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Patient Education and Counseling 74 (2009) 309–317

A practitioner’s guide to persuasion: An overview of 15 selected persuasion
theories, models and frameworks

Kenzie A. Cameron *

Division of General Internal Medicine and Center for Communication in Healthcare at the Institute for Healthcare Studies,

Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, 10th Floor, Chicago, IL 60611, USA


Article history:

Received 29 July 2008

Received in revised form 3 December 2008

Accepted 5 December 2008




Health communication


Objective: To provide a brief overview of 15 selected persuasion theories and models, and to present

examples of their use in health communication research.

Results: The theories are categorized as message effects models, attitude–behavior approaches,

cognitive processing theories and models, consistency theories, inoculation theory, and functional


Conclusions: As it is often the intent of a practitioner to shape, reinforce, or change a patient’s behavior,

familiarity with theories of persuasion may lead to the development of novel communication

approaches with existing patients.

Practice Implications: This article serves as an introductory primer to theories of persuasion with

applications to health communication research. Understanding key constructs and general formulations

of persuasive theories may allow practitioners to employ useful theoretical frameworks when

interacting with patients.

� 2008 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

Patient Education and Counseling

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / p a t e d u c o u

1. Introduction

At an interest group session on the theoretical bases of
communication in healthcare at the International Conference in
Communication in Healthcare (ICCH) in 2007, a practitioner noted
that he was aware that the use of theory in health communication,
whether in clinical practice or research, was touted as desirable.
However, he countered, what references were available for a busy
practitioner to obtain a concise overview of theories and models
that may be of use in understanding patient behavior, behavior
change, or lack of behavior change? This question became the
foundation of this manuscript.

Theory in health communication research is used to under-
stand, explain and predict health beliefs, attitudes, intentions, and
behaviors of individuals, groups, and mass audiences. Persuasive
theories are one subset of theories applicable to health commu-
nication; they can be applied at many levels including intraperso-
nal, interpersonal, organizational, and mass communication.
Knowledge of this subset of available theories can assist
practitioners in better understanding their interactions with
patients as well as patient behavior. Entire textbooks are written,

* Tel.: +1 312 503 3910; fax: +1 312 503 2755.

E-mail address:


0738-3991/$ – see front matter � 2008 Elsevier Ireland Ltd. All rights reserved.

and courses taught on the topic of persuasion and persuasive
theory, but practitioners seldom have the opportunity to engage in
such deep study and reflection. This article serves to fill that lacuna
by providing a selective overview of persuasion theories and
concepts, and referring interested readers to other sources for
more extensive explanation and commentaries of these and other
theories [1–5].

There are almost as many different definitions of persuasion or
persuasive communication as there are persuasion scholars. A
common theme throughout these definitions is that ‘‘persuasion
involves a conscious effort at influencing the thoughts or actions of
a receiver’’ [6]. One definition of persuasive communication
attractive in its inclusiveness is Miller’s [7]: ‘‘any message that is
intended to shape, reinforce, or change the responses of another, or

others.’’ Persuasive communication, then, can be viewed as
comprising three processes: response shaping, response reinfor-
cing, and response changing.

Response shaping relates to the creation of responses to a new
stimulus: prior to exposure to a new stimulus, an attitude toward
the stimulus cannot yet exist. Information provision about a new
product or an unfamiliar event can constitute response shaping.
Practitioners may provide information about a disease, condition,
or test unknown to the patient. Patients may be aware of the
existence of specific screening tests, but unaware of associated
risks and benefits. Response reinforcing occurs when an individual
already holds an attitude or is enacting a behavior advocated by the

Table 1
Persuasive theories, models, and frameworks applicable to the patient-provider


Theoretical category Theories discussed

Message effects models Message learning approach:

‘‘Yale Model of Persuasion’’

Fear appeals:

