Visual Metaphors in Health Messages: A Strategy to De-Stigmatize Opioid Use Disorder
By
Ali Dunlap
Senior Honors Thesis
School of Media and Journalism
University of North Carolina at Chapel Hill
2018
Approved by:
_____________________________ Allison Lazard, PhD, Thesis Advisor
_____________________________
Elizabeth Adams, Reader
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ABSTRACT
The opioid epidemic is a devastating drug crisis in American history with more
than 28,000 deaths attributed to opioid use each year. Health communication campaigns
can impact perceptions about the harmful effects of opioids, but they must be engaging to
do so. Visual metaphors – artful deviations that visually link to abstract concepts – are
one way to increase audience engagement. We sought to assess visual metaphors as a
strategy to effectively communicate the harms of opioid use with a one-way experiment
comparing opioid messages with a visual metaphor with opioid messages without a visual
metaphor. Participants were 220 U.S. adults recruited from Amazon Mechanical Turk.
Outcomes were beliefs, negative affect, perceived effectiveness, message quality,
message strength, and cognitive elaboration. To assess the impact on stigma, both
message conditions were compared to a no message condition. People who saw opioid
messages with visual metaphors reported significantly greater negative affect than those
who saw messages without a metaphor. Including a visual metaphor did not significantly
impact the other perception outcomes or stigma (all p > .05). Our findings indicate that
visual metaphors may be an effective strategy for eliciting emotional reactions, which can
act as a critical first step for message engagement about serious health topics.
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ACKNOWLEDGEMENTS
I owe my greatest thanks to my advisor and mentor Dr. Allison Lazard. I have so
much appreciation for her patience and encouragement throughout this process. This
project would not have been possible without her support, guidance, and expertise. I am
also grateful for my reader, Elizabeth Adams, for her valuable comments on this thesis.
Finally, a special thank you to my family for supporting me in all of my
endeavors. I am grateful everyday for my sister, who is my steady guide and role model,
and my parents, who have given me the gift of opportunity and whose belief in me never
wavers.
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TABLE OF CONTENTS
CHAPTER 1....................................………………………………………………5 Introduction………………………………………………………………..5
CHAPTER 2…………………………...………………………………………….8 Literature Review………...………………………………………………..8 Metaphors in Communication…………………………………………..…8
Visual Metaphors in Advertising & Health Communication……………11 Opioid-Related Stigma……………………………………………….......12
CHAPTER 3……………………………………………………………………..16 Hypotheses and Research Questions…………………………………….16
CHAPTER 4…………………………………………………………………......17 Participants…………………………………………………………….....17 Stimulus Material…………………………………………………….......17 Procedure…………………………………………………………….......18 Measures………………………………………………………………....19
CHAPTER 5……………………………………………………………………..23 Results…………………………………………………………………....23
Impact on Beliefs…………………………………………………….......23 Impact on Affect…………………………………………………………23 Impact on Message Perceptions………………………………………….24 Stigma……………………………………………………………………25
CHAPTER 6……………………………………………………………………..26 Discussion………………………………………………………………..26 Conclusion……………………………………………………………….30
FIGURES….……………………………………………………………………..31 Figure 1…………………………………………………………………..31 Figure 2….……………………………………………………………….33
REFERENCES…………………………………………………………………..35
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CHAPTER 1
Introduction
In the United States, the opioid epidemic has been characterized by unprecedented
increases in both prescription and nonmedical pain-relieving drug uses and related deaths
(Binswanger & Gordon, 2016). Over the last 20 years, the loosening of laws that mandate
prescribing regulations for the treatment of chronic non-cancer pain by state medical
boards has contributed to a significant increase in opioid use (Manchikanti et al., 2012).
The Centers for Disease Control and Prevention (CDC) reports that from 1999 to 2010
the amount of prescription opioids sold to pharmacies, hospitals, and doctors’ offices
nearly quadrupled, despite there being no overall change in the amount of pain reported
by Americans (CDC, 2017). Given prescribing rates, we can infer the public does not
know the true risks of opioids. A significant relationship exists between sales of opioid
pain relievers and deaths (Manchikanti et al., 2012). In 2016, 42,249 people died from an
opioid overdose (Department of Health and Human Services, 2017). On average, 115
people die each day from opioid overdose (CDC, 2017).
The media disseminates a number of varying narratives that frame opioid use in
different ways. Pharmaceutical companies are promoting a campaign highlighting the
alleged under-treatment of pain in an effort to increase pain medication prescriptions
(Manchikanti et al., 2012). This portrayal of opioids has been encouraged through various
organizations advocating the use of opioids in large doses, increased awareness of the
right to pain relief, and aggressive marketing tactics by the pharmaceutical industry
(Manchikanti et al., 2012). These positions are reinforced through assumptions that
opioids are highly effective and safe, and will not cause adverse events when prescribed
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by physicians (Manchikanti et al., 2012). On the other hand, opioid use is frequently
portrayed negatively in the news media. This representation is especially common when
focusing on opioid use (McGinty et al., 2016). One study found that from 1998 to 2012,
the news media were more likely to portray opioid use disorder as a criminal justice issue
rather than a treatable health condition (McGinty et al., 2016). The media’s demonization
of drug users has exacerbated social stigmas directed at people affected by opioid use
disorder (McGinty et al., 2016).
