise 
2. Trustworthiness 
B. Attractiveness 
1. Liking 
2. Similarity 
3. Familiarity 
C. Power 
D. Number, unanimity, etc. 
11. Message variables 
A. Style 
B. Type of appeal 
C. Type of argument, information 
D. Inclusions and omissions 
E. Organization 
F. Repetition 
III. Channel (medium) variables 
A. Number and type of sensory modalities 
B. Direct versus mediated 
C. Verbal versus nonverbal 
D. Context 
IV. Receiver variables 
A. Amount of participation 
B. Demographics 
C. Personality 
D. Abilities 
V. Destination (target) variables 
A. Knowledge versus attitudes versus action 
B. Immediate versus delayed 
C. Change versus resistance 
Input Factors: The Communication Variables 
Communication input variables can be usefully divided into five broad 
classes-source, message, channel, receiver, and target factors. Each of these 
can be further subdivided; for example, message variables include style, type of 
appeal, argument structure, messages included or left out, organization of the 
material, and quantity of the material. Each of such message subcategories is 
itself further divisible into subsets of more specific variables, for example, “mes- 
sage style” into literalness, speed, vividness, and so on, as discussed further 
elsewhere (19) and in the next section. A list of the broader categories of these 
input communication variables is presented in Table 1. Considerable research has 
been done on how each of the input communication variables in such a list affects 
each of the output microprocesses that make for persuasive impact (19). The 
campaign designer can use the input factors as a checklist of possible resources 
out of which effective communications can be constructed. 
INDUCING BEHAVIORAL CHANGE 
TABLE 2 
OUTPUT FACTORS: PROCESSES MEDIATING COMMUNICATION IMPACT 
315 
I. Exposure to the communication 
II. Attending to it 
III. Liking, interest in it 
IV. Comprehending it (learning what) 
V. Skill acquisition (learning how) 
VI. Yielding to it (attitude change) 
VII. Retention of the change 
VIII. Search and retrieval of the new attitude 
IX. Decision in accord with the retrieved 
X. Behaving as decided 
XI. Reinforcement of these acts 
XII. Postbehavioral consolidation 
Output Factors: Behavioral Steps Mediating Persuasive Impact 
If a communication is to have the desired impact on health attitudes and be- 
havior, an individual must be exposed to it, pay some attention to it, become 
sufficiently engrossed in it to persist, comprehend what it says, agree with it, and 
ultimately must act as the message urges. A list of such intervening processes, 
which mediate ultimate impact, includes those shown as Table 2. 
The health campaign designer, in considering whether to add a given commu- 
nication input factor, should reflect on its likely impact on each of these mediating 
processes to estimate its overall pattern of effects. For example, if one is consid- 
ering adding humor to the communication to enhance attention or make it better 
liked, one should also consider possible detrimental effects such as distraction 
that might interfere with comprehension or facetiousness that might reduce ac- 
ceptance. Or, were one to consider beefing up the agreement step by vividly 
portrayingthe dreadful health effects of obesity, one must also weigh the possi- 
bility that anxiety aroused by vivid portrayal of dangers will interfere with atten- 
tion or retention (6, 7). Once a tentative communication has been put together, 
such a list of output steps can serve as a checklist for diagnosing its likely effec- 
tiveness by analyzing the extent to which input components already in the cam- 
paign will suffice to evoke each of these needed output steps. When the com- 
munication inputs seem deficient for eliciting one of the needed output steps, the 
input list in the previous section can be used to suggest additional inputs whose 
introduction might evoke the neglected output step without interfering dispro- 
portionately with other output steps. This is only an attempt to sketch the general 
procedure; it is not meant to detail the mechanics of how such a communication/ 
persuasion input/output matrix can be utilized to construct, evaluate, and improve 
public health communication campaigns. Fuller discussions are available else- 
where (13, 14, 19). 
APPEALS FOR USE IN PUBLIC HEALTH CAMPAIGNS: GUIDING-IDEA 
THEORIES OF THE PERSON 
The preceding section described how a health-promoting communication can 
be constructed by using the communication/persuasion matrix. This final section 
316 WILLIAM J. MC GUIRE 
TABLE 3 
GUIDING-IDEA THEORIES WHOSE PARTIAL VIEWS OF HUMAN NATURE SUGGEST MOTIVATIONAL 
APPEALS FOR USE IN PUBLIC HEALTH EDUCATIONAL AND PERSUASION CAMPAIGNS 
Action initiation 
Action termination Need for Stability Need for Growth 
State Relationship Active Reactive Active Reactive 
Internal 1. Consistency 2. Categoriza- 5. Stimulation 6. Problem 
Cognitive tion solver 
External 4. Hermeneutic 3. Inductional 8. Autonomy 7. Teleo- 
logical 
Internal 13. Tension 14. Ego-defensive 9. Attraction 10. Identiti- 
Affective reduction cation 
External 16. Expressive 15. Repetition 12. Assertion 11. Contagion 
Note. Column headings are concerned with whether the individual strives either to maintain current stability 
(homeostasis, equilibrium theories) or to promote growth (becoming, actualization theories) and whether behavior 
is actively evoked by forces from within the person or is a reaction to outside situations; row headings are concerned 
with whether the end state to which action tends is cognitive or affective and whether action is terminated by an 
internal arrangement of components within the person or by the person’s relationship to the external environment. 