Protection Motivation Theory

Extended Parallel Process Model

Language Expectancy Theory

Attitude–behavior approaches Theory of Reasoned Action/Theory of Planned


Triandis Model of Interpersonal Behavior

Cognitive processing theories

and models

Elaboration Likelihood Model

Heuristic-Systematic Model

Social Judgment Theory

Consistency theories Balance Theory

Cognitive Dissonance Theory

Probabilogical Models

Inoculation theory Inoculation Theory

Functional approaches Functional Approaches

K.A. Cameron / Patient Education and Counseling 74 (2009) 309–317310

persuader. Support groups, such as Alcoholics Anonymous, fill the
function of being response reinforcing: they exist to reinforce a
decision (e.g., sobriety) [8]. Encouraging medication adherence can
be response reinforcing: a provider may reinforce accurate and
consistent patient behavior. Response changing is the most
recognized aspect of persuasion: that of value, belief, attitude,
intention or behavior change. A critical factor across all three
processes is that persuasion is constrained to intentional behavior.
This manuscript provides a necessarily brief overview of 15
theories or perspectives oft identified by their development or
scholarly description as persuasive theories: those identifying
constructs and variables intended to shape, reinforce, or change
the response of others. Table 1 presents the theories discussed in
this manuscript.

2. Persuasion theories applicable to the patient–provider

Although the response shaping, reinforcing, and changing
processes are elucidative when explaining persuasion, individual
theories may apply to more than one process. For example, a
theory may be useful both for a practitioner encouraging a patient
to continue performing a desired health behavior (response
reinforcing) and also for a practitioner attempting to change a
patient’s health behavior (response changing). Therefore, the
theories discussed are not delineated based on the three
persuasive processes, but rather via often used categories of
message effects models, attitude–behavior approaches, cognitive
processing theories and models, consistency theories, inoculation
theory, and functional approaches [3,6,8–10]. Following a concise
overview of each theory, examples of health contexts in which the
selected theories have been applied are presented.

2.1. Message effects theories and models

Message effects theories seek to predict ‘‘the format and
content of messages that produce effects on cognitive, attitudinal,
and emotional outcomes (Capella, 2006, p. S265)’’ [10]. Some
theories (e.g., Protection Motivation Theory (PMT)) are considered
‘‘value expectancy models,’’ which assume a fairly rational
approach to decision making. These models propose that
individuals engage in a cost-benefit analysis, taking into account

the severity of a potential risk, and selecting an action to maximize
the expected outcome [11–14].

2.1.1. The message learning approach

Although Aristotle identified the persuasive aspects of source,
audience, and words presented (message) in the 4th century B.C.,
the origins of scientific study of persuasion are attributed to Carl
Hovland, who with his colleagues developed the message learning
approach, referred to as ‘‘The Yale Model of Persuasion’’ [15].
Hovland, Janis and Kelley identified four underlying processes
derived from studies as to how individuals learn [3,15]. A
persuasive message must both gain a receiver’s attention and be
comprehended by the receiver. A receiver must yield to the message,
which occurs if the message raises questions in the receiver’s mind
and identifies incentives for attitude change. Finally, a receiver
must retain the information in the message for persuasion to occur.
These four processes are identified as mediating processes in the
message learning approach. The independent variables preceding
these processes are the source (the originator of the message),
message (what was said), channel (or medium through which the
message was delivered), and receiver or recipient (the person or
persons to whom the message was said). Potential outcomes, or
‘‘consequent communication effects,’’ include belief, attitude, and
behavior change [3,6,15]. This approach was never formalized as a
theory; however, it is of great historical relevance as the persuasive
effects of source, message, channel, and receiver are identified in
multiple theories. Interested readers are referred to other sources
for more extensive discussion of this model [2,3,6,16–18].

