COMMUNICATING CHILDBIRTH: A MEMORABLE MESSAGES AND
CONTROL THEORY APPROACH
_______________
A Thesis
Presented to the
Faculty of
San Diego State University
_______________
In Partial Fulfillment
of the Requirements for the Degree
Master of Arts
in
Communication
_______________
by
Kristen LaVon Everhart
Summer 2014
iii
Copyright © 2014
by
Kristen LaVon Everhart
All Rights Reserved
iv
DEDICATION
I dedicate me thesis to the people who pass on the opportunity to live to their full
potential because they are blind to it. I pray that one day you awaken to see that you are
capable of so much more than the world says you are. The encouragement of Dr. Snavely,
Dr. Pauley, Dr. Moran, and the faculty is why I am motivated to take advantage of great
opportunities. Thank you Dr. Pauley for believing in me and not allowing me to give you
anything but my best work. Many people pray for a mentor-advisee relationship like I found
working with you, and it has truly been a blessing.
To my friends in Never Neverland, may you continue to refuse to grow up and live
your lives boldly, without limits. Thank you for providing me with a space to work and
letting me be part of a life I cannot live. Thank you Carnahan’s my sanity would not be intact
without your support. All through high school and college you have welcomed me into your
family and allowed me to live alongside the memory of your son. Kyle may you rest in peace
and live through us, I promise I will never give less than my best Superman.
To my Nonie and Papa who are so patient, letting me read and rehearse my
presentations, you have always been my refuge and accepted me. Brother, Terry, and Tarynn,
your story inspires the questions I ask about families, because your relationship is purely
defined by the love you have for each other. To my sister Lacey, Amaya, Avery, Fletcher,
and Frank: your story motivates these pages and the research I have done on childbirth.
Lacey, you are a wonderful mother, sister, and wife, but you are also bold and so much your
own person. I cannot wait for God to reveal what all He has planned for you. I love you. Dad,
thank you for knowing when to be tough, when to let me cry, and for teaching me how to
care less about what others think of me. Mom, we are so much the same person, we travel
alongside each other through everything. Always moving forward and forever growing closer
our souls are so deeply connected, that our love will never fail. Mom and Dad you are always
yourselves and I thank you for loving me unconditionally.
Thank you to all of my extended family for celebrating all of my achievements and
Grandma Mary and Grandpa Bill for boasting about me continuously.
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Be strong and courageous. Do not be terrified; do not be discouraged, for the Lord your God
will be with you wherever you go.
—Joshua 1:9
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ABSTRACT OF THE THESIS
Communicating Childbirth: A Memorable Messages and Control
Theory Approach
by
Kristen LaVon Everhart
Master of Arts in Communication
San Diego State University, 2014
This study was an initial step toward understanding how memorable messages about
childbirth socialize women into having a certain set of expectations for their birth experience.
One of the primary goals of the present study was to expand the current state of birthing and
interpersonal communication research by measuring the principles and behaviors that
underlie memorable birthing messages, factors that in turn shape birthing expectations. A
total of 71 women participated in an online questionnaire study that assessed the form and
content of, as well as reactions to, pregnancy- and childbirth-related memorable messages.
Consistent with previous findings, data from the present study revealed that more than 70%
of the sample identified pain as a topic of childbirth memorable messages, however, only
30% reported pain as the topic of their most memorable message. Overall, memorable
messages from friends and/or family dealing with pain, positive emotional experiences, and
the people involved in the birthing experience produced the highest levels of positive
behavioral change. Feeling vulnerable because of a memorable message and experiencing
negative emotional arousal in response to a message were associated with low levels of
positive behavioral change. Women’s pre-pregnancy health-related values were not
associated with her pregnancy health self-concept or how likely she was to change her
behavior in response to a memorable message. This research extends the integration of
control theory and memorable messages into the communicated sense-making of childbirth.
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TABLE OF CONTENTS
PAGE
ABSTRACT ............................................................................................................................. vi
LIST OF TABLES ................................................................................................................... ix
LIST OF FIGURES ...................................................................................................................x
CHAPTER
1
INTRODUCTION .........................................................................................................1 2
MEMORABLE MESSAGES ........................................................................................5 Memorable Messages and Control Theory ..............................................................6 Memorable Messages in Health Communication Research ....................................8 Theoretical Dimensions of Health Memorable Messages .................................8 Future Directions for Memorable Messages in Health Research ......................9 Memorable Messages and Childbirth Expectations .................................................9 Topic of Childbirth Memorable Messages ......................................................10 Sources of Memorable Messages.....................................................................11 Persuasive Strength of Childbirth Memorable Messages ................................11 Argument Strength ...........................................................................................11 Message Directness ..........................................................................................12 Induced Vulnerability ......................................................................................12 Health Self-Concept and Behavioral Change ..................................................13 3
METHOD ....................................................................................................................15 Participants .............................................................................................................15 Sampling ..........................................................................................................15 Survey ..............................................................................................................16 Measures ................................................................................................................16 Health Self-Concept .........................................................................................17 Memorable Messages.......................................................................................18 Recency ............................................................................................................18 Source ..............................................................................................................18 viii
Argument Strength ...........................................................................................19 Message Directness ..........................................................................................20 Conversation Length ........................................................................................20 Message Vulnerability .....................................................................................20 Message Topic .................................................................................................21 Emotional Arousal ...........................................................................................21 Behavioral Health Intentions ...........................................................................22 Behavioral Intentions .......................................................................................22 4
RESULTS ....................................................................................................................24 Descriptive Statistics..............................................................................................24 Hypotheses and Research Questions .....................................................................25 5
DISCUSSION ..............................................................................................................32 The Role of Memorable Messages in Maternity Healthcare Behavior..................34 Topics of Childbirth Memorable Messages .....................................................36 Sources of Childbirth Memorable Messages ...................................................36 Message Dimensions and Intention to Enact Behavioral Change .........................37 Argument Strength ...........................................................................................37 Message Directness ..........................................................................................38 Perceived Vulnerability ...................................................................................38 Health Self-Concept, Emotional Arousal, and Behavioral Intent ....................39 Strengths, Limitations, and Conclusions ...............................................................40 Limitations .......................................................................................................41 Conclusions ......................................................................................................42 Implications for Health Practitioners ...............................................................43 REFERENCES ........................................................................................................................44 ix
LIST OF TABLES
PAGE
Table 1. Comparison Table of Participant Groups Based on Level of Experience with
Birthing .....................................................................................................................24 Table 2 Correlation Matrix ......................................................................................................26 Table 3. Topics of Most Memorable and All Memorable Messages .......................................27 Table 4. Regression Results from Baseline Model and Hierarchical Model ...........................31 x
LIST OF FIGURES
PAGE
Figure 1. Theoretical model of childbirth memorable messages and control theory.................7 1
CHAPTER 1
INTRODUCTION
The average cost of giving birth in the United States is higher than most other
developed countries at $10,002 for a vaginal birth and $15,240 for a cesarean birth
(International Federation of Health Plans, 2013). When the cost of giving birth is bundled
with pregnancy and newborn care, the numbers increase to $30,000 for a vaginal birth and
$50,000 for a cesarean birth (Rosenthal, 2013). While this cost inflation is due in part to the
extensive list of costly and often unnecessary routine procedures (Hunter, 2006; Rosenthal,
2013), lowering the number of cesarean births would help decrease the national cost of
giving birth. The cost differential between vaginal births and cesareans births is considerable
and highlights the importance of researching why the United States has a higher rate of
cesarean births than any other developed nation (Martin et al., 2012). According to census
data from Martin et al. (2012), from 1996 to 2009, the rate of cesarean births in the United
States rose 60%, resulting in a total 32.8% of women giving birth via cesarean during 2010.
Increases in the rate of cesarean births in the United States, have been linked to a number of
possible causes including the routine use of epidurals (Anim-Somuah, Smyth, & Jones, 1996;
Bainbridge, 2012; Lieberman et al., 1996) and a woman’s fear of childbirth (Armstrong,
2000; Romano & Lothian, 2008).
Although correlation does not mean causation, it is important to present the evidence
associating epidural anesthesia with an increased likelihood of cesarean intervention and
instrument-assisted vaginal birth. Analysis by Osterman and Martin (2011) found that in
2008, an average 61% of women giving birth in the United States received an epidural. They
also investigated different perspectives regarding the ethics of routinely offering epidural
anesthesia to women, finding that most doctors believe epidurals should be an available
alternative for pain management despite the fact that side effects of epidural anesthesia
include increased risk of maternal fever, maternal hypotension, and fetal distress resulting in
cesarean intervention (Anim-Somuah et al., 1996). According to Bainbridge (2012), epidural
anesthesia has been associated with longer labor duration, and Lieberman et al. (1996) found
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that women who received an epidural were 3.7 times more likely to have a cesarean
intervention than women who birthed without an epidural. After the birthing process is over,
women who experienced unexpected cesarean interventions or extended labor duration are at
greater risk of having characteristics of post-traumatic stress disorder and post-partum
depression (Czarnocka & Slade, 2000; Halbreich, 2005). Anim-Somuah et al. (1996)
discovered that women who received an epidural had longer second phase labor, increased
instrument assisted births, heterogeneous satisfaction (i.e., mixed or inconsistent feelings of
satisfaction), and longer post-delivery recovery periods.
