1 – Resistance to health messages
Research on health resistance (
12) has contributed explanations for the deliberate disregard or dismissal of health messages by seemingly reasonable people. In fact, in response, studies in health resistance have increased in recent years to explain unsuccessful campaigns and efforts to sustain an original positive outcome (
13). Meta-analytical studies comparing empirical research on preventive efforts toward a particular disease burden (e.g. drinking, obesity prevention) have found varying results between studies following the same aims and methods (
14,
15).
Health resistance, as Crossley (
16) argued, is not an issue of lack of understanding, skills or any other barrier found in what we know as response ability. It is also not a result of problems in opportunity (e.g. access issues or divergent rules). Resistance is found to be squarely the result of lack of motivation to comply with the appeal or call to action.
From a humanist perspective, the causes for this can be traced back to two main forces (
12). The first one relates to scepticism toward science and medicine, from funded research to government sponsored public campaigns. While science had to compete with doctrines (17th century astronomy, evolution, global warming) for centuries, due to a more dispersed and uncontrolled media landscape, science now faces an opposition that is organised and often furious, empowered by multiple scientific and non-scientific sources and interpretations (e.g. ways of being infected by viruses like the human immunodeficiency virus (HIV) and Ebola, the autism and vaccination debate).
From a humanist perspective, in Western culture and thought the second force is derived from a high value placed on the need for individuality, individual freedom and decision-making. It includes the phenomena of risk-taking and sensation-seeking but also includes personal (subjective) definitions of health and healing and meaning-creation of life and living in general.
Thompson and Kumar (
13) succinctly summarised the key defiant responses as resistance, denial and ‘othering’. An increasing number of health messages telling the public what they should eat, how they should act and what they have to do not only irritate or alienate the very groups that are targeted (
17), but are also perceived as paternalistic infringements by the government on one’s autonomy (
18). In addition, when individuals believe that they are less at risk of an illness or risk-prone lifestyle than others, they tend to engage in denial (
19,
20).
The humanist concept of individual responsibility also highlights what appears to be a moral issue. Judgments by health campaign audiences of what is ‘right’ or ‘wrong’, ‘healthy’ or ‘unhealthy’, influence not only their own health behaviour but also their attitudes towards those who are not engaging in the same behaviours (
12). This discourse of moral disapproval highlights a phenomenon that is the product of social interaction. As Stevenson and Burke (
21) pointed out, ‘the problems in the field of health promotion discourse result from a contradictory conceptualisation of health, community empowerment and the role of the state as policy maker and enabler of community action’.
In psychological and communication studies the concept of reactance is not new (
22–
24). In essence, psychological reactance is motivated by an individual’s basic need for self-determination in affecting his or her own social and physical environment. When these perceived freedoms are threatened by proscribed attitudes or behaviours, an individual will experience a motivating pressure towards restoring these threatened freedoms (
25). Since cognitive responses are usually accompanied by the affective response of anger, the literature has discussed whether reactance is best explained as a dual or intertwined process, whereby anger precedes cognition (
26). The two examples of government-imposed lock-out laws for late-night bar patronage and college administrations’ attempts to create alcohol-free campus events, which both attempt to reduce binge drinking and the health risks associated with it, might illustrate the idea of reactance when observing public responses to them. The forceful opposition to either intervention appears to be aimed more at the source of the message rather than at the message itself. It is not a reaction that says ‘I do not understand what you want from me’ but rather one that says ‘you do not tell me what to do with my life’. And, as the above examples have also shown, the tendency to favour information that confirms one’s pre-existing beliefs and attitudes – a phenomenon known as confirmation bias – aggravates the resistance to perceived outside control (
27).
A humanistic approach to this phenomenon argues that the message needs to take into consideration a person’s individuality. It pertains to a deeper understanding of the quality, types and confidence in counterarguments when they occur during reactance responses. While not well understood as of yet, there appears to be a difference between direct rebuttals of message arguments, source derogation, pure negative affect (irritation) and ‘stubborn’ insistence on one’s own point of view. Understanding the types of resistance strategies that people use will improve the effectiveness of health messages in that they pick up on and reflect arguments that directly address the specific kinds of thoughts raised by individual audience members (
27–
29).
2 – Rational vs. intuitive response processes
The typical canon in health promotion is that a campaign is the result of credible facts, gathered via scientific research, and translated into logical cause–effect messages. To achieve this ‘translation’ and hence the desired response, the message needs to predict and then communicate a single memorable behaviour proposition, akin to commercial marketing’s unique selling proposition (
30). Reflecting desired states or accepted truths, the message becomes part of the target public’s knowledge base and eventually leads to desired behaviour responses.