2.1.2. Fear appeals

Janis and Feshbach activated scientific interest in using fear (or
‘‘fear appeals’’) to promote behavioral change in 1953 [19].
Multiple theorists attempted to explain individuals’ reactions to
threatening messages; their explanations fit in three categories:
drive theories, parallel response models, and subjective expected
utility models [20]. As the validity of drive models [15,19,21,22]
has been largely discounted by quantitative reviews [23,24], they
are not presented here. Subjective expected utility models, such as
Protection Motivation Theory, suggest that individuals will chose
an action or behavior most likely to lead to a reward and avoid a
punishment [20,25,26]. Parallel response models such as that
proposed by Leventhal [27], and later augmented by Witte [28,29],
posit that both an emotional response and a desire to eliminate the
danger are trigged upon exposure to a fear appeal. Protection Motivation Theory. Protection Motivation The-
ory explores the cognitive processes of threat appraisal and coping
appraisal, which combine to form one’s protection motivation
[30,31]. PMT originally proposed perceived noxiousness (harm),
perceived susceptibility, and perceived efficacy of the behavioral
response as three integral components of an effective fear appeal.
The efficacy component was later specified to include both
response efficacy (i.e., is the behavior advocated going to reduce
the threat?) and self-efficacy (i.e., is the person able to enact the
advocated behavior?) [31,32]. According to PMT, one evaluates a
threat (threat-appraisal process), and one’s ability and alternatives
to cope with the threat (coping appraisal process); these combined
appraisals form a motivation to protect oneself against the
emergent risk. Protection motivation is hypothesized to reach
its peak when the threat is both harmful and severe, one feels at
risk, the behavior advocated is seen as effective and achievable, to
engage in a maladaptive behavior results in little benefit, and one
perceives few if any barriers to engaging in the advocated behavior
or adaptive response.

PMT has been applied to health behaviors such as cancer
screenings, exercise and healthy eating, condom use, medical

K.A. Cameron / Patient Education and Counseling 74 (2009) 309–317 311

adherence, and safety and environmental issues [33–35]. Despite
its broad use, criticisms remain, including critiques noting the
concept of fear itself is not explicated in the model [20] or is
effectively excluded [28], and that PMT assumes rational
information processing, not accounting for habitual behaviors or
social and environmental factors. Extended Parallel Process Model. Witte’s Extended Parallel
Process Model (EPPM), which expanded Leventhal’s earlier work
[27,36], proposed that a fear appeal message initiates two
appraisals. The first is the threat appraisal where one assesses
both perceived susceptibility and perceived severity of the (health)
threat (e.g., consequences of unprotected sex). If perceived
susceptibility and severity are low, the EPPM proposes that one
will cease to process the message. If perceived susceptibility and
severity are high, one is expected to proceed to the efficacy
appraisal. Here one assesses her self-efficacy and the efficacy of the
response being offered. One may consider if she perceives herself
able to engage in safer sex by using condoms (self-efficacy) and if
she believes that condoms will protect her from sexually
transmitted infections and/or pregnancy (response efficacy). A
high level of efficacy coupled with a high level of threat is predicted
to lead to self-protective action. For a fear appeal to be successful it
must instill susceptibility and severity in the receiver, as well as
self-efficacy and response efficacy regarding the proposed
behavior change.

Initial tests of the EPPM focused on primarily response changing
processes in the contexts of HIV/AIDS prevention [29] and
promotion of bicycle safety helmets [37]. Subsequent research
assessed the influence of fear appeals in breast-self examination
[38], HIV/AIDS prevention [39,40], influenza vaccination [41],
radon testing [42], and prevention of firearm injury and death [43],
among others.

Meta-analyses of fear appeal research suggest no single model
is well supported by the research, although fear is generally
correlated with attitude and behavior change [23,24,44]. Despite
these criticisms, both PMT and the EPPM are widely used to
evaluate health interventions, and to identify modifiable factors for
future intervention design.

2.1.3. Language Expectancy Theory

Language Expectancy Theory (LET) identifies language as being
a ‘‘rule governed system’’ through which individuals develop
expectations and preferences for what is considered ‘‘appropriate’’
usage in varying situations [45]. Expectations are largely a function
of sociological and cultural norms; preferences tend to be a
function of societal standards and cultural values [45,46].