Stigma is an important health determinant, and the stigma toward individuals with
substance use disorders is persistently high (Kennedy-Hendricks et al., 2016). The stigma
associated with opioids is impeding meaningful progress in reducing the number of
deaths attributed to opioid use (Olsen & Sharfstein, 2014). The misconception that opioid
use disorder is a moral weakness or a willful choice contributes to the stigma and inhibits
a realistic understanding of opioid use (Olsen & Sharfstein, 2014). Unmasking the
devastation of opioid abuse through communication campaigns may help facilitate
greater understanding of the inherent risks of opioids and could deter misuse (Schuchat,
2017).
Health communication campaigns have the potential to increase understanding
about the inherent risk of opioids, reduce false assumptions, and improve the
conversation about opioids (Schuchat, 2017). The framing of opioid medications in the
media can influence how audiences understand opioid use and abuse. The media acts as a
critical intermediary for translating important health information in a way that is easily
understood by the public (Wallington et al., 2010). Using metaphors, including visual
metaphors, in campaign design may be one strategy for effective communication about
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opioid use (Messaris, 1997). The use of metaphors enables individuals to understand
abstract or unfamiliar concepts in terms of more concrete concepts (Palmer-Wackerly &
Krieger, 2015). Metaphors allow information to be organized meaningfully, which can
facilitate the understanding of complex ideas (Eppler, 2003).
Specifically, visual metaphors achieve this through images. The use of visual
metaphors in advertising has relevance for campaigns with the goal of communicating a
public health perspective (Phillips & McQuarrie, 2009). Visual metaphors represent
abstract concepts by showing one visual idea in terms of another (Messaris, 1997). The
combination of the two images implies a message greater than each of the parts alone.
Visual metaphors that involve some aspect of distorted reality can serve the dual function
of attracting attention as well as eliciting emotions (Messaris, 1997).
This study was designed to test health messages with visual metaphors to inform
strategies to effectively communicating about opioid use. This project used a one-way,
between-subjects experimental design to test whether opioid addiction health messages
with visual metaphors influence the viewer’s beliefs, negative affect, perceived
effectiveness, perceived quality, perceived message strength, cognitive elaboration, and
stigma toward opioid use among participants compared to messages without metaphors
or no messages.
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CHAPTER 2
Literature Review
2.1 Metaphors in Communication
Metaphors are commonly defined as a rhetorical style that compares two
dissimilar objects, through which the characteristics of one object are applied to the other
(Jeong, 2008). Metaphors are shown to play a key role in individuals’ understanding and
communication of subjective experiences (Lazard et al., 2016). They allow information to
be organized meaningfully, which can help with the understanding of complex ideas
(Eppler, 2003). Lakoff and Johnson (1980) assert that metaphors help form the basis of
conceptual systems that influence people’s thoughts, feelings, and actions. Thinking itself
is metaphorical in nature, and people make decisions through metaphorical processes
(Lakoff & Johnson, 1980). This idea can be understood through the concept argument
and the conceptual metaphor argument is war. Not only is this metaphor reflected in a
variety of expressions about arguments (“He attacked all of my weak points”), it is also
shown in the way people think about arguments in terms of winning or losing (Lakoff &
Johnson, 1980). Lakoff and Johnson (1980) argue that many of the things people do in
arguing are partially structured by the concept of war. Thus, the conceptual system used
in thinking and acting is fundamentally metaphorical (Lakoff & Johnson, 1980).
Recent theorists of metaphor recognize its fundamental role in thinking and
behavior and assert that metaphors serve as interpretative frameworks (Kaplan, 1990).
Metaphors can possess the ability to alter belief systems because individuals process
metaphors without noticing the underlying conceptual theme (Phillips & McQuarrie,
2009). Sopory and Dillard (2002) suggest that metaphorical rhetoric enhances attitude
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change. They attribute this effect to the three broad categories of cognitive, motivational,
and affective processes (Sopory & Dillard, 2002). Cognitive explanations involve the
superior organization of information or elaboration of thoughts (Jeong, 2008).
Motivational effects involve the increased perception of source credibility (Jeong, 2008).
Models of affective processing consider motivational factors as the underpinnings of
behavioral choices (Edwards & Clevenger, 1990). Further, emotion acts as a driving
force in an individuals choosing of a particular course of action (Edwards & Clevenger,
1990).
