Cancer Survivor Narratives, Matt Kreuter, PhD

The story on stories:Findings from a decade of research on cancer survivor narratives Matthew W. Kreuter, PhD, MPH Health Communication Research Laboratory January 23, 2011

HCRLActive research programs• Linking health & social services• Health information design• Dissemination systems• Tools for PH agencies• Minority media• Narrative

StoryCorpsCancer survivors talking to their children • 12 days, 85 participants • 31 hours of stories

Early conceptual thinkingTwo key papers• Conceptual, theoretical, empirical overview Hinyard & Kreuter (2007)• Framework for research and application Kreuter, Green et al (2007)

Defining “narrative” Key characteristics • Cohesive, coherent story • Beginning, middle, end • Scenes & characters • Conflict & resolutionHinyard & Kreuter (2007) Hlth Beh & Educ, 34 (5) 777-792

Types of narrative(Schank & Berman, 2002)• Official stories• Invented stories• Experiential stories• Secondhand stories• Culturally common stories

Theoretical basisTransportation-Imagery Model (Green,2004)• Attention, imagery & emotions engaged• Less counter-arguing• Realism + identification = influence

Three key conceptsNarrative mechanisms• Engagement/transportation• Counterarguing• Identification

Typology of narrative capabilities Focused on cancer Pre-diagnosis Post-diagnosis Overcoming resistance √ Facilitating processing √ √ Social connections √ Emotional, existential issues √Kreuter, et al (2007) Ann Beh Med, 33(3): 221-235

Living Proof: Can survivor stories increasemammography in African American women?

St. Louis, MOIncidence of late-stagebreast cancer 2Xexpected rates for MO,by census tract

Research questions Three randomized studies of survivor stories1. Active ingredients2. Narrative vs. informational videos3. Efficacy trial of mammography use

What are the active ingredients of cancer survivor stories?

Narrative qualitySix indicators• Character development• Dramatic tension• Showing emotion• Evoking imagery• Self-disclosure• Cultural references

Health message strengthSix indicators• Repetition• Centrality• Modeling• Explicit recommendation• Overcoming obstacles• Identifying incentives

Neighborhood VoiceReaching out for cancer prevention and control

Design: 300 stories, 200 womenCross-classified data structure Video Video Video Clip 1 Clip 2 Clip 3 Participant Participant 1 2

Study outcomesImmediate reactions• Positive thoughts• Level of engagement• Recall of key messages

Kreuter MW, Buskirk T, et al., (2008) J Ca Surv, 2 (1) 33-44.

Video contentThree broad topics• Breast cancer risk• Openness about breast cancer• Importance of mammograms

11 key breast cancer messagesExamples:• You can get breast cancer at any age• It’s important to learn your family history• Women can survive breast cancer• Get a mammogram every 1-2 years

Do women prefer to watch anarrative or informational video?

R Part 1: Part 2: Part 3: It can happen Let’s talk 10 minutes to to anyone about it save your life N N N N N N N N N N N N(n=25) (n=25) (n=25) (n=25) (n=25) (n=25)

Production quality Mean score on six dimensions, by DVD type 4.75 4.76 Mean scoreKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Easy to understand Mean score three items, by DVD type 4.24 4.18 Mean scoreKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Which video did you enjoy most? (n=149) percent 30% 7%Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Which video was most interesting? (n=150) percent 32% 11%Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Which would you show a group of friends? (n=150) 59% percent 36%Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Would you like a copy of either video? (n=150) 65% percent 31%Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Can stories increaseuse of mammography?

Randomized efficacy trial (n = 489)Comparing effects of videos onmammography vs.

Neighborhood VoiceMobile research unit

St. Louis, MOIncidence of late-stagebreast cancer 2Xexpected rates for MO,by census tract

Participant characteristicsAfrican American women ≥ 40 (n=489)• Mean age: 60.8 years• 32% < HS education• 57% ≤ $10,000 pre-tax household income

Follow-upThree points in time• Immediate post-exposure• 3-month follow-up• 6-month follow-up (92.6% retention; n = 453)

Outcomes of interestThree broad categories• Reactions to videos• Cancer-related beliefs• Use of mammography