In addition, both epidural anesthesia and psychological distress can slow the natural
progression of labor and increase a woman’s likelihood of requiring instrumental assistance
(Armstrong, 2000; Romano & Lothian, 2008). Epidural anesthesia can impair a woman’s
natural physiological response, which leads to the suppression of a woman’s hormone
regulation system (Romano & Lothian, 2008). In addition, a woman’s experience of
emotional distress during labor can also suppress her physiological ability to moderate pain
naturally and progress labor (Armstrong, 2000). Data from Romano and Lothian (2008)
suggest that birth is “a delicate hormonal process that unfolds optimally when conditions
minimize fear, pain, and stress” (p. 94). A woman’s natural physiological response during
labor is responsible for releasing “maternal catecholamines and endogenous betaendorphins” which advance contractions and moderately inhibit pain (Romano & Lothian,
2008, p. 94). While increased the risks of cesarean and instrument-assisted birth are
correlated with epidural anesthesia and psychological distress, these are not the only negative
effects of physiological impairment.
A healthy physiological response is necessary for optimal labor and post-labor health
outcomes of the mother and baby. According to Tamagawa and Weaver (2012), when a
woman’s natural physiological process is inhibited by stress or epidural anesthesia, her
oxytocin receptors are desensitized negatively, affecting her duration of breastfeeding
(Halbreich, 2005; Tamagawa & Weaver, 2012). This is problematic given that benefits of
breastfeeding include reduced odds of infant asthma and obesity as well as a reduction in the
mothers’ risks of breast and ovarian cancers (Faucher, 2012). Tamagawa and Weaver (2012)
review controversial findings that suggest the consequences of epidural oxytocin suppression
affect both the mother’s oxytocin level as well as the infant’s when epidural anesthesia
3
crosses the placenta, which may cause oxytocin augmentation in the infant, a condition that is
linked to childhood behavioral development disorders such as autism spectrum disorders.
Building a birth environment that optimizes a woman’s natural physiologic response can
therefore reduce depletion of breastfeeding, minimize lifelong health risks, and decrease the
odds of childhood behavioral development disorders. This data suggests that moderating
psychological and emotional stress during pregnancy can promote healthy physiologic
processes.
Researchers need to investigate how fear in the birthplace is socially propagated in
order to decrease the rate of instrument-assisted vaginal births and caesarean births. An
initial step is discovering how a woman’s birthing expectations are shaped and how they
might affect her emotional state. Today’s concept of childbirth pressures women to accept
the “values, expectations, and orientations of the hospital,” (Armstrong, 2000, p. 587). This
concept of birth prioritizes medical preparedness and a healthy baby over all else
(Armstrong, 2000; Beck, 2004). Some socio-behavioral scholars posit that infant mortality
and preterm labor prevention have shifted from being viewed as societal issues to becoming a
woman’s responsibility, thereby decreasing self-efficacy by framing childbirth as a high-risk
medical condition (Armstrong, 2000; Bedwell, Houghton, Richens, & Lavender, 2011).
Understanding how societal pressure, conveyed through information sharing, cultural
storytelling, and media, affects a woman during her pregnancy requires further research. In
an effort to increase positive birthing outcomes, this study focuses on the communicative
processes that construct women’s childbirth expectations. By knowing how these
expectations are shaped, future research can develop effective health interventions that
reduce uncertainty leading up to pregnancy.
Although birthing researchers have developed a large body of literature illustrating
the components of a satisfying and safe childbirth, we are less aware of what influences
mothers’ expectations going into the birth environment. This study is a preliminary
investigation aimed at identifying both the source and construction of birthing expectations.
Health communication research shows that people receive healthcare advice from spouses,
family members, friends, health practitioners, and the media (Smith et al., 2009). Although
empirical knowledge indicates that first-time expectant mothers receive birthing advice, how
women make sense of the messages and how the messages shape their birth experience is
4
unclear. Applying the framework of memorable messages to this uncertainty-filled situation,
this study will examine both the sources and influences of childbirth memorable messages
that shape a woman’s beliefs and expectations about birth.
5
CHAPTER 2
MEMORABLE MESSAGES
Language molds our perception of the world by assigning meanings, influencing, and
persuading people into a system of beliefs. These beliefs can be explicit or implicit in how
they cognitively direct thought patterns. A person’s interpersonal communication and media
consumption contain influential messages that are largely responsible for constructing an
understanding of interactions and events. Goffman (1974) introduced the concept of ‘frames’
as interpretative schemata that explain how individuals organize their interpretation of cues
(emphasizing cultural influences) in order to create their perception of social events. It is
within these ‘frames’ that individuals organize social cues into situational understandings
that regulate their behavioral responses (Goffman, 1974). Knapp, Stohl, and Reardon (1981)
refer to Goffman’s ‘frames’ to explain how people construct and remember interpersonal
exchanges differently, resulting in a variety of assigned meanings or message interpretations.
Knapp et al. (1981) found that most interpersonal messages exchanged “are
processed, responded to, and forgotten” (p. 27), however, they also assert that some messages
stand out as memorable messages. They suggested that, over the course of a lifetime, a few
memorable messages are captured and serve as lifelong principles to guide behavior. Knapp
et al. (1981) specifically defined a memorable message as “a communication unit which
seemed to be a common but memorable event in most people’s experience and which was
reported to exert a powerful influence on the course of one’s life” (p. 2). Memorable
messages have four dimensions: structure, form and organization, content, and context of
message exchange. The most common structure of a memorable message is a short and easily
replicable rule-based phrase (p. 31). The second dimension, form and organization, usually
includes a condition, prescriptive marker, behavioral act, and consequence (p. 31). This
organization typically produces a proverbial phrase that can be as short as a single sentence
depending on the content of the message. The third dimension, message content, is typically
high in personal relevance to the message recipient. Knapp et al. (1981) found that lengthier
memorable messages have additional content aimed at increasing message credibility, such
6
as personal testimony or anecdotal evidence. The inclusion of testimonial type content often
depends on the context of message delivery. The fourth dimension, exchange context, is
typically during a time of duress when the receiver is seeking advice from the message
sender.
Another unique aspect of memorable messages is the ability for people to recall with
some degree of confidence the exact phrasing and original source of the message even after a
considerable amount of time has passed. Knapp et al. (1981) discovered that the cognitive
recall of messages is enhanced because memorable messages have a high degree of personal
relevance, source credibility, and a simple linguistic structure. Holladay (2002) posits that the
memorable messages approach is a promising new framework through which scholars can
understand how “people develop conceptions of themselves, others, and situations that serve
as guidelines for behavior” (p. 682). Memorable messages are a tool of socialization to teach
“expected behaviors, decision premises, and preferred attitudes” (Holladay, 2002, p. 683;
Koenig-Kellas & Kranstruber, in print).
MEMORABLE MESSAGES AND CONTROL THEORY
Recent studies focused on capturing memorable messages have applied the lens of
control theory to their investigations (e.g., Ellis & Smith, 2004; Miczo, Danhour, Lester, &
Bryant, 2013; Smith & Ellis, 2001). The purpose of research grounded in control theory is to
offer an explanation of people’s self-regulation system; this has also been referred to as
general systems theory (Carver & Scheier, 1982). Carver and Scheier (1982) contend that
control theory is a useful approach for understanding how people “attempt to maintain their
physical well being,” particularly in health psychology research (p. 112). A central premise
of the theory is that every person’s self-regulation system has a negative feedback loop, aptly
named for its role in negating potential conflict between an referent (i.e., expectation) and
present state (i.e., experience). There is great potential for this theory to help explain what
happens when memorable birthing messages build a set of expectations for a woman’s birth
experience that may or may not result in conflict with her present state during active labor.
Studies investigating the behavioral influences of memorable messages have favored the
combination of a memorable messages approach and three sub-systems of control theory: the
systems level, the principle level, and the program level (Ellis & Smith, 2004; Miczo et al.,
7
2013; Smith & Ellis, 2001). The following sections detail the applicability of memorable
messages and control theory to conversations about childbirth (Figure 1).
Figure 1. Theoretical model of childbirth memorable messages and control theory.