Visual Metaphors
Visual metaphors are classified as a type of rhetorical figure, which has been
defined as an artful deviation from expectation (McQuarrie & Mick, 1996). In other
words, they are highly structured images that allow viewers to understand one concept in
terms of another concept (Zeeshan, 2015). An ad for Elite paper napkins showed a picture
of a while lily with some of the petals depicted as napkins (Mohanty & Ratneshwar,
2015). Despite the literal differences between flowers and napkins, the figurative linking
of them allows viewers to interpret that Elite paper napkins are as soft as the petals of
white lilies. This example displays how visual metaphors make an analogical comparison
between two concepts, allowing the ideas to be understood of terms of the other
(Mohanty & Ratneshwar, 2015). Some researchers define visual metaphors as an
expressive symbol that acts as a source of information about another object (McAllister,
2013). Visual metaphors are similar to verbal metaphors, but they utilize the synaptic
structure of visual persuasion (Messaris, 1997). Jeong (2008) explains the difference
between visual and verbal metaphors as how visual metaphors juxtapose two images
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without the addition of a verbal explanation, rather than verbally describing the two
objects that are linked analogically. Thus, visual metaphors are typically more implicit
and complex, allowing for several possible interpretations (Jeong, 2008).
Visual metaphors utilize unique conceptual combinations to effectively
communicate and spread an idea (McQuarrie & Mick, 1996). The addition of visual
metaphors has been shown in advertising to effectively grab people’s attention (Zeeshan,
2015). Messages containing visual metaphors have great power to affect consumer
response (Jeong, 2008; Phillips & McQuarrie, 2009). The display of unexpected
information in visual metaphors can elicit cognitive elaboration and lead to higher recall
(Jeong, 2008; Lazard et al., 2016). The deviation exhibited in such metaphors encourages
the viewer to attend to, process, and encode the message being shared (Lazard et al.,
2016). Research conducted by Proctor et al. (2005) suggests that metaphorical style of
argumentation invites audiences to elaborate on the message arguments. Kadry (2016)
also found that visual metaphors have a strong persuasive effect and encourage viewers
to engage in more elaborative processing.
Visual metaphors are also able to elicit pleasure, due to the interest and
motivation stimulated by the initial ambiguity and the subsequent rewarding resolution
(Jeong, 2008). McQuarrie and Mick (1996) suggest that the use of this rewarding feature
of artful deviation in visual metaphors results in a more positive perception toward
advertisements as effective. Mohanty and Ratneshwar (2015) credit the rewarding, and
pleasurable when positive, experience to the process of comprehending a visual
metaphor, which they compare to successfully solving a puzzle. There are also desirable
effects of negative emotional responses that can be evoked through an advertisement with
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a visual metaphor. In a study on the pictorial warning labels on tobacco products, Mutti-
Packer et al. (2017) found that negative emotions were an underlying factor in the
perceived effectiveness of graphic health warnings. They found that the graphic warnings
encouraged smokers to think about the risks of smoking, which elicited negative
emotional responses such as fear and worry, which ultimately increased intentions to quit
(Mutti-Packer et al, 2017).
There has been significant research exploring the interpretation of the metaphor,
the impression and meaning that audiences associated with the advertisement (Jeong,
2008; Mohanty & Ratneshwar, 2015). There has also been research examining the
moderating roles of metaphor types, abstract or concrete, finding that there is a distinct
advantage in the use of concrete metaphors in terms of comprehension (Morgan &
Reichert, 1999). To date, most research has focused on the use of visual metaphors in
product advertising and marketing (Mohanty & Ratneshwar, 2015), with few exceptions
looking at the role of visual metaphors for health (Lazard et al., 2017). Thus, the effects
of visual metaphors in the communication of serious health topics have not yet been
widely researched.
2.2 Visual Metaphors in Advertising & Health Communication
Modern advertising relies heavily on visual metaphors rather than straightforward,
text-based communication (van Mulken, van Hooft, & Nederstigt, 2014). One reason for
this is that advertisers seek to provide their audience with an engaging experience in
finding the solution to understand the metaphor (van Mulken, van Hooft, & Nederstigt,
2014). Visual metaphors are perceived more universally and are especially crucial when
there is a need for capturing attention in a short amount of time (Kadry, 2016).
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In addition to being used in product marketing and education materials, text-based
and visual metaphors have been featured in public health campaigns (Landau, Arndt, &
Cameron, 2018). In health communication, metaphorical language is commonly used to
communicate and enhance the effectiveness of health education messages (Krieger,
Parrott, & Nussbaum, 2010). Research has been conducted that proves text-based
metaphors have the intended effects on health attitudes and behavior (Scherer, Scherer, &
Fagerlin, 2015). Scherer and colleagues (2015) exposed participants to messages that
framed the flu metaphorically, describing it as a “wild beast that preys on the body” or a
“riot that revolts against the body”. Compared to a literal description of the flu, the
metaphoric messages increased intentions to get a flu shot (Scherer et al., 2015). It has
been suggested that visual metaphors create an emotional jolt that helps viewers
understand the urgency of a health risk (Landau, Arndt, & Cameron, 2018). Research
asserts that the effectiveness of health message depends on its portrayal of both the risk
and the prevention behavior (Landau, Arndt, & Cameron, 2018). Visual metaphors are
one strategy that can help communicate both risks and prevention behavior in a
meaningful way. In a study that used visual metaphors to promote preventative measures
against skin cancer, Landau et al. (2018) found that metaphoric messages significantly
impacted prevention-related emotions and intentions.