LET proposes that persuasion can be facilitated or inhibited
when expectations are violated [45]. Positive violations, facilitat-
ing persuasion, can occur if: [1] a communicator enacts a behavior
perceived by the receiver as ‘‘better’’ or ‘‘more preferred’’ than
expected, or [2] a source initially evaluated negatively behaves in
accordance with societal norms, cultural values, or situational
demands [45–47]. Negative violations, inhibiting persuasion, occur
when the communicator employs language or message strategies
considered to be socially unacceptable; the receiver may
experience no attitude change, or may change in the opposite
direction of that advocated [45–47].

LET has been applied to examine gender differences related to
patient compliance and satisfaction with a physician [48,49], and
the effects of sun-safety messages for children [50]. Criticisms of
the theory include concerns over precise definitions of ‘‘expecta-
tions,’’ and call for a priori specification of expectations in
experimental research. Additional limitations question cultural
generalizability; the fact that much empirical testing (with notable
exceptions) has been conducted in laboratory settings; the effects

of expectancies over time; and how expectancies relate to
sequential messages (e.g., repeated visits to and discussions with
a provider about the need to develop and maintain an exercise
program) [46]. A theoretical extension of LET, Reinforcement
Expectancy Theory [51–53], focuses on the issue of expectancies,
and how they may evolve, in such sequential interactions.

2.2. Attitude–behavior approaches

These approaches attempt to predict a behavior from an
attitude, or attitudes. Both research and common sense recognize
that the attitude–behavior correlation is not perfect; attitudes are
one of many variables affecting individual behavior. Entire books
have been written about attitudes [4,5]; due to space limitations
only three theories are presented here.

2.2.1. Theory of Reasoned Action/Theory of Planned Behavior

The Theory of Reasoned Action (TRA) [54,55] and the Theory of
Planned Behavior (TPB) [56,57] have enjoyed frequent use as
organizing frameworks for numerous attitude and behavior change
studies. The TRA aims to explain volitional behaviors, and identifies
one’s behavioral intention as the immediate precursor and best
determinant of behavior. Behavioral intention is composed of one’s
attitudes toward the behavior and subjective norms. Attitudes are a
function of the evaluation of the belief one holds about the behavior
and the strength with which each belief is held [54,55]. Subjective
norms are composed of normative beliefs, or what is believed to be
the expectation of important others (e.g., colleagues, family, etc.),
and one’s motivation to comply with these others. Individuals weigh
their own attitudes against their perceptions of others attitudes; if
these attitudes are in discord, they decide how to behave based upon
costs and benefits of ascribing more weight to either one’s own
attitudes or those of others.

The TPB is an extension of the TRA, to allow the theory a wider
application by adding perceived behavioral control at the same
level as attitudes and subjective norms. Perceived behavioral
control comes from Bandura’s concept of self-efficacy, and refers to
one’s perceived ability to perform a given behavior [58–60].
Control beliefs, or the perception of the existence of facilitating or
impeding factors to performance of the behavior, and perceived
power, the perception of the impact of each factor in facilitating or
inhibiting the behavior, determine one’s perceived behavioral

A comparison of the two theories indicated that the addition of
perceived behavioral control (in TPB), significantly increased the
amount of variance explained [61,62]. The TRA and the TPB have
enjoyed recurring use in health, with studies assessing condom use
[63–65], smoking behavior [66,67], drug use [68,69], exercise
behavior [70–72], and cancer screening [73].

2.2.2. Triandis model of interpersonal behavior

Triandis’ model is similar to the TRA and TPB; it proposes that
attitudes and social normative considerations determine beha-
vioral intentions [4,74,75]. However, Triandis separated one’s
attitude into (1) affect toward the act and (2) value of perceived
consequences of the act (similar to behavioral beliefs in the TRA)
and included a ‘‘habit’’ construct, to represent those automatic
actions that ‘‘occur without self-instruction’’ (p. 204) [75]. Triandis
proposed that the probability of a behavior would be dependent on
habits and behavioral intentions. Initial tests of the model
discovered that it was no more consistent in predicting intentions
and behaviors than the TRA [4,76], although later tests reported the
Triandis model accounted for a greater percentage of the variance
of exercise intentions [77]. This model continues to be employed in
health communication research [78–80], although less frequently
than the TRA or TPB.