At its most basic, the systems-level concept refers to a person’s referent of
themselves, an “idealized self-image of personal characteristics that [a person] wants to
embody” (Carver & Scheier, 1982, 114). People refer to this perception of self periodically to
confirm that their behavior is matching who they want to be. In the case of the present study,
the perception of self is as a healthy, expectant mother preparing for birth. Directly
subordinate to the systems level is the second element of control theory called the principle
level. The principle level is the starting point for describing how people self-regulate (Carver
& Scheier, 1982). Principles are a description of behavioral qualities, such as considering
oneself to be a healthy person or knowledgeable about healthcare, but do not qualify as actual
behavior. As previously discussed, memorable messages often contain guiding principles that
are coupled with a recommended course of action. The action component, called the program
level, is the third theoretical element of control theory used by Smith and Ellis (2001). Carver
and Scheier (1982) compare program level to a script because “programs, in effect, provide
some behavioral content in which a principle can be reflected” (p. 116). Taking all of these
components into consideration, an example of a memorable birthing message that combines
the (a) systems level, (b) principle level, and the (c) program level would be: to (a) be a good
mom (b) a woman needs to be dedicated to (c) eating as healthy as possible while she is
8
pregnant. Obviously, not all memorable messages will be as straightforward as this example,
but the specified three elements of control theory should still be present implicitly or
explicitly.
MEMORABLE MESSAGES IN HEALTH COMMUNICATION
RESEARCH
Studies of health communication have used memorable messages to understand
multiple concepts including breast cancer communication (Smith et al., 2009), final
conversations reported by terminal disease survivors (Keeley, 2004), messages about aging
(Holladay, 2002), familial messages about sex (Kauffman, Orbe, Johnson, & Cooke-Jackson,
2013), and H1N1 flu prevention (Miczo et al., 2013). Of this previous literature, the
conceptual and operational definitions of memorable messages provided by Smith et al.
(2009) and Miczo et al. (2013) are particularly salient when considering memorable
messages about childbirth. For example, Smith et al. (2009) examined the source and content
of memorable breast cancer messages and measured behavioral responses to these messages.
They found that all topics of memorable messages about breast cancer were equally likely to
motivate prevention and detection behaviors, as were all sources except medical
professionals (p. 302). On the basis of this apparent disconnect between healthcare providers’
communication and patients’ positive health behaviors, Smith et al. (2009) offered healthcare
providers an understanding of how memorable messages can play an important role in
influencing people’s awareness of breast cancer.
Theoretical Dimensions of Health Memorable
Messages
In the second memorable message study with implications for the present
investigation, Miczo et al. (2013) measured sources, content, and health protection
motivation and behaviors derived from memorable messages about the H1N1 flu virus. Their
study examined a sample of college students, asking them to recall a memorable message
about how to avoid the H1N1 flu virus. The most frequently reported source of H1N1
messages were advertisements posted around campus followed by advertisements from
media outlets (p. 640). This suggests that when advertisements are targeted and personally
relevant to the recipient, they produce memorable messages that are effectively stored and
9
recalled. It is worth noting that memorable H1N1 messages closely followed the structure
identified by Knapp et al. (1981) and contained principles advising participants on how to
avoid the flu, such as engaging in frequent hand washing, avoiding others who are sick, or
making sure to get the flu vaccine (Miczo et al., 2013). Identifying the most common health
protection behaviors and message sources can help construct inexpensive and effective health
campaigns. Miczo et al. (2013) found that memorable messages from an interpersonal source
(e.g., a parent) resulted in a higher degree of prevention behaviors. In addition, results
indicated that the behavioral responses to carrying out principles of memorable messages
were linked to a person’s health concept. Since self-concepts are most strongly influenced by
trusted or respected others, Miczo et al. (2013) posit that messages linked to an interpersonal
source resulted in a higher probability of behavioral change.
Future Directions for Memorable Messages in Health
Research
Until recently, memorable message research has primarily utilized a qualitative
approach to studying dimensions of message content (Holladay, 2002; Kauffman et al., 2013;
Keeley, 2004; Kranstuber, Carr, & Hosek, 2012), however, this study sought to include
quantitative measures for content and behavioral response such as health protection or health
risk behaviors. In an attempt to move memorable messages research away from
qualitative/descriptive analysis, this study retested Miczo et al.’s (2013) three dimensions of
message content: argument, directness, and vulnerability. To address reliability and validity
concerns of Miczo et al.’s (2013) three dimensions, this study will add new items to each
subscale and retest the potential for using a dimensions approach to analyze memorable
messages.
MEMORABLE MESSAGES AND CHILDBIRTH
EXPECTATIONS
Memorable messages are snapshots of conversations that communicate rules or
principles, which serve as reference values to govern an individual’s behavior. Smith and
Ellis (2001) suggest that people use reference values to assess the appropriateness of their
behavior or how they should act in a given situation. A woman’s first pregnancy is a unique
experience, during which she will typically seek support or advice from credible others who
10
have given birth. One of the most salient ways that reference values are formed is through the
communication of stories. When people share stories about motherhood and childbirth, they
are participating in the socialization of a set of beliefs or values about what childbirth
experiences are. To our knowledge, how memorable messages affect an expectant mother’s
health behavior and shape what she expects childbirth to be like are unknown. Green,
Coupland, and Kitzinger (1990) surveyed women before and after labor and found that
women who expected labor to be painful found that it was, and those that expected their
childbirth to be a fulfilling experience reported that it was. Although this study did not
specifically test the memorable messages framework, it is plausible that these women’s
attitudes were strongly influenced by the normative stories they heard during pregnancy; in
other words, memorable messages might explain why some women expect a painful or
fulfilling labor while others do not. Understanding how memorable messages participate in
the formation of preconceived notions of childbirth and how these notions can impact a
woman’s experience of labor can help identify communicative factors that influence first
time expectant mothers.
Topic of Childbirth Memorable Messages
Several studies have surveyed couples or examined women’s narratives about their
childbirth experiences, and collectively, results from those studies suggest that birthing is a
multi-faceted event with emotional and physical components that influence women’s
satisfaction (Fremgen, 2001; Green et al., 1990; Harriott, Williams, & Peterson, 2005;
Hodnett, Gates, Hofmeyr, & Sakala, 2012). Typically studies look at how different
characteristics or components of the birth environment affect the woman’s psychological or
physical response to labor. However, this study is interested in finding out the most common
topics affiliated with early and active labor that are embedded in memorable messages.
Smith et al. (2009) examined the source and content of memorable breast cancer messages
and found that different sources were associated with different categories of message content.
So the present study seeks to uncover which topics of memorable messages are associated
with the childbirth experience.
RQ1: What topics of childbirth messages are reported as memorable?
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Sources of Memorable Messages
In addition, the most frequent source of memorable messages and the relationship
between topic and source can provide insight into who has the most influence on women’s
expectations of childbirth. Based on Smith et al.’s (2009) study of memorable cancer
messages and Gotcher and Edwards (1990) imagined interactions of cancer patients, there are
10 possible sources of a memorable message. Miczo et al. (2013) found that the source of
H1N1 memorable messages influences their persuasiveness to induce behavioral change.
Since this study is an initial investigation of memorable messages about childbirth, the topics
and sources of memorable birthing messages is unknown.
RQ2: Which memorable message topics affect both (a) behavioral intentions and
(b) emotional arousal?
RQ3: Which memorable message sources affect both (a) behavioral intentions
and (b) emotional arousal?
Persuasive Strength of Childbirth Memorable
Messages
In an effort to capture how rule-based contents of childbirth memorable messages
induce emotional arousal and behavior change, this study uses three subscales to measure
message persuasiveness: argument strength, directness, and vulnerability. To find out which
of the three dimensions of health influence messages is most likely to induce behavioral
change, each dimension is tested separately.
Argument Strength
Miczo et al. (2013) define argument content as the “use of reasons in messages, [that]
reflects the focus of health-related messages on behavior changes” (p. 628). This study
measures argument strength with assessments of source credibility and personal relevance
(i.e., a woman believes there is a reasonable chance the message will pertain to her birth
experience). Given that previous studies have found that memorable messages from a close
relational partner were more influential that those received from a healthcare provider (Smith
et al. (2009), it stands to reason that the personal connection to the speaker might be one
contributing factor to the perceived strength of the argument. Thus the respondent’s
emotional arousal and behavioral change in response to the message are dependent on the
argument’s strength.
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H1: Argument strength is positively related to both (a) behavioral intentions and
(b) emotional arousal.
Message Directness
The second dimension of health influence messages, directness, was constructed by
Miczo et al. (2013) to measure the delivery mode of memorable messages. Knapp et al.
(1981) found that memorable messages are typically “brief oral injunctions that prescribe
rules of conduct” (p.39), but that memorable messages come in different lengths: some are a
single sentence whereas others are brief statements. Some messages may include rules of
conduct; others contain anecdotal evidence or testimonial narratives (Miczo et al., 2013).
Those studies suggest that messages that are not embedded in long narratives and contain
explicit intentions may induce more behavioral change. Since both, the message sender’s
ability to deliver a clear and direct rule based message and the length of the conversation
might influence the message’s persuasive effect on the receiver the associations are
predicted:
H2: Directness is positively related to both (a) behavioral intentions and (b)
emotional arousal.
H3: Directness is correlated to conversation length.