Despite the importance of using metaphors to communicate about medical,
psychological, emotional, and social complexity of opioid addiction, there has not yet
been research on metaphors in opioid communication.
2.3 Opioid-Related Stigma
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The opioid epidemic in the United States is a relatively new and complex issue
(Barry et al., 2015). In the past decade there has been a sharp increase in rates of opioid
pain reliever abuse and misuse (Barry et al., 2015). However, stigma toward individuals
with substance use disorder is persistently high (Kennedy-Hendricks, 2017).
Health-related stigma is rooted in the socio-cultural process in which social
groups are devalued and rejected due to a socially discredited health condition
(Livingston, 2011). In the context of the opioid epidemic, stigma can deter from a
comprehensive understanding of opioid use and misuse (Olsen & Sharfstein, 2014). It
impacts the way that individuals feel toward, think about, and treat persons with a drug
addiction (Earnshaw, 2013). Several studies have found that substance use disorders face
greater stigma than other health conditions (Livingston, 2011). Substance use disorders
are often regarded as a moral or criminal issue rather than a health concern (Livingston,
2011). They are often viewed as a combination of crime and disease (Janulis, Ferrari, &
Fowler, 2013). The stigma toward people with substance use disorders has the potential
to adversely impact all domains of life (Mattoo et al., 2014). These potential negative
outcomes include poor mental and physical health, delayed treatment seeking, and non-
compliance with treatment (Livingston, 2011; Mattoo et al., 2014).
Stigma can be carried through several mechanisms, like stereotyping, social
distance and discrimination (Earnshaw, 2013). Stereotypes contain group-based beliefs
about people who have been addicted to drugs that are subsequently applied to specific
individuals (Earnshaw, 2013). These stereotypes include beliefs that drug users are non-
compliant, out-of-control, and unwilling to change their behaviors (Earnshaw, 2013).
Many of the stereotypes surrounding substance use disorders have a small degree of
14
accuracy (Livingston, 2011). Despite this, these stereotypes are a significant barrier to
counteracting the stigma associated with substance use disorders (Livingston, 2011).
Social distance describes an individual’s willingness to engage persons with mental
illness (Corrigan et al., 2001). It can act as a proxy for discriminatory behavior towards a
person with an illness (Corrigan et al., 2001). Discrimination involves behavioral
expressions of prejudice directed at people with a history of drug addiction (Earnshaw,
2013). Since drug use itself is illegal, discrimination based on drug addiction is
widespread and socially acceptable (Earnshaw, 2013).
People with a history of opioid use disorder experience stigma from multiple
sources. Research has primarily focused on exploring the stigma this group receives from
healthcare workers (Anstice, Strike, Brands, 2009; Brener, von Hippel, & Kippax, 2007;
von Hippel, Brener, von Hippel, 2008). Earnshaw (2013) suggests that this focus may
have occurred because stigma from healthcare workers acts as a deterrent to healthcare
retention, which could threaten treatment retention among those with a history of drug
addiction. However, there are also other sources from which this group receives stigma.
Ahren and colleagues (2007) identified family and friends as primary sources of stigma
toward drug users after their sample reported the most common types of discrimination
experienced were from family (75.2%) and friends (65.8%). Stigma from family
members may threaten an individual’s social support, which is an important factor in
treatment success (Earnshaw, 2013). Additionally, research shows that friends may play a
critical role in encouraging users to seek and stay in treatment (Gyarmathy & Latkin,
2008). Further, stigma received from work colleagues can increase stress levels as well as
threaten employment status (Earnshaw, 2013). Taken together, stigma from these sources
15
has the potential to act as a barrier to treatment success and undermine the mental health
of people with a history of drug addiction (Earnshaw, 2013).
The literature demonstrates the influence of metaphors in communication
campaigns (Jeong, 2008; Phillips & McQuarrie, 2009; Sopory & Dillard, 2002).
Specifically, the use of visual metaphors has been shown to result in a myriad of effects,
such as elaboration (Proctor et al., 2015) and persuasiveness (Kadry, 2016). Thus, visual
metaphors may be an effective design strategy for communicating about opioids and
potentially reducing stigma. Personal variables, such as past experience with opioid
addiction, may also act as a strong factor in the effectiveness of health messaging
working to de-stigmatize opioid addiction. The literature shows how stigma can act as a
barrier to a comprehensive understanding of opioids (Olsen & Sharfstein, 2014), as well
as the ability of communication design strategies and personal experience to contribute
significantly to the understanding of an issue like opioid use disorder (Landau et al.,
2018). Thus, it is likely that the utilization of a design strategy, such as visual metaphors,
will enhance opioid health messaging and enable it to have greater effects that will
ultimately lead to decreased stigma.