K.A. Cameron / Patient Education and Counseling 74 (2009) 309–317312

2.3. Cognitive processing theories and models

Cognitive process models moved from focusing on ‘‘variable-
oriented’’ approaches to persuasion, to ‘‘process-oriented’’
approaches [81], seeking to identify the variables leading to
persuasion, and to specify the process by which such message
aspects influence one’s attitudes. These models recognize that pre-
existing attitudes may alter reception of a message and provide a
framework to predict and explain how a single message may be
processed among multiple receivers.

2.3.1. Elaboration Likelihood Model

The Elaboration Likelihood Model (ELM) was formulated to
explain contradictory research findings, specifically the effects of
messages on attitude change [82,83]. The literature provided
explanations for persuasive effects, yet dissention remained as to
the routes through which persuasive messages traveled. The ELM
proposed that receivers ‘‘elaborate’’ (i.e., engage in issue-relevant
thinking) to varying degrees upon receipt of a message. The ELM
posits two processing routes leading to attitude change [82,84,85].
Central processing occurs when one is motivated and able to
carefully evaluate the arguments and to scrutinize the quality of
messages; the message receiver engages in systematic thinking. In
peripheral processing, elaboration is fairly low and the receiver
employs a cognitive shortcut to evaluate the message (e.g., is the
source of the message authoritative?) [82,84,86].

Despite frequent use, critics question the efficacy of the ELM,
particularly regarding what is identified as ‘‘single-channel
processing’’ presented in theoretical descriptions of the ELM.
Readers are referred to a series of articles published in Commu-
nication Monographs, for elucidation of the criticisms against the
model, and the model originators’ responses [87–90]. Regardless,
the ELM remains widely used in health communication research.
Studies have hypothesized and tested participant responses to
ELM-based mammography messages [91], explored the effects of
direct-to-consumer prescription advertising on the elderly [92],
and proposed key message elements for inclusion in nutrition
information [93]. Other researchers have suggested using elements
of the ELM (e.g., issue relevance) in conjunction with existing
theories (e.g., TPB) to better predict and explain health behaviors
and events [71,94].

2.3.2. Heuristic-Systematic Model

A second cognitive processing model is the Heuristic-Systema-
tic Model (HSM) [95], which differs from the ELM by explicitly
recognizing dual processing. As opposed to viewing information
processing on a continuum, as the ELM seems to suggest (e.g.,
endpoints of peripheral and central processing), the HSM proposes
that these processes occur jointly, or in parallel [95–97].
Systematic processing in the HSM is similar to central processing:
one scrutinizes a message, judging the arguments presented to be
strong or weak, and gives thoughtful consideration to all
information before (or while) making a decision. Heuristic
processing draws upon simple decision cues, often termed ‘‘rules
of thumb,’’ and occurs when individuals lack motivation or
cognitive resources. This processing occurs at a superficial level,
allowing the receiver to form judgments based on cues such as
credibility, attractiveness, and message length. Heuristic proces-
sing may be employed when using heuristics leads to attitudes one
can hold with sufficient confidence [98].

The HSM has been applied to risk-related issues such as eating
contaminated fish [99] and carbon dioxide [100], where findings
indicated that the induction of fear resulted in systematic
processing of information. Other scholars utilize the HSM in
studies of organ donation [101,102] and in providing risk
information in genetic counseling interactions [103].

There have been attempts to extend the HSM to determine
predictors of the type of processing. Both the ELM and HSM specify
that motivation and ability are key predictors of message
processing; the HSM’s ‘‘sufficiency principle’’ states that active
processing will occur up until the point where one believes she has
reached the necessary level of depth and breadth of understanding
[97]. Focus on the predictors of processing within a risk setting
found that the difference in the level of understanding one has
about a risk and the level of understanding needed to make a
decision about the risk was related to one’s use of systematic or
heuristic processing [99,104].