Emotional response to video Immediate follow-up (n=482; p<.01) 4.99 mean 3.38Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Unprompted recall of video content 3- and 6-month follow-up (both p<.01) 72% 60% percentKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Identified with women in the video Immediate follow-up (p<.001) 4.1 3.8 meanKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Counter-arguing against key messages 3-month follow-up (n=448; p<.01) 2.3 mean 2.0Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Talked to family members about video 3-month follow-up (n=448; p<.01) 77% 65% percentKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Perceived community impact of cancer 6-month follow-up (n=433; p<.05) 65% 55% percentKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Intention to get a mammogram Immediate follow-up (p<.01) 3.6 mean 3.4Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Barriers to mammography Immediate, 3-, 6-month follow-up (p<.01) mean 1.9 1.7Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Self-reported use of mammography 3- or 6-month follow-up (n=222; ns) 49% 40% percentKreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Mammography No friend or family w/ BC (n=104; p=.06) 49% percent 31%Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Mammography < 12 years education (n=72; p<.01) 65% percent 32%Kreuter MW, Holmes K, et al (2010) Patient Educ Couns, 81S, S6-S14

Cognitive and affective reactions to breast cancer survivor stories Amy McQueen

SEM: Immediate reactions to videos Six inter-related outcomes • Affect • Realism • Ease of understanding • Negative evaluations • Similarity, liking, trust • Engagement (transportation)McQueen A & Kreuter MW (2010) Patient Educ Couns, 81S, S15-21.

Structural equation modeling Potential moderators • Education • Medical mistrust • Cancer fatalism • Mammography status • Breast cancer experienceMcQueen A & Kreuter MW (2010) Patient Educ Couns, 81S, S15-21.

Consistent with theorycommunication → behaviorMcQueen A & Kreuter MW (2010) Patient Educ Couns, 81S, S15-21.

Direct and indirect effects ofnarrative in a longitudinal SEM Amy McQueen

McQueen A, Kreuter MW et al (2011) Hlth Psychol, 30 (6).

Narrative effects:What role for negative emotions? Jina Yoo

Action tendencies of emotions(Lazarus, 1991; Dillard, 2006) • Different emotions, different effects • Enhance or inhibit information processing

Deconstructing negative emotionsDimensions & action tendencies • Fear • Anger • Sadness

Deconstructing negative emotionsDimensions & action tendencies • Fear → escape/avoid or problem solve • Anger • Sadness

Deconstructing negative emotionsDimensions & action tendencies • Fear → escape/avoid or problem solve • Anger → impedes message processing • Sadness

Deconstructing negative emotionsDimensions & action tendencies • Fear → escape/avoid or problem solve • Anger → impedes message processing • Sadness → inward evaluation, systematic processing

Yoo HJ et al, International Comm Assoc (2012)

What parts of survivor stories elicit strong emotions? Sarah Bollinger

Randomized experimentStories (n=29) vs. informational video(n=29)• real-time, moment-to-moment emotional intensity• specific emotions at five emotional peaks

LIVING PROOF 10 SECOND TIME SMOOTHING- with outliers 100 90 80 70 60 Means 50 40 30 20 10 0 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 10 SECOND BINS Video: 1=LP, 2=FFL Living proofBollinger S & Kreuter MW, Hlth Educ Res, (in press)

What evoked emotion?Content vs context (n=290 peaks; p<.05) percent 37% 25%Bollinger S & Kreuter MW, Hlth Educ Res, (in press)

Open recallOf core video content (ns) 96% 83% percentBollinger S & Kreuter MW, Hlth Educ Res, (in press)

Are race-specific survivorstories available online? Kate Eddens

Survivor stories online, by race Reviewed 738 sites, 7995 stories Survivor stories U.S. population 88% 68%Eddens K, Kreuter MW, et al., J of Med Internet Res, 2009.

Developing and testing a clinical story tool for cancer patients Donna Jeffe & Graham Colditz

What do we know?About survivor stories

What do we know? About survivor storiesConnect & feel

What do we know? About survivor storiesConnect Attend, → & feel engage

What do we know? About survivor stories Accept &Connect Attend, → → remember & feel engage content

What do we know? About survivor stories Accept &Connect Attend, Believe, → → remember → & feel engage perceive content

What do we know? About survivor stories Accept &Connect Attend, Believe, Decide → → remember → → & feel engage perceive & do content

Thank you!

McQueen A & Kreuter MW (2010) Patient Educ Couns, 81S, S15-21.

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