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CHAPTER 3
Hypotheses and Research Questions
This study will assess whether the inclusion of visual metaphors in health
messages is an effective strategy to reduce the stigma associated with opioid misuse and
addiction. The following hypotheses and research questions will be posed:
H1: Health messages with visual metaphors will have a stronger effect on the
viewer’s beliefs than health messages without visual metaphors.
H2: Health messages with visual metaphors will elicit significantly more negative
affect than health messages without visual metaphors.
H3: Health messages with visual metaphors will be perceived as more effective
than health messages without visual metaphors.
H4: Health messages with visual metaphors will be perceived as higher quality
than health messages without visual metaphors.
H5: Health messages with visual metaphors will be perceived as stronger than
health messages without visual metaphors.
H6: Health messages with visual metaphors will produce greater cognitive
elaboration of complex ideas than health messages without visual metaphors.
RQ1: Do health messages with visual metaphors help reduce stigma associated
with opioid use disorder?
RQ2: Does personal experience with opioid use disorder affect the interpretation
of health messages about opioids?
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CHAPTER 4
Methods
This study sought to assess the effects of visual metaphors in health messages
about opioid use. In order to do this, a between-subject experiment was used. This
experiment was conducted through an online survey. Participants were randomly
assigned to one of three conditions: health messages with straightforward visuals, health
messages with visual metaphors, and no message.
4.1 Participants
Participants for this study were recruited from Amazon Mechanical Turk through
a short posting describing the survey. Participants were recruited through a short posting
describing the survey. They were compensated for their time spent taking the survey. A
total of 220 respondents completed the survey. Participants ranged from 20 to 67 years
old (M = 34.21, SD = 9.85). Majority of participants identified as white (n = 167, 75.6%),
with a small number of participants identifying as African American, Hispanic, Asian, or
biracial. There were slightly more male participants (n = 126, 57.0%) than female. Nearly
half of participants (n = 93, 42.3%) reported having personal experience with opioid
addiction.
4.2 Stimulus Material
This study included campaign materials that are used to communicate about
opioid use and misuse. The study design utilized three conditions: health messages with
visual metaphors, health messages with straightforward visuals, and no message or
visual. The stimuli were adopted from an existing campaign. The non-metaphor versions
were manipulated to have a straightforward visual. These messages contained an image
18
of a prescription pill bottle on a black background [Figure 1]. The messages with visual
metaphors showed a prescription pill bottle as a grenade and as the cylinder in a gun on a
black background [Figure 2]. This visual metaphor shows that opioids are more
dangerous than people think. It is commonly accepted that guns and grenades are
hazardous, but people do not necessarily think about the risks associated with pills that
also make them dangerous. This visual communicates this danger to a broad audience.
The textual messaging remained the same in both the non-metaphor and visual metaphor
images.
4.3 Procedure
Participants were provided with a brief overview of the study prior to signing up.
It read: “We are conducting an academic research survey (~10 min) about consumers'
perceptions of a health message. During this survey you will be asked give your opinion
about the message and share basic information about yourself.” Participants were
informed that the study is about perceptions of a health message. They were able to
complete the survey on their personal computers via a link they received.
Prior to opening the questionnaire, participants gave consent. If they consented to
participating in the study, participants were randomly assigned to one of three
experimental conditions: health messages with straightforward visuals, health messages
with visual metaphors, and no message or visual.
Participants assigned to the first condition were exposed to straightforward visuals
and completed items to assess negative affect, perceived effectiveness, perceived quality,
message strength, and cognitive elaboration. Those given the second condition were
shown visual metaphors and completed the same evaluative items as the participants
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assigned to the first condition. Participants assigned to the third condition did not see any
health message and were directed straight to the stigma items. All participants completed
opioid addiction stigma items and provided demographic information, including age,
gender, race, and experience with opioid addiction. Once participants finish the survey
they were be debriefed.
4.4 Measures
Beliefs About the Message
Ten items were developed to measure participants’ beliefs about the message
(CDC, 2017; NIDA, 2018). The items included: “Using opioids can have serious side
effects”; “Opioid use could result in death”; “Most drug overdose deaths involve the use
of opioids”; “It is dangerous to misuse opioids;” Opioid abuse is a serious public health
issue;” “Taking opioids in a way that is different from what the doctor prescribed is drug
abuse;” “Anyone who takes opioids can become addicted”; “Opioids are necessary to
manage pain;” “Prescription drugs do not have the same risks as illicit drugs”; “Opioids
are among the most abused drugs in the United States”. Participants were asked to rate
their degree of belief using a 5-point Likert scale anchored with strongly disagree (1) and
strongly agree (5). Items were assessed individually.