This frame of thinking is widely based on a rational actor assumption, prevalent in many sciences. In fact, the idea of a rational human actor is as old as Western philosophy and science. From Plato and Aristotle to Hume, Descartes and Russell, a common notion was that a person’s output or reaction can only be understood if an assumption of rationality and logical thought pattern (that is, predictability from our perspective) is made.
In the case of disease prevention, the stimulus is composed of a scientific argument supported by solid empirical evidence wrapped in a persuasive marketing tool (e.g. humour). A rational human being will not only understand this message but also come to accept it as the most reasonable course of action. Admittedly, behaviouristic research has incorporated some affective responses (e.g. fear appeals) and peripheral or heuristics processing (
20,
31). But stripped to its core, the average health promotion effort is a unidirectional argument linking scientific evidence with corollary expected responses.
The standard psychology models used in public health promotion, like the Health Belief Model (
32), the Transtheoretical Model (
33) or the Theory of Planned Behaviour (
34), emphasise a logical cognitive path toward the ultimate behavioural response. Where empirical findings diverge from this path, explanations tend to converge on lack of skill or educational attainment, or the aforementioned rationally based counterargument response (
23). Not surprisingly, at the time these models were proposed, an analogous trend occurred in psychological therapy research. The cognitive–behavioural perspective related cognitive structures and processes (thoughts, beliefs) to resulting behavioural consequences. These became known as reciprocal determinism (
35). It has later come under criticism for – among other reasons – its lack of evidence that rational thinking is the sole reason for psychological well-being (
36).
Not surprisingly, many motivational decisions and modifications in our daily routines are automatic and at a level of consciousness that we often fail to explain after the behaviour occurred. From a humanistic perspective, behaviour change need not proceed in a linear fashion as our senses and our reason both play a role. Changes from one attitude to another (e.g. exercise, not exercise) can occur in a single complete transformation, happen unintentionally, involve periods of going back and forth on the issue, or occur in response to apparently insignificant triggers (e.g. a not-to-be-missed TV show). This means that, unlike linear models, our behaviour is often chaotic, i.e. our wants and needs compete in a messy system for control over our actions (
37).
3 – Different values and political philosophies between power holders and publics
Critics of health policy point to the politicised nature and prevailing ideologies in medicine and policymaking (
38,
39) that blur the line between facts and opinion and drive policy more so than factual evidence (
40). This pertains to questions of how those in charge make choices about prioritising health problems, target audiences and intervention strategies. For instance, stress being addressed as a personal problem rather than the result of workplace or relational exploitation potentially marginalises disagreeable rival explanations and systems (
40).
From a humanist perspective, health communication can become part of organised government practices through which citizens are not only governed but through which they govern themselves. By undertaking government-induced actions for their health and well-being through management of lifestyles, citizens may reduce reliance upon governmental supports. As the right to health is re-constructed as the responsibility for ‘accepting and adopting the imperatives issuing both from the state and other health-related agencies concerning the maintenance and protection of good health to prevent placing a burden on the healthcare system’ (
41: 65), it creates subject positions from the self-satisfied ‘good citizen’ to the stigmatised, who require increased levels of surveillance and intervention (
42).
The manner and circumstances in which health issues become problematised at any given time indicate that health practitioners and related entities of power (e.g. the media) hold particular values and political philosophies. The overreaction related to infectious disease outbreaks (e.g. Ebola, Zika virus) or the creation of a moral panic around obesity provides fitting case studies for this assertion (
43–
45). The movement toward ‘positive health promotion’ or ‘well-being promotion’, resulting from the redefinition by the 1986 WHO Ottawa charter of what health means, seemed at first glance beneficial in its attempt to disentangle health promotion from disease models (
46). At an individual level, it has complicated matters further as, once the disease grounding is lost, all that remains are points of view about how people should behave, associate and act toward each other – which lie in the domain of political philosophy (
40).
From a humanist perspective, the communication of a health condition has rhetorical significance beyond the epidemiological reality as it creates a moral imperative for self-management of that very issue. Humanists would say that once a health issue is called a national health problem every individual ought to contribute to its solution as a matter of common concern for the public good (
44). Non-humanists might expect the government to change unhealthy conditions in a top-down approach, such as policies and some campaigns, rather than attempt behaviour change via dialogue and participation. As the ongoing example of obesity prevention via proper nutrition exhibits, suggested solutions tend to disproportionately impact families, who are economically vulnerable or lack other forms of capital, and identify certain population groups as being ‘at risk’ and in need of intervention to meet a ‘norm’ (
47,
48). This has not only led to resisting behaviour of those most in need of support (as many obesity statistics illustrate), but the one-directional communicative approaches are in themselves antagonistic to an inclusive, i.e. humanistic, communication model.