Together, these dimensions produce the family of theories named in each numbered cell. 
focuses still more closely on one crucial aspect of this construction, namely, the 
selection of motivational appeals to be used in the health message. While “type 
of appeal” is only one of many input factors that must be examined in con- 
structing a campaign, a discussion of it serves to illustrate the wide range of 
resources available to one in putting together this kind of campaign. 
A review of theories of the individual (18) suggests that there are at least 16 
popular guiding-idea theories about human nature, each of which suggests a va- 
riety of persuasive appeals that can be used to construct a health campaign. Each 
theory constitutes a partial view of human nature which focuses attention on one 
limited aspect of the individual (for example, as a learning machine, a consistency 
maximizer, a tension reducer, a meaning seeker, an ego defender) and thus pro- 
vides creative insights into appeals and arguments one can use to make a public 
health message persuasive. 
Table 3 shows the 16 guiding ideas organized by four dichotomous dimensions, 
each dimension consisting of a contrasting pair of insights into human action. 
Two dimensions (shown as column headings) concern conditions that instigate 
the person to action; the third and fourth dimensions (shown as row headings) 
concern conditions that terminate an individual’s action. When these four di- 
chotomous dimensions are arrayed into the Table 3 matrix they produce 16 cells, 
each of which represents a family of theories constituting one partial view of 
human nature. Space limitations here prevent description of each view, but they 
have been discussed more fully (including a discussion of the implications for the 
design of public persuasion campaigns) elsewhere (16). At this time, only one or 
two theories from each of the four quadrants of the Table 3 matrix will be men- 
tioned as illustrations. 
Cognitive Stability Theories 
The four families of cognitive stability theories (upper left-hand quadrant of 
Table 3) depict the person as instigated to action by a need to maintain equilibrium 
INDUCING BEHAVIORAL CHANGE 317 
and as terminating action with the maintenance or restoration of this cognitive 
state. The consistency theories in cell 1 were dominant through the early 1970s; 
the cell 4 hermeneutic (or attributional) theories have been dominant for the past 
decade. The consistency theories suggest, for example, the Socratic method 
whereby the person can be induced to adopt a more healthful lifestyle simply by 
being asked a series of questions that bring home to the person that his/her current 
unhealthful lifestyle is at variance with his/her own values (17). The cell 4 her- 
meneutic theories stress the importance of providing the person with some 
meaning to which he/she can attribute experiences, as in the work of Pennebaker 
(24), Leventhal et al. (8), and Viney (33) on how conceptions of human biology 
and interpretations of disease and treatment symptoms can affect recovery from 
major heart and cancer surgery. 
Cognitive Growth Theories 
The tetrad of cognitive growth theories (shown in the upper right-hand quadrant 
of Table 3) also depicts the person as tending toward a cognitive end state, but 
as striving for cognitive growth rather than (like the previous four) for cognitive 
stability. The cell 8 autonomy theories are quite popular currently, stressing the 
importance to the person of maintaining some control (or at least an illusion of 
control) over his/her life and environment. For example, elderly persons in 
nursing homes may survive longer if allowed even minor control over their per- 
sonal environments (26). 
Affective Growth Theories 
The four types of affective growth theories (the lower right-hand quadrant of 
Table 3) also depict the individual as provoked to action by a need to grow, but 
depict action as tending toward attainment of an affective (rather than cognitive) 
end state. For example, the attraction theories (cell 9) stress the person’s need 
to love and be accepted by others, and the needs for romantic attachments and 
physical attractiveness. These concepts may pose a peculiar dilemma for the 
public health campaigner who may feel that good dental hygiene behavior should 
be carried out for health reasons but finds that risk reduction is more effectively 
achieved by stressing cosmetic benefits in the communication. Nor should al- 
truism be overlooked relative to self-interest appeals in designing health cam- 
paigns; for example, women who could not stop smoking for their own health 
may cease when they become pregnant to avoid harming the fetus, and men who 
could not break the habit to save their own lungs or cardiovascular systems may 
manage to stop when, as fathers, they worry about harming their children through 
setting a bad example or through sidestream smoke. 
Affective Stability Theories 
The final quartet of affective stability theories (shown in the lower left-hand 
quadrant of Table 3) also depicts the person as tending toward an affective end 
state but stresses the human need for maintaining affective stability rather than 
for achieving affective growth. For example, the tension-reduction theories 
(cell 13) stress avoidance of highlevels of arousal and so call into question the 
318 WILLIAM J. MC GUIRE 
wisdom of using high-fear campaigns to induce people to get medical checkups, 
drive more carefully, etc., since high-fear campaigns can backfire by directing the 
person to cope with the affect rather than the problem (for example, by avoidance 
of and hostility toward the campaign rather than compliance with it (6, 8)). The- 
ories in this quadrant stress the importance of focusing the communication cam- 
paign on the availability of solutions rather than on the seriousness of the 
problem: in urging the person to get inoculations for self or children, the campaign 
is more effective when it focuses not on how important the inoculations are but 
on the details of exactly how one goes about getting them (9). 
CONCLUSION 
This review has been confined to a quick tour of the horizon across a territory 
for which more detailed maps are available elsewhere (IS, 19). The educational- 
persuasion road to inducing individuals to take more effective responsibility for 
their own health maintenance is not an easy one to travel, but an adequate grasp 
of the dangers and resources encountered en route, as sketched here, enhances 
the likelihood of reaching the goal of better public health. 
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