Negative Affect
Negative affect generated by the messages was measured by asking participants to
what extent the messages made them feel “scared”, “on edge”, “disgusted”, and “sad”
(Hall et al., 2018). Responses were indicated on a five-point scale, ranging from not at all
(1) to extremely (5). Scores were averaged across the four items (α = .81).
Perceived Effectiveness
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Three items were used to assess effectiveness of the message: “This message
makes opioid use seem unpleasant to me;” “This message makes me concerned about the
harmful effects of opioid use;” and “This message discourages me from wanting to use
opioids” (Baig et al., 2017). The five-point response scale ranged from strongly disagree
(1) to strongly agree (5). Scores were averaged for the three items (α = .83).
Perceived Message Quality
Two items were used to measure the overall message quality: “This message was
persuasive” and “I feel the message made its point effectively” (Lazard et al., 2016).
Responses were measured with five-point Likert-type items ranging from strongly
disagree (1) to strongly agree (5). Scores were averaged for the items (r = .71).
Elaboration
Six items were used to measure the extent to which participants carefully attended
to the message (Kahlor, 2003; Lazard et al., 2016; Zhao, 2017). Items were “I had many
thoughts in response to this message;” “I thought about what actions I myself might take
based on the message;” “I found myself making connections between the message and
what I’ve read or heard about elsewhere;” “I thought about how what I had seen related
to other things I know;” “I tried to think of the practical applications of the message;” and
“I tried to relate the ideas in the message to my own life”. Responses were measured on
the same 7-point Likert scale, ranging from strongly disagree (1) to strongly agree (7),
and averaged (α = .75).
Perceived Message Strength
Three items were used to measure the message strength. Participants were asked
the extent to which they found the messages to be believable, convincing, and powerful.
21
Responses were measuring using a 7-point Likert scale that ranged from strongly
disagree (1) to strongly agree (7). Scores were averaged across items (α = .86).
Opioid Addiction Stigma: Stereotyping, Social Distance, and Discrimination
Three aspects of opioid addiction stigma were measured using a number of items.
The first, stereotyping, was assessed using three items to gauge the belief someone has
about a person with an opioid addiction. Participants were asked to rate their agreement
with the following statements: “I would see myself as weak if I had an opioid addiction
and could not fix myself”, “People with an opioid addiction should pull themselves
together”, and “People with opioid addiction are unpredictable”. They were given five
response categories ranging from strongly disagree (1) to strongly agree (5). Scores were
averaged across the items (α = .61).
The second aspect of opioid addiction stigma, social distance, was measured with
six items that assessed participants’ willingness to engage with individuals who are
addicted to opioids. Participants were given the following stem: “How willing would you
be to…” and the following social situations: (a) “move next door to a person with an
opioid addiction,” (b) “spend an evening socializing with someone who is an opioid
addict,” (c) “make friends with a person that is an opioid addict,” (d) “have an opioid
addict start working closely with you on a job,” (e) “have an opioid addict marry into
your family,” (f) “share an apartment with an opioid addict.” Responses were measured
on a scale ranging from definitely not willing (1) to definitely willing (5). Scores were
averaged across the items (α = .93).
The third aspect of opioid addiction stigma, discrimination, was measured with
two items. Participants were be presented with the following statements: “If I had an
22
opioid addiction, I would never admit it to my friends” and “If I had an opioid addiction,
I would never admit it to my family.” Participants rated their agreement with the
statements on a scale ranging from strongly disagree (1) to strongly agree (5). Scores
were averaged across the items (α = .78).
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CHAPTER 5
Results
A total of 220 participants voluntarily responded to the online survey. Of the
participants who completed the study, 67 participants saw messages with visual
metaphors, 86 participants saw messages with straightforward visuals, and 67 participants
were in the control group with no messages.
5.1 Impact on Beliefs
Hypothesis 1 predicted that health messages with visual metaphors would have a
stronger effect on the viewer’s beliefs than health messages without visual metaphors.
This hypothesis was not supported. There were no differences among endorsed beliefs for
each health message condition, p > .05.
Addressing RQ2, there were significantly different beliefs between those who
have experienced opioid use disorder and those who have not. People who experienced
opioid use disorder, M = 4.27, SD = .81, were significantly more likely to endorse the
belief “It is dangerous to misuse opioids” than people who have not, M = 3.87, SD = .91;
F(1,148) = 8.12, p = .005. Additionally, people who experienced, M = 4.79, SD = .51,
were significantly more likely to support the belief “Opioid abuse is a serious public
health issue” than people who have not, M = 4.49, SD = .80; F(1,148) = 6.55, p = .012.
