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

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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

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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

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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.

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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

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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.

31

FIGURES

Figure 1

32

33

Figure 2

34

35

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