Induced Vulnerability
The third dimension, vulnerability, is based on prevalent health-related theory that
measures influence messages (Miczo et al., 2013). The underlying idea is to test whether the
message appeals to the receiver’s feelings of vulnerability to an undesirable aspect of
childbirth. Miczo et al. (2013) clarifies that “feelings of vulnerability are not message
features, but because they likely vary from person to person, they can still be captured by a
dimensional approach” (p. 629). Vulnerability is measured by assessing the respondent’s
perceived susceptibility and healthiness (e.g., how healthy a respondent feels increases their
self-efficacy to overcome or resist the negative consequences expressed by the message
principle). In addition, the more often a woman hears the same message of an undesirable
feature of childbirth, the more vulnerable she will feel, particularly when she fears that she is
likely to experience the same or similar unpleasant outcomes.
H4: Vulnerability is positively associated to both (a) behavioral intentions and (b)
emotional arousal.
13
H5: Message frequency is positively correlated to perceived vulnerability.
Health Self-Concept and Behavioral Change
Control theory suggests that individuals will adjust their current behavior to align
with principle- and program-level concepts only when a message’s reference value conflicts
with current behavioral practices. The conflict between idealized self-concept and a
message’s reference value activates a negative feedback loop to induce principle- (i.e., nonbehavioral) and program- (i.e., behavioral) level changes. The feedback loop continues until
the three systems are in equilibrium, having adjusted the individual’s self-concept to the
message’s rule or value that originally caused the conflict. Knapp et al. (1981) said that the
recipient uses the memorable message to integrate his or her future experiences “into a
coherent, useful shorthand rule of thought or behavior” (p. 34) and that receptivity to these
messages is highest during crises involving one’s self-concept. The involvement of selfconcept activates the assessment of behavior and clarifies what behavior is and is not
congruent with the person’s self-concept (Smith & Ellis, 2001). Miczo et al. (2013) said it
should then follow that “if the idealized self-image is the health self-concept, then the actual
situation refers to the performance of healthy behaviors” (p. 630). When a woman’s behavior
is incongruent with her health self-concept she will use memorable messages to assess and
clarify how to improve her performance of healthy behaviors. Essentially, if a woman has a
positive health self-concept, messages that suggest otherwise should motivate her to
implement behavioral changes. For instance, if a woman believes walking a mile a day
(program) means she is an active person (principle level), but hears pregnant woman should
walk three miles a day (conflict message), then her system level concept will need to reassess
her behavior.
The likelihood of a message inducing conflict at the systems level depends on
whether a woman’s health self-concept is positive or negative. Women with a positive health
self-concept will have higher health protection motivation (i.e., engage in healthy behaviors)
whereas women with a negative health self-concept will engage in more health risky habits
(Miczo et al., 2013; Wiesmann, Niehörster, Hannich, & Hartmann, 2008). Positive and
negative health self-concepts explain differences in women’s system-level sensitivity.
14
Although pregnancy is a heightened period of health conscientiousness for most women, not
all women will be behaviorally motivated by memorable messages. Thus:
H6: Health self-concept is positively related to health behavior intentions.
In addition to health-self concept, a message must induce emotional arousal to effect
behavioral change. The moderating role of memorable birthing messages is hypothesized as
follows:
H7: Health self-concept moderates the relationship between dissonance-related
arousal and health protective behaviors such that arousal and health-protective
behaviors will be positively associated when health self-concept is positive and
uncorrelated when health self-concept is low.
15
CHAPTER 3
METHOD
PARTICIPANTS
Participants from the present study were recruited from online message boards and
social media interest group pages related to maternity. Agreement to informed consent was
the only requirement for participation. A total of 110 participants were recruited for
participation in this study, however, a total of 71 women (65% of the initial sample) provided
a detailed response to a pregnancy-related memorable messages and were subsequently
included in the final sample.
Sampling
Participants were recruited for this study using both cluster sampling and snowball
sampling strategies. The researcher employed cluster sampling by using online social media
sites, electronic mail distribution lists, and public domain maternity-related webpages
(representing each one of the United States) to post a recruitment flier with a dedicated link
to the survey. In addition, the researcher presented the recruitment flier and verbally recruited
for the study on 6 separate occasions at prenatal education classes hosted in two Southern
California “Babies R Us” stores. The attendees of these prenatal classes were additionally
asked to refer anyone they knew who qualified for participation to participate in the study
and were provided with extra fliers to distribute to other potential participants. These fliers
described the purpose of the study and included information about how to be entered into a
drawing for one of four $50 Babies R Us gift cards. Entry into the drawing was completely
voluntarily, and participants were made aware that the odds of winning were 1 in 38.
Offering gift card incentives to participate in survey research is a common method of
recruitment: Rand (2012) conducted two experimental tests on the reliability of an online
survey-recruiting network that offers gift card incentives. The first used IP addresses to
verify self-reported country of residence and determined a 97% response accuracy. The
second experiment compared multiple self-report demographics between two surveys and
16
found between 81% and 98% agreement. These data suggest that respondents participating in
online research with gift card incentives are accountable samples.
Survey
All participants completed an online self-enumerated questionnaire containing three
sections with a total of 98 items. All responses were voluntary, meaning if respondents were
uncomfortable with a question they were permitted to leave it blank and continue with the
rest of the survey. This survey was administered from February 26, 2014 to April 23, 2014.
The final data were reviewed and altered as necessary to limit the risk of disclosure by
removing names and/or identifying information to ensure participant confidentiality.
MEASURES
Immediately following informed consent, participants were presented four items
intended as pre-screening questions. Responses to these items did not disqualify participants
but provided information that could potentially explain outliers in the data. Participants were
asked if they were between the ages of 24 to 40 years, if they were pregnant, whether their
pregnancy was considered high risk, and if they had lived in the United States for at least half
of their life. Age can moderate the effect memorable messages have on a woman’s behavior
because as women enter adulthood their self-image begins moving into an identity of
motherhood and nurturing (Slade, Cohen, Sadler, & Miller, 2009). There is a greater degree
of transformation for young adolescents to shift into motherhood, which can make their
experience more fragmented as they move from one self-image to another. In addition,
participants were asked about their current level of experience with childbirth because this
affects the level of uncertainty they may feel in negotiating a response to memorable
messages. Third, respondents were asked if their pregnancy was considered high risk based
on family history, previous health conditions, past miscarriages, or conversations with their
health practitioner. Pre-existing or current health conditions that determine a high-risk
pregnancy may influence a woman’s psychological or physical experience of birth
potentially influencing her health self-concept. The last prescreening item asked if
participants have lived permanently in the United States for at least half of their lifetime. This
item was added to control for the impact of foreign healthcare systems and socialized health
17
beliefs about childbirth outside the United States. Childbirth is perceived and treated
differently in every country and this study seeks to capture childbirth memorable messages
exchanged across the United States.
Health Self-Concept
The next section of the survey contained sixteen items from 76-item Health-Related
Self-Concept Scale (HRSC-76: Wiesmann et al., 2008). The full measure contains five
independent dimensions representing “both positive and negative facets of the health-related
self-concept” (p.765). In the interest of keeping their survey brief, Miczo et al. (2013) applied
two sub-scales, the health-motivation and health-risky habits measures, from the HRSC-76 to
their study of memorable H1N1 messages in order to operationalize the systems level of
control theory. This study used these same two subscales measuring health motivation
behavior (HMB) and health-risky habits (HRH) of first-time expectant women, using a
Likert-type format (i.e., 1=not at all like me to 5=exactly like me) to measure positive and
negative health-related perceptions of self. The HMB includes eight items such as “I look
after my health consciously” and “practicing healthy behaviors is good for me,” and the HRH
includes eight items such as “My life-style is risky” and “I think it is exhausting to practice
healthy behaviors” (Wiesmann et al., 2008, p. 760).
A principal component factor analysis with oblique rotation was conducted to assess
the 16 items measuring health self-concept. The analysis produced a three-factor solution
with a Kaiser-Meyer-Olkin coefficient = .82 that accounted for 67.79% of the common
variance. An analysis of the factor loadings revealed that three items were essentially
unrelated to items correlated with the first two factors and loaded onto the third factor. Miczo
et al. (2013) reported the same factor structure in their analysis of H1N1 memorable
messages, so following their guidance, these items were removed from the analysis and a
second factor analysis with a two-factor solution was conducted. The second model produced
a KMO coefficient of .86 that accounted for 69.86% of the common variance. The two
factors produced by this model were consistent with the HMB and HRH subscales identified
by Wiesmann et al. (2008).
Following the recommendations of Miczo et al. (2013), both scales were summated
and a discrepancy score was calculated for each participant by subtracting the HRH mean
18
value from the HMB mean value. This produced an overall health self-concept score (M =
.27, SD = .21) that was positive when participants’ motivation to enact healthy behavior was
higher than their tendency to enact risky health behaviors.
Memorable Messages
The second section of the questionnaire began with an open-ended prompt that asked
participants to recall and write down “the most memorable message that you can remember
hearing about giving birth.” The process of writing down the memorable message was
intended to increase the participant’s response accuracy to the survey items that refer
specifically to this memorable message. The open response item also included the following
brief description of a memorable message:
Memorable messages are brief phrases that serve as guidelines for behavior, often
providing principles or rules for how to respond to a particular event. Some
messages are short for example, ‘Giving birth is the most fulfilling experience,
you will remember it forever!’ whereas some memorable messages serve as the
moral of the story in a longer conversation such as when another person tells you
their entire birth plan to suggest that if you have a birth plan your labor will be
better.