Lastly, those who have experienced opioid use disorder, M = 4.57, SD = .69, were also
significantly more likely to support the belief “Opioids are among the most abused drugs
in history” than those who have not, M = 3.98, SD = .99; F(1,148) = 15.57, p < .001. All
other beliefs did not differ, p > .05.
5.2 Impact on Affect
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Hypothesis 2 proposed that health messages with visual metaphors would elicit
significantly more negative affect than health messages without visual metaphors.
Hypothesis 2 was supported. Participants exposed to messages with visual metaphors, M
=2.51, SD = 1.04, reported significantly greater negative affect than individuals who saw
straightforward visuals, M = 2.10, SD = .97; F(1,149) = .8.20, p = .005. The difference
between these message conditions was statistically significant.
Notably, there were also main effects for those with personal experience with
opioid addiction. People who have experienced opioid use disorder, M = 2.63, SD = 1.05,
were significantly more likely to experience negative affect than those who have not
experienced it, M = 2.03; SD = .927; F(1,149) = 15.31, p < .001.
5.3 Impact on Message Perceptions
Hypotheses 3 proposed that health messages with visual metaphors would be
perceived as more effective than health messages without visual metaphors. This
hypothesis was not supported.
Hypothesis 4 predicted that messages with visual metaphors would be perceived
as higher quality than health messages without visual metaphors. This hypothesis was not
supported. Interestingly, there was a significant difference based on those who reported
having experience with opioid addiction. People who have experienced opioid use
disorder, M = 4.46, SD = .73, were significantly more likely to perceive the message as
higher quality than those who have not, M = 4.18, SD = .85; F(1,149) = 5.62, p = .02.
Hypothesis 5 suggested that health messages with visual metaphors would be
perceived as stronger than health messages without visual metaphors. This hypothesis
was not supported. Notably, there was a significant difference between those who have
25
personal experience and those who have not. People who have experienced, M = 4.61, SD
= .65, were significantly more likely to perceive the message as stronger than people who
have not, M = 4.39, SD = .78; F(1,149) = 4.22, p = .04.
Hypothesis 6 proposed that health messages with visual metaphors would produce
greater cognitive elaboration of complex ideas than health messages without visual
metaphors. This hypothesis was not supported.
5.4 Stigma
The research question asked whether using messages with visual metaphors is an
effective way to reduce opioid addiction stigma. Results did not show a significant
difference by condition for any of the three facets of opioid addiction stigma:
stereotyping, social distance or discrimination, all p > .05.
There were, however, significant differences in stereotyping and social distance
were found based on previous experience with opioid addiction. People who reported
having experienced opioid use disorder, M = 3.73, SD = .84, were significantly more
likely to endorse the stereotyping reactions than people who have not experienced it, M =
3.47, SD = .91; F(1, 214) = 4.73, p = .031. Conversely, those who have experienced
opioid use disorder, M = 3.73, SD = .84, were significantly less likely to desire social
distance than people who have not, M = 3.47, SD = .91; F(1, 214) = 4.73, p = .031.
26
CHAPTER 6
Discussion
The opioid epidemic is a growing issue for the United States, with an average of
91 people dying every day from opioid overdose (CDC, 2017). Opioid use is frequently
portrayed negatively in the media, especially when focusing on opioid abuse (McGinty et
al., 2016). There is a significant social stigma tied to people with addiction, which further
promotes the negative public profile (Lavack, 2006). Communication campaigns have the
potential to improve the conversation and facilitate greater understanding of the inherent
risks of opioids (Schuchat, 2017). Given the severe effects of opioid abuse and misuse
(e.g. overdose and death), it is important to develop strategies to effectively communicate
to decrease stigma and thus help people with opioid addiction acknowledge their
problems and seek help (Crisp et al., 2005).
This study showed how the inclusion of visual metaphors in health messages has
potential to act as a first step in reducing opioid addiction stigma. We found that
messages with visual metaphors produce greater negative affect. Intense emotion is
shown to be more motivating than neutral affect (Edwards & Clevenger, 2006).
Experiencing negative emotions has been shown to result in a narrowing of attentional
focus, which is likely to lead the person to take corrective action (Graham et al., 2008).
This idea is supported through the dual-process model of reactions to perceived stigma,
which suggests that social perception involves two processes, one that is an automatic,
emotional process and the other that is a controlled, reflective process (Lavack, 2006).
The initial process is host to the immediate negative attitudes toward a stigmatized person
or group, whereas the secondary process is where these attitudes can be altered over time
27
with more information (Lavack, 2006). Thus, an immediate negative reaction might
influence attitude change over time. Visual metaphors are one design strategy that can
help promote a greater understanding of opioid use disorder and thus facilitate the
transition from the immediate negative response to a cognitive learned response of
tolerance and humanity toward people who struggle with opioid use disorder.