2.3.3. Social Judgment Theory

Social Judgment Theory (SJT) focuses on perceptions of how
much a message agrees or disagrees with one’s current attitude
[105,106] proposing that one’s attitude acts as an anchor, from
which messages are interpreted or judged. Three latitudes,
together forming a continuum, are proposed: the latitude of
acceptance includes the most acceptable position or attitude to an
individual, plus other attitudes also judged as acceptable. Latitudes
of non-commitment contain those positions discrepant from one’s
attitude, but not so much so as to be rejected. Latitudes of rejection
are those positions one deems unacceptable, or wrong.

At the moment of message perception, one compares the
message to one’s current attitude (i.e., the anchor), which, by
definition, is located at the exact center of the latitude of
acceptance. If a message falls within the latitudes of acceptance
or non-commitment, then the greater the discrepancy (the
distance between one’s attitude and the message), the greater
the predicted persuasion. A message too discrepant from the
receiver’s attitude will fall within the latitude of rejection: no
persuasion will occur. If attitudes change or are reinforced due to a
message, then one’s latitudes adjust accordingly, the new attitude
becomes the anchor.

Assimilation occurs when a receiver perceives a message to be
very close to her own attitude; contrast occurs when the message
is perceived to be very discrepant from her attitude. Assimilation
can reduce the persuasive effect of a message: one may perceive a
message as not that different from her own attitudes, causing little
need to change. Contrast effects cause an exaggeration of the
perceived differences between one’s attitude and the message;
further reducing the likelihood of persuasion. If one is highly ego-
involved (i.e., the issue is very important) then one’s latitude of
acceptance is likely to be narrow, and one’s latitude of rejection is
likely to be wide [106,107].

SJT has been called an ‘‘incomplete’’ theory [9] focusing on the
position advocated in the message and how clearly the message
pinpoints the position, while other possible variables (e.g., argument
strength) are ignored. For some SJT has fallen out of favor [9]; others
appreciate its discussion of assimilation and contrast effects and the
focus on receivers’ attitudes in the persuasion process [108]. SJT has
been applied to clinical judgments regarding patients’ coronary
heart disease risk [109]; the need for restraint and/or seclusion of
psychiatric patients [110]; and team recommendations for dis-
charge housing of stroke patients [111–113]. Recent work notes the
need to educate providers to better understand influences on these
individual and team decisions.

2.4. Consistency theories

Consistency theories suggest that when we have thoughts or
actions inconsistent with our attitudes or behavior, we are
motivated to change as inconsistency is an uncomfortable state.
Consistency theories have been applied less in health commu-
nication than other persuasive theories; however, increased
interest in their potential application has arisen.

K.A. Cameron / Patient Education and Counseling 74 (2009) 309–317 313

2.4.1. Balance Theory

Balance Theory focuses on the triadic relationship involving
two people (the perceiver, P), the perceiver’s attitude toward
another (O, the other individual) and their attitudes toward an
object (X, the attitudinal object) [114,115]. The resulting triad can
be balanced or unbalanced. If all three possible relationships (PO;
PX; OX) are positive, or one is positive and two are negative, the
triad is balanced. If all three relationships are negative, or one is
negative and two are positive, an unbalanced triad results, often
motivating one to alter one of the three relationships [114,115].

In Balance Theory an attraction effect describes those triads
with a positive relationship between the two people (P and O),
deemed to be more ‘‘pleasant’’ than a negative relationship. An
unbalanced triad therefore could be perceived as pleasant if the
individuals had a positive relationship. The agreement effect arises
when both individuals rate the attitudinal object similarly (either
negatively or positively); some unbalanced triads could be
perceived as pleasant if both P and O agreed in their like or
dislike of the attitudinal object (X). Balance Theory predicts that
balanced triads are more …

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