Recency
Following this open-ended writing prompt, participants were asked “How recently
did you hear this memorable message” with response options based on Knapp et al.’s (1981)
time frame. Options included: within the last week (n = 7, 9.9%), within the last month (n =
10, 14.1%), within the last 4 months (n = 15, 21.1%), within the last year (n = 16, 22.5%),
and over a year ago (n = 22, 31%). The mean value for this 1-5 response indicated that the
average length between the receipt of their most memorable message and the present was
slightly more than four months ago (M = 3.51, SD = 1.34).
Source
The source of the a message was assessed with two items: first participants were
asked the source of their most memorable message, and then they were asked the source of
any other memorable messages they had heard. Response options were adapted from
Edwards, Honeycutt, and Zagacki’s (1988) measure of Dialogue Partner and Smith et al.’s
(2009) source categories of memorable breast cancer messages. Participants chose from
19
family member (n = 23, 32.4%), friends (n = 23, 32.4%), media (n = 6, 8.5%), work/job
colleagues (n = 5, 7%), health practitioners (n = 5, 7%), spouse/romantic partner (n = 4,
5.6%), other (n = 4, 5.6%) and one missing.
Argument Strength
The argument strength of participants’ most memorable message was assessed using
the Personal Involvement Inventory Scale (PII: Zaichkowsky, 1986) and the authoritative
dimension of the Source Credibility Scale (SCS: McCroskey, 1966). Respondents were
presented a list of nine items designed to measure the message’s persuasiveness based on
argument strength.
Using McCroskey’s (1966) authoritative subscale of the SCS, participants were asked
to rate how strongly they felt six adjective pairs described the speaker of their memorable
message: reliable/unreliable, uninformed/informed, unqualified/qualified,
intelligent/unintelligent, valuable/worthless, and inexpert/expert. All items were scaled such
that the positive adjective was assigned a value of 7 and the negative adjective was assigned
a value of 1, meaning that higher scores represented higher speaker credibility. A reliability
analysis showed the scale had acceptable reliability ( = .83).
To measure personal relevance, three items were adapted from Zaichkowsky’s (1986)
PII scale, which is designed to measure the message based on personal needs or interests of
the receiver. Zaichkowsky’s (1986) personal elements, such as how relevant the message is
to the receiver are antecedents to involvement, which signifies interest and motivation
(Munson & McQuarrie, 1987). The three sets of bipolar word pairs were selected from
Zaichkowsky’s (1986) PII: important/unimportant, significant/insignificant, wanted
advice/unwanted advice. Participants were asked to report how personally relevant they felt
the memorable message was to themselves. Barge and Schlueter (2004) found that
memorable messages typically come from a source with a higher social status than the
receiver and the content is such that the advice within the message has the receiver’s best
interest at heart. Reliability analysis demonstrated that the scale was reliable ( = .92).
These two dimensions were combined to form a composite index of argument
strength. Principal components analysis using oblique rotation was conducted, producing a
satisfactory Kaiser-Meyer-Olkin coefficient (KMO = .79). Three components were produced
20
with eigenvalues >1.0 that accounted for 81.52% of the common variance. Analysis of the
factor loadings indicated that items were grouped according to their phrasing such that
positively- and negatively-worded items primarily loaded on different factors. It was
therefore decided to collapse the factor structure and test the combined measure as a single
dimension of argument strength. After both subscales were summated, the total values were
combined to form a nine-item scale with an overall score for the messages argument strength.
This composite measure had a reliability of  = .89.
Message Directness
The first two items measuring message directness are pre-existing items from Miczo
et al. (2013) that ask how explicit/implicit and direct/indirect the topic of the reported
memorable message is. Miczo et al. (2013) found that their measure of message directness
had low reliability and suggested adding another item. This study tested one additional item
that inquired whether the topic of the most memorable message was not clear or clear.
Participants were asked to rank the directness of their most memorable message on a 1-7
scale with higher values indicating more directness. Initial reliability tests revealed that the
scale was not internally consistent,  = .64, and an analysis of the item-total correlations
revealed that one item, explicit/implicit, was not consistent with the remaining items on the
measure. Removing this item from the measure significantly improved the reliability of the
message directness measure,  = .73.
Conversation Length
Participants were asked to report an estimate of how long the conversation in which
they heard their most memorable pregnancy-related memorable message lasted. The item
was open response and participants typed in their numeric estimate in minutes. On average,
these conversations lasted for about 20 minutes (M = 22.46 minutes, SD = 25.91).
Message Vulnerability
The vulnerability dimension had three items: vulnerability, susceptibility, and
healthiness. However, these items had low reliability when tested by Miczo et al. (2013), so
they suggested adding an item to assess a participant’s frequency of message exposure.
Following this guidance, the present study included one additional item to include frequency
21
as a component of the message vulnerability dimension because hearing the consequences of
a particular behavior from many sources might increase the degree of message vulnerability
and improve measurement reliability. Participants were asked how vulnerable, susceptible,
and healthy the message made them feel on a 1-5 scale where lower scores indicated more
vulnerability to the message and higher scores indicated less vulnerability. The frequency
item was assessed on a scale of 1-5 such that higher values indicated that the message was
received infrequently. A principle component factor analysis with oblique rotation was
conducted to assess the 4-items measuring message vulnerability. The factor analysis
produced an unsatisfactory Kaiser-Meyer-Olkin coefficient (KMO = .54) and indicated a
two-factor solution based on eigenvalues >1.0 that accounted for 78.90% of the common
variance. Results from the factor analysis indicated that the frequency item loaded on its own
factor (b = .96), so it was decided that the single-item frequency measure would serve as its
own discrete value. The remaining items were summated and treated as a one-dimensional
construct of message vulnerability ( = .78).
Message Topic
Previous memorable message research has constructed a coding scheme specific to
capture the topics of memorable messages relevant to their content (Kranstuber, Carr, &
Hosek, 2012; Miczo et al., 2013). This study referred to archival data and healthcare
professionals to generate 12 possible childbirth-related topics. Participants were presented
these items twice. In the first iteration, participants were asked to rank order these topics in
order of relevance to their most memorable message. In the second iteration, participants
were instructed to select all topics that had been embedded in a pregnancy-related memorable
message.
Emotional Arousal
To assess participants’ emotional arousal in response to hearing their most
memorable message, the 21-item Positive and Negative Affect Scale (PANAS: Watson &
Clark, 1999) was used. Respondents were asked to rate their response to the message (e.g.,
interested, distressed, excited, upset, etc.) on a 1-5 scale such that higher values indicated
greater activation of the emotion in question. A principal components factor analysis with
22
oblique rotation was conducted to assess the 21-items measuring emotional arousal. Given
that PANAS includes two factors, one related to positive and one related to negative
emotional arousal, a two- factor solution was requested. The analysis produced a satisfactory
Kaiser-Meyer-Olkin coefficient (KMO = .86) and the two factors accounted for 60.34% of
the common variance. The items loaded in accordance with the guidelines of Watson and
Clark (1999), forming one set of positive and one set of negative emotional responses. The
positive emotions scale was summated and had a good reliability ( = .92). The negative
emotions scale was summated and had a good reliability ( = .92).
Behavioral Health Intentions
There were seven items adopted from the Theory of Planned Behavior Questionnaire
(TPBQ; Azjen, 2002) that were used to assess participants’ behavioral intentions related to
the receipt of their most memorable message. This measure includes items intended to
measure expectant mothers’ health behavioral intentions including “I intend to eat healthier”,
“get more exercise”, and “take a prenatal class”. Response options included a 7 point scale
that ranges from 1=very unlikely to 7=very likely. A principal components factor analysis
with oblique rotation was conducted to assess the seven items measuring behavioral
intentions in response to the memorable message. The analysis produced a satisfactory
Kaiser-Meyer-Olkin coefficient (KMO = .79). Two components emerged with eigenvalues
>1.0 that accounted for 68.70% of the common variance, however, because the second factor
included only one item, “attend a prenatal education class,” the scale was collapsed into a
single dimension that was reliable ( = .83).
Behavioral Intentions
To understand how a memorable message may affect a woman’s behavior, three
items were adopted from the Implementation Intentions Scale (IIS) from Gollwitzer and
Brandstätter (1997) measuring implementation intentions and goal pursuit based on recalling
a message. Participants were asked, “When confronted with a reminder of (MOST
MEMORABLE MESSAGE) I try to follow the suggestions within this message”, “I intend to
do what the speaker of this message recommends”, and “I expect that this message will
provide me with wisdom and guidance”. Responses were based on a 7-point scale that ranged
23
from very unlikely (1) to very likely (7). A principal components factor analysis with oblique
rotation was conducted to assess the 7 items measuring behavioral intentions in response to
the memorable message. The analysis produced a Kaiser-Meyer-Olkin coefficient = .72. One
component was produced with eigenvalues >1.0 that accounted for 84.96% of the common
variance. Although the KMO value was modest, the factor loadings for individual items
indicated a high degree of internal consistency for the measure. Therefore to be consistent
with existing research with this scale (Gollwitzer & Brandstätter, 1997), the items were
summated and treated as a single dimension. Reliability analyses indicated that the scale was
reliable ( = .91).