Opinions about people with opioid addiction are subject to many influences,
including the media and, in some instances, personal experience with a person with the
addiction (Dahlberg, Waern, & Runeson, 2008). The importance of personal knowledge
had notable influence on beliefs, affect, message perceptions, and two facets of stigma.
People who reported having personal experience with opioid addiction were significantly
more likely to endorse beliefs regarding the severity of misusing opioids and the
epidemic in general. This effect was also found with negative affect and perceptions of
message strength and quality. This suggests that those who are more familiar with the
struggles of opioid addiction are more affected by messages that convey the risks of
opioid misuse.
Lastly, personal knowledge also had an effect on stereotyping and social distance.
Interestingly, those who had experience with opioid addiction were significantly more
likely to endorse stereotypical statements about opioid addicts than those who had no
personal experience. One factor that may have contributed to this result is the influence
of the individual attributes of the person with an opioid addiction. These attributes may
endorse different variations in suffering or stability, which could contribute to the support
of a stereotypical statement (Lyndon et al., 2016). Thus, people with experience were
more likely to project negative attributes (e.g., weakness, unpredictability) onto people
28
with opioid use disorder than those without experience. This idea is further supported by
a study conducted by Ahren et al. (2007) that identified family and friends as the most
common sources of discrimination toward drug users. However, overall there is not much
research that explains this relationship between personal experience and stereotyping. In
fact, there are a number of studies that have found the opposite. In a study by Lyndon et
al. (2016), people who were familiar with someone with a mental illness were less likely
to stigmatize the condition. Although personal experience can be more likely to reduce
mental illness stigma based on the thought that it is a moral weakness, the same does not
apply to opioid use disorder.
Conversely, those with experience were also significantly more likely to want a
smaller social distance than those who had no experience. Thus, although those who had
personal experience endorsed the stereotypical beliefs, they also showed a desire to
decrease the social distance with opioid addicts. This finding is supported through a study
conducted by Corrigan et al. (2001) that proposed a causal path in the role familiarity
plays in the perception of dangerousness, which in turn influences fear and ultimately
social distance. This relationship was further supported in a study by Angermeyer et al.
(2003) that also found people who were more familiar with a particular disorder were less
likely to view that group as dangerous, which corresponded closely with less fear of such
people and led to less social distance desired from them.
A study in 2004 found that almost two-thirds of American families have been
affected by addiction to drugs and alcohol (Lavack, 2006). This statistic displays how
widespread personal experience to addiction is, and thus the importance of utilizing this
factor when designing campaigns. As this study has shown, personal experience
29
significantly influenced beliefs, negative affect, message perceptions and social distance,
all of which contribute to a greater understanding and work towards de-stigmatization of
opioid addiction. This is an important factor to be aware of in message development, as
knowing how those with personal experience understand and process opioid addiction
will lead to the creation of more targeted communication materials. People with
experience thought this message was strong likely because it was an important issue,
however they still endorsed stereotypical ideas toward people with opioid addiction.
Thus, new visual metaphors might try to better link opioid addiction with people,
highlighting how common addiction is in a way that salient and relevant.
Future messages with more detailed information and connection to other concepts
may have a greater influence on a wide audience. The messages with visual metaphors
used in this study were straightforward and powerful. The visual metaphors were
concrete and were combined with simple text. Thus, these messages did not prompt
“new” ideas or the connection to other ideas. New messages might explore metaphors
accompanied by text that encourages audiences to think differently or more deeply about
solutions or cultural influences of the opioid epidemic to increase argument strength
(Petty & Cacioppo, 1986).
This study is not without limitations. Although the experimental design allowed
for cause-and-effect message evaluations, the one-time exposure may not have provided
enough time with a complex topic, opioid stigma, for a true evaluation of changing
beliefs. Although no significant changes from visual metaphors were detected for
stereotyping, social distance or discrimination, it is likely that beliefs and attitudes toward
opioid addiction as revealed through these measures are more adept to change over the
30
course of time. Changes in these areas are often slow processes and it is difficult to
directly link these changes to a campaign because there are a variety of factors that
contribute (Lavack, 2006). Additionally, these items used to measure stigma did not fully
cover the complexity of these concepts. Our findings that messages with visual
metaphors led to greater negative affect but not reduced stigma reveal a need to further
explore how message processing impacts how people think about opioid addiction.
Conclusion
Visual metaphors can increase message effectiveness by producing greater affect,
improving perception of the message, increasing elaboration and potentially influencing
beliefs and attitudes (Jeong, 2008; Lazard et al., 2016; Messaris, 1997; Mutti-Packer et
al., 2017). This study provides evidence that using visual metaphors is an effective
strategy for communicating about a complex health topic and should be considered a tool
for starting to change attitudes and beliefs about opioid use and reduce its associated
stigma. Further, it demonstrated that personal experience leads to greater effects of the
health message, highlighting the importance of utilizing the audience’s experience to
better convey ideas that will reduce stigma of opioid addiction.
35
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