After completing the survey, respondents were thanked for their participation and
given an opportunity to provide their email address to be entered in the drawing for a $50
Babies R’ US gift card.
24
CHAPTER 4
RESULTS
DESCRIPTIVE STATISTICS
All descriptive statistics reported here in were based on a total of 71 women included
in the final sample. Of this sample, the majority were non-expectant mothers (n = 27),
followed by first-time expectant women (n = 25), expectant women (n = 18), and other (n =
1). Before analyzing the hypotheses and research questions, a comparison analysis of these
groups was conducted to compare values on dependent and independent variables. Results of
a one-way ANOVA revealed no significant differences in any of these variables on the basis
of current pregnancy status (Table 1).
Table 1. Comparison Table of Participant Groups Based on Level of Experience with
Birthing
Variable
Not
Pregnant
Pregnant
1st Time
Pregnant
Not 1st
Other
F
Behavioral
Change
1.58 (.73)
1.63 (.63)
1.75 (.43)
1.73 (.32)
.28
Health SelfConcept
.23 (.26)
.34 (.16)
.18 (.16)
.27 (.26)
1.97
Positive Emotion
3.40 (1.16)
3.00 (1.00)
3.09 (.96)
3.44 (.93)
.70
Negative
Emotion
1.81 (.70)
2.08 (1.02)
1.68 (.60)
1.69 (.81)
.97
Vulnerability
3.79 (.96)
3.42 (1.30)
3.63 (1.02)
3.73 (1.09)
.45
Argument
Strength
5.79 (1.49)
6.03 (.99)
6.27 (1.20)
6.04 (.69)
.49
Message
Directness
4.80 (.50)
4.68 (.52)
4.50 (.82)
4.20 (1.04)
1.48
34.52
(33.64)
49.76
(58.15)
19.19
(17.76)
22.40
(11.65)
1.99
Word Count
25
The majority of the participants were European American or White (n = 61, 85.9%),
Latina (n = 5, 7%), Asian or Asian American (n = 5, 7%), African American or Black (n =
2, 2.8%), American Indian or Alaska Native (n = 1, 1.4%), and Middle Eastern (n = 1,
1.4%). In addition, three participants reported other ethnicities (4.2%), and one person
declined to indicate her ethnic origin. These percentages total more than 100 because
participants were allowed to select more than one ethnicity based on guidelines for
measuring race and ethnicity by the United States Office of Management and Budget (1997).
Participants’ age (M = 29.90 years, SD = 4.73) ranged from ages 16 to 39 years of age with
five participants aged 16 to 23, 30 aged 24 to 30, 25 aged 31 to 39, and one missing value.
Most women reported experiencing a low-risk pregnancy (n = 56), however, some
participants’ pregnancies (n = 15) were identified as high risk.
The average length of a conversation surrounding a woman’s most memorable
message was 22.46 minutes, however the top five most frequently reported conversation
lengths were 30 minutes (n = 12, 16.9%), 15 minutes (n = 11, 15.5%), 10 minutes (n = 11,
15.5%), five minutes (n = 10, 14.1%), and two minutes (n = 7, 9.9%). It is interesting to note
that the reported length of memorable message conversations ranged from zero minutes to an
hour and a half.
Participants were asked to type out their most memorable message so that they could
refer back to the specific message when responding to the rest of the questionnaire. A total of
n = 68 women provided their memorable message, and the average word count for the most
memorable message was 35.61 words (SD = 42.28). In terms of source frequency, most
women reported hearing their most memorable message from a family member (n = 23,
32.4%) or a friend (n = 23, 32.4%). The next most frequent source of a woman’s most
memorable message was the media (n = 6, 8.5%), then work colleagues (n = 5, 7%) or a
health practitioner (n = 5, 7%). The least reported source of memorable messages was a
woman’s spouse (n = 4, 5.6%), and other sources (n = 4, 5.6%). Means, standard deviations,
and intercorrelations of all measured variables appear in Table 2.
HYPOTHESES AND RESEARCH QUESTIONS
Research question one (RQ1) inquired about the common topics of pregnancy-related
memorable messages. For both general memorable message topic and most memorable
.21
.82
.27
1.85
Negative Emotion
1.05
25.91
3.23
Positive Emotion
.60
22.46
1.66
Behavioral
Intention
1.11
1.36
3.65
Vulnerability
.64
1.20
SD
2.49
4.65
Directness
Message
Frequency
Conversation
Length
Health SelfConcept
6.05
µ
Argument Strength
Variable
Table 2 Correlation Matrix
.09
.20
.04
-.36**
.58**
.56**
.25*
.38**
--
Arg.
Streng
th
.06
.26*
-.11
-.18
.24*
.20
.17
--
Directness
.12
.23
.03
.69**
-.44**
-.42**
--
-.02
.27*
.07
-.36**
.66**
--
Vulner- Behavio
ability
r Intent
-.04
.35**
.14
-.47**
--
Positive
Emotion
-.11
-.034
-.15
--
-.20
-.16
--
Negative Message
Emotion Freq.
-.11
--
Convo
Length
--
Health
SelfConcept
26
27
message topics, pain emerged as the most frequently-cited topic, see Table 3 for frequency
report of both categories of memorable messages.
Table 3. Topics of Most Memorable and All Memorable Messages
Topic
Most Memorable
%
Memorable
Messages
%
Healthcare Practitioner
4
5.8
22
31
Supportive Other
Healthcare Professional
2
--
2.9
--
35
27
49.3
38
Beginning Stages of Labor
1
1.4
24
33.8
Routine Obstetric Procedures
2
2.9
30
42.3
Invasive Procedures During Labor
3
4.3
32
45.1
Physical Labor
8
11.6
35
48.3
Pain
16
23.2
50
70.4
Epidural
5
7.2
34
47.9
Alternative Pain Coping Strategies
2
2.9
33
46.5
Emotional Labor
9
13
44
62
Emotion After Birth
9
13
37
52.1
NA or Other
8
11.6
2
2.8
Total
69
100
405
569.5
RQ2 and RQ3 inquired about the effects of topic (RQ2) and source (RQ3) on the
behavioral change and emotional arousal effects of memorable messages. In order to
examine these research questions, a series of three-way analysis of covariance (ANCOVA)
analyses was conducted with topic, source, and the topic-by-source interaction as categorical
variables, pre-pregnancy health self-concept as the covariate (to control for pre-pregnancy
health attitudes), and behavioral change and emotional arousal as the dependent variables.
The categorical variables used in these analyses were based on the aforementioned source
28
and frequency data; however, it was necessary to collapse several of the values into broader
categories for analysis. In terms of most memorable message topic, the twelve categories
were collapsed into the following four: pain (n = 23), emotional experience (n = 17), the
physical process of childbirth (n = 14), and the people involved in the birthing process (n =
6). In terms of message source, the aforementioned categories were collapsed into friend (n =
20), family (n = 19), and all other sources (e.g., spouse/partner, the media, healthcare
provider, n = 21).
In terms of memorable message topic, results of the first ANCOVA revealed no
significant main effects of topic, F(3, 60) = .19, p = .900, or source, F(2, 60) = 1.88, p = .164,
however, the interaction effect involving source and topic was significant, F(6, 60) = 2.45, p
= .039. In order to probe this significant interaction effect, the two categorical predictors
(topic with four categories and source with three categories) were collapsed into a single
categorical variable with 12 categories. This variable was then entered as the independent
factor in a one-way ANOVA and post-hoc analyses based on the Student-Newman-Keuls (SN-K) procedure were conducted. Results of the S-N-K analysis revealed that memorable
messages related to the people involved in the birthing experience (e.g., spouses/partners,
health care providers, etc.) that were received from non-friend and non-family sources
elicited lower levels of behavioral change (M = .61) than did memorable messages from
friends dealing with emotional aspects of childbirth (M = 1.89), memorable messages from
family dealing with pain (M = 2.00), and memorable messages from friends dealing with the
people involved in the birth experience (M = 2.11).
In order to examine the effects of memorable message topic on emotional outcomes,
the emotional arousal variables (positive and negative emotional arousal) were entered into
separate ANCOVAs given their strong negative correlation (Table 1). Results from the
positive emotion ANCOVA revealed no significant main or interaction effects (all ps > .05).
Likewise, the negative emotion ANCOVA revealed no significant main or interaction effects
(all ps > .05).
Taken together, these results suggest that, although neither the source nor the topic of
the memorable message produced any effect on behavioral change intentions or emotional
arousal on their own, the combined effect of source and topic did lead to differences in
expectant mothers’ behavioral change intentions.
29
Hypothesis one (H1) predicted that argument strength is positively related to both (a)
behavioral intentions and (b) emotional arousal. Results from the Pearson product-moment
correlation analysis revealed a positive relationship between argument strength (M = 6.05,
SD= 1.20) and behavioral intentions (M = 1.66, SD = .60), r (69) = .56, p < .001, and positive
emotional arousal (M = 3.23, SD = 1.05), r (68) = .58, p < .001 and negative emotional
arousal (M = 1.85, SD = .82), r (68) = -.36, p < .001. Taken together, these results suggest
that argument strength is positively associated with (a) a woman’s intention to follow the
advice within the message and (b) a woman’s positive emotional and negative emotional
arousal. The hypothesis is supported.
H2 predicted that directness is positively related to both (a) behavioral intentions and
(b) emotional arousal. Correlation analysis revealed the relationship between message
directness (M = 4.65, SD = .64) and (a) behavioral intentions (M = 1.66, SD = .60), r (66) =
.20, p = .051 was not significant, nor was the relationship between message directness and
(2b) negative emotional arousal (M = 1.85, SD = .82), r (66) = -.18, p = .076. However, there
was a significant relationship between message directness and (2b) positive emotional
arousal (M = 3.23, SD = 1.05), r (66) = .24, p < .05. Thus, message directness is not
associated with behavioral intent or negative emotional arousal but it is positively associated
with positive emotional arousal. H2 was partially supported.
H3 predicted that directness is correlated with conversation length. Correlation
analysis revealed a positive relationship between directness (M = 4.65, SD = .64) and
conversation length (M = 22.46, SD = 25.91), r (65) = .26, p = .03. Thus, the length of the
conversation that surrounds a memorable message affects the messages clarity and
directness. H3 is supported.
H4 predicted that vulnerability is positively associated with both (a) behavioral
intentions and (b) emotional arousal. Correlation analyses revealed a negative relationship
between vulnerability (M = 3.65, SD = 1.11) and (a) behavioral intentions, r (66) = -.42, p <
.001, as well as (b) positive emotional arousal, r (66) = -.44, p < .001. In contrast, negative
emotional arousal was positively associated with vulnerability, r (66) = .69, p < .001. These
results indicate that feeling vulnerable because of the content of a pregnancy-related
memorable message was strongly and positively associated with negative emotional arousal
30
and moderately and negatively correlated with behavioral intentions and positive emotional
arousal. Despite the significance of the correlations, H4 is only partially supported.
H5 predicted that message frequency is positively correlated with perceived
vulnerability. Correlation analysis revealed that there is no relationship between message
frequency and perceived vulnerability, r (69) = .03, p = .79. Thus, how frequently a woman
hears the same memorable message does not relate to how vulnerable she feels to the
principle or program level content of the message. The hypothesis is not supported.
H6 predicted that health self-concept is positively related to behavior intentions.
Correlation analysis revealed that there is no relationship between health self-concept (M =
.27, SD = .21) and behavior intentions, r (68) = -.02, p = .43 Thus, a woman’s health self
concept prior to becoming pregnant is not associated with how she intends to change her
behavior in response to a memorable message. H6 is not supported.
Hypothesis seven (H7) predicted that a woman’s health self-concept moderates the
relationship between negative emotional arousal and behavioral intention such that negative
emotional arousal and behavioral intentions will be positively associated when health selfconcept is positive and uncorrelated when health self-concept is low. This hypothesis was not
supported. A hierarchical linear regression tested the moderation effect of negative and
positive emotional arousal on behavioral intentions induced by a message. Analysis was
conducted in three stages based on the recommendations of Cohen, Cohen, West, and Aiken
(2003). The first stage involved creating mean-centered predictor variables to reduce any risk
related to multicolinearity. The second stage involved the creation of an interaction term
based on the product of the mean centered health self-concept and negative emotion
variables. In the last stage, one linear regression with two blocks of predictors was
calculated: the first was with the centered predictors and the second contained the interaction
term. Results from the overall model indicated that the model containing these three variables
predicted behavioral intentions, F (3, 68) = 3.72, p = .016; however, the only significant
predictor of behavioral intention was negative emotional arousal,  = -.38. Results from the
regression analysis appear in Table 4. These results mean that a woman’s pre-pregnancy
health self-concept does not affect whether a high degree of emotional arousal from a
message will induce behavioral intentions.
31
Table 4. Regression Results from Baseline Model and Hierarchical Model
Variable
B

T
Model 1 (Revised)
Health Self-Concept
Negative Emotion
Model 2
Health Self-Concept
Negative Emotion
HealthSC x NegEmo
R2
.12
-.18
-.28
-.07
-.38
-.57
-3.33*
.11
-.18
-.28
.18
-.07
-.38
.05
-.57
-3.32*
.44
32
CHAPTER 5
DISCUSSION
This study was an initial step toward understanding how memorable messages about
childbirth socialize women into having a certain set of expectations for their birth experience.
No matter what form memorable messages take, they present an important area of
investigation given their role in determining appropriate behavioral responses, a factor that
might be particularly salient when receivers of the messages face highly stressful situations
like pregnancy and childbirth. Results from the present study demonstrate several important
aspects of pregnancy-related memorable messages that influence their efficacy, each of
which will be discussed in turn.
In terms of the characteristics of the message, neither the topic nor the source (i.e.,
sender) of the memorable message exerted any effect on how the message was received.
Given that previous studies had shown some modest and inconsistent effects for these
message-related variables, it was somewhat surprising that neither variable was shown to
influence either expectant mothers’ behavioral intentions or their emotional arousal in
response to the message. In addition, it is particularly interesting that the interaction of these
variables did produce a modest effect. When considered collectively, memorable messages
related to the people involved in the birthing process received from non-friend and nonfamily sources produced the least change in behavioral intentions whereas memorable
messages from friends dealing with emotional aspects of childbirth, memorable messages
from family dealing with pain, and memorable messages from friends dealing with the
people involved in the birth experience all exerted a fairly strong effect on behavioral
intentions.
In terms of the rhetorical features of the memorable messages themselves, results
from the analysis revealed that strength, directness, and vulnerability each contributed to the
efficacy of memorable messages in different ways. Argument strength was positively
associated with a woman’s intent to follow the advice within the message and the woman’s
positive emotional and negative emotional arousal. Memorable messages with a clear and
33
specific purpose induced a positive emotional response, but nothing else. Additionally, the
more vulnerable the message made a woman feel, the less likely she was to respond
positively or change her behavior, even when the message was repeated several times.
Although vulnerability was associated with negative emotional arousal and a lack of intent to
change behavior, a regression analysis controlling for pre-pregnancy health concept revealed
that negative emotional arousal was the only significant predictor of intent to change
behavior. This suggests that there might be a distinguishing point of negative emotional
arousal that still induces behavioral change without going so far as to make a woman to feel
vulnerable to a message.
Memorable messages achieve behavioral guidance because of their ability to
influence sense-making processes that Slade et al. (2009) argue are culturally established
practices that help women adapt to the tasks of pregnancy. Women’s anticipation of
childbirth can evoke intense and ambivalent emotions (Slade et al., 2009) that result from the
conflict between her fundamental self-concept and her attributions of pregnancy; it is because
of this internal process of restructuring that women turn to intimate relationships for
guidelines that can assist her in the process of sense-making. For example, scholarship
investigating family behaviors and dynamics turns to narrative research as a way of capturing
communicated sense-making. Koenig-Kellas and Kranstruber (in press) identify memorable
messages as one approach to investigating communicated sense-making, a process they
defined as “the way people communicate to make sense of their relationships, lived
experiences, identities, and difficulties and how the content and process of communicated
sense-making affect and reflect health and well-being” (p. 81).
Although sense-making involves analysis of message content, some studies have
found that the actual content of the memorable message is less important than the sender’s
intent for sharing the message (Kranstuber et al., 2012). Results indicated that this might also
be true for childbirth memorable message because argument strength (which measures
perceived personal relevance of the message as well as source credibility) was associated
with both emotional arousal and intent to enact behavioral change. In addition, this study
found an association between level of message directness and both positive emotional arousal
and conversation length. This suggests that longer memorable message conversations have
greater implications for positive emotional arousal, and that although MM’s are sometimes
34
short (Knapp et al., 1981) they can also be longer narratives that serve as tools for
communicating sense-making (Koenig-Kellas & Kranstruber, in press). This has important
implications for how direct we make our conversations when sharing and exchanging advice.
While personal relevance, credibility, and conversation length are all positive characteristics
of memorable messages, induced vulnerability is not. This study found that the more
vulnerable a message made a woman feel, the less persuaded she felt to change her behavior
no matter how frequently she heard the same message. In addition, there was no relationship
between how healthy a woman was before her pregnancy and how likely she is to change her
behavior in response to a memorable message. Women who reported healthy habits prepregnancy do not appear to be any more sensitive to fluctuations in behavioral intent than
women who reported unhealthy habits pre-pregnancy.
An examination of the results revealed some interesting new findings, some are
consistent with similar studies of memorable messages and others are not. In the following
sections, memorable messages related to maternity and childbirth will be situated within the
broader framework of health-related memorable messages. From there, some tentative
conclusions about the role of memorable messages in health-related behavior change will be
offered. This discussion will also include a description of the strengths and limitations of the
current study before concluding with some reflections on childbirth-related memorable
messages.
THE ROLE OF MEMORABLE MESSAGES IN MATERNITY
HEALTHCARE BEHAVIOR
This research extends the integration of control theory and memorable messages into
another area of health communication research increasing the heuristic value of such an
approach: the collective experience of pregnancy and childbirth. Expectations are a difficult
latent concept to capture and predict because they involve capturing data that contain
complex beliefs and ideals connected to socio-cultural, neurobiological, and psychological
representations of the self and others (Slade et al., 2009). One of the primary goals of the
present study was to expand the current state of birthing research by measuring the principles
and behaviors that underlie memorable birthing messages, factors that in turn shape birthing
expectations. Previous birthing research consistently identifies the pain of childbirth as a
35
prominent concern of expectant women (Armstrong, 2000; Fremgen, 2001; Romano &
Lothian, 2008;). In support of those previous findings, data from the present study revealed
that more than 70% of the sample identified pain as a topic of memorable childbirth
messages; however, only 30% reported pain as the topic of their most memorable message.
Even though people heard a lot of pain-related messages overall, they were one of four
memorable message topics that were reported at about the same frequency as the most
important. One explanation is that during the reframing process, Fremgen (2001) says
women who are most adaptable to pregnancy tasks tend to hold on to information that helps
them positively restructure cognitions associated with childbirth. Since this positive
restructuring involves drawing the focus away from negative attributes of childbirth, women
might attempt to neglect thoughts and messages of labor pain which is why this topic
frequency does not carry over into their most memorable message.
Another possible implication of this focus on pain-related communication is the role
that memorable messages play in the management of uncertainty; Holladay (2002) posited
that people use memorable messages as a form of uncertainty reduction, learning and
generating knowledge on topics that induce the greatest amount of uncertainty. Given that
many women indicate that pain is their greatest pregnancy- and childbirth-related concern,
the exchange of memorable messages might represent a strategic action on the part of the
sender to provide a message of comfort or support to the presumably anxious recipient (see
Burlseon, 2009, for a discussion of support provision). If these messages are indeed being
offered to expectant mothers in an effort to assuage their concerns and reduce their anxiety, it
is important to note that salient message features often moderate the effectiveness of
supportive communication (Burleson, 2009; Goldsmith, 2004). In fact, Goldsmith (2004)
notes that the rhetorical strategy involved in the creation of a supportive message is one of
the most important factors to consider before attempting to enter into a discussion of
“troubles talk.” Toward that end, in order to reduce a woman’s degree of pregnancy-related
anxiety, Fremgen (2001) suggests that language used in association with pain should be
reframed by describing physical experiences of labor in levels of intensity versus the total
amount of pain to be expected. Rhetorically constructing memorable messages so that they
do not cause greater concern or panic—perhaps by focusing on factors like intensity rather
36
than pain—might be one way that would-be supporters could construct pregnancy-related
memorable messages that help instead of harm expectant women (Beck, 2004).
Topics of Childbirth Memorable Messages
One of the more surprising findings to emerge from the present study is that only four
participants reported healthcare professionals as the topic of their most memorable message.
A plethora of research has shown that healthcare professionals are an essential part of the
childbirth experience (Bick, 2003; Goodman, Mackey, Tavakoli, 2004; Hofberg & Ward,
2003; Maputle, 2010). When healthcare professionals develop an interdependent relationship
with the mother, studies show women have increased self-efficacy, empowerment, and
informed decision-making during childbirth (Hofberg and Ward, 2003; Maputle, 2010; Soet,
Brack, & Dilorio, 2003;) posit that it is imperative that healthcare professionals with an
interest in the mental health of a mother play a supportive role in childbirth because they are
trained to recognize pregnancy-related anxiety (i.e., tokophobia is the fear of childbirth) and
risk of suicide (the leading cause of maternal death). The fact that women do not often report
healthcare professionals as the topic of their most memorable message might indicate the
lack of agency a woman feels in obtaining the care that she wants (Lazarus, 1994). Due to
how the healthcare system is structured in the United States, socio-economic status limits
women’s choices in perinatal care as well as their ability to act on knowledge of childbirth
(Armstrong, 2000; Lazarus, 1994). It is interesting that when health professionals were the
topic of a woman’s most memorable message, the message was associated with a significant
level of behavioral intent. One potential explanation for this association is that, for a message
to be persuasive, it must include directions for how to avoid a threatening situation. It is
possible, that unlike messages about pain (which were not associated with behavioral
change), messages about healthcare professional contain explicit directions for how to enact
behavior that will bring about the desired birth outcome.
Sources of Childbirth Memorable Messages
In addition, it is important to know to whom women are listening to when it comes to
their prenatal healthcare decisions. Despite the credibility of their position, this study found
that healthcare professionals are unlikely to be a source of women’s most memorable
37
childbirth messages. These findings are consistent with research of memorable messages in
other healthcare contexts (Miczo et al., 2013; Smith et al., 2009), which also found that
physicians are not a frequent source of memorable messages, but that instead, interpersonal
sources (e.g., family and friends) are the most likely source of a most memorable message
and induce behavioral change. The absence of association between women’s most
memorable message and healthcare professionals is consistent with research on family birth
narratives (Koenig-Kellas & Kranstuber, in press) and family systems theory (Pecchioni &
Keeley, 2013) that women are not as strongly influenced by their provider as much as they
are by their social network. Theory about the role of family communication in health
contexts suggest that this is because families are a system through which people are told
stories to socialize members’ expectations for healthcare-related experiences (Koenig-Kellas
& Kranstuber, in press; Pecchioni & Keeley, 2013). It is important then, that we seek to
understand how to utilize this relationship to disperse effective prenatal education so that
women are receiving balanced information.
MESSAGE DIMENSIONS AND INTENTION TO ENACT
BEHAVIORAL CHANGE
To progress theoretical implications suggested by Miczo, et al. (2013) the following
conclusions about memorable message dimensions in childbirth are summarized. Overall the
adjustments to each dimensions resulted in satisfactory outcomes.
Argument Strength
This study found that memorable messages with a high level of argument strength
(i.e., from a credible source and personally relevant to the receiver) were associated with
greater emotional arousal and intention to make behavioral changes. Research shows that
persuasive arguments are stronger when they are personally relevant (Petty & Cacioppo,
1986; Zaichkowsky, 1986) because they encourage interest and motivation (Munson &
McQuarrie, 1987). The extended parallel process model (EPPM: Witte, 1992) posits that
personal involvement and source credibility are antecedents to engaging the listener in a
narrative, both cognitively and emotionally, which then results in elaboration of the
persuasive message and influences attitude and behavioral change (Bilandzic & Busselle,
2013; Slater & Rouner, 2002). Although argument strength was significantly associated with
38
emotional arousal and behavioral intent, some studies have found that the actual content of
the memorable message is less important than the sender’s intent for sharing the message; the
extent to which a receiver is aware of such intent might be that factor which motivates and
engages the message receiver (Kranstuber et al., 2012). The significance of source credibility
in childbirth memorable messages is consistent with previous research that memorable
messages are often received from sources with a higher social status who are older than the
receiver (Barge & Schlueter, 2004). Given that the argument strength dimension emerged as
a strong and consistent predictor of both emotional arousal and behavioral change intentions
in the present study, future studies examining the role of memorable messages on pregnancyand childbirth-related expectations should delve deeper into understanding the features of the
sender, context, and relationship that lend credibility to these memorable messages.
Message Directness
Results also indicated that the clarity and directness of memorable message content
results in more positive emotional arousal but does not necessarily influence a woman’s
intention to change her behavior. One potential explanation for this finding is that directness
does not allow the same degree of narrative involvement as a longer message embedded
within another’s testimony. It is important to note that previous studies are conflicted over
whether narrative is more persuasive than direct information such as statistic or directions
(Bilandzic & Busselle, 2013). The third hypothesis perpetuates this inconsistency by
suggesting that directness increases as the length of a conversation increases, so it still cannot
be concluded whether shorter or longer messages induce more emotional arousal or
behavioral intention. The only clarification gained concerning directness is that longer
memorable message conversations are associated with message clarity and positive
emotional arousal. There is no indication that message clarity influences behavioral change
or negative affect.
Perceived Vulnerability
In addition, feelings of vulnerability induced by a memorable message were
associated with increased levels of negative arousal and lower likelihood of behavioral
change; these are the opposite of theoretical predictions based on cognitive dissonance and
39
control theory. Control theory suggests that when a message makes a person experience
dissonance (i.e., negative affect or cognitive conflict), it will trigger their principle and
program level process to negate the tension by changing either their beliefs or behavior until
the conflict is resolved (Carver & Scheier, 1982). However, in contrast the results of this
study suggest that when a woman experience cognitive dissonance in response to a
memorable message, she becomes resistant to processing the message and in turn is less
likely to change her behavior to accommodate the principle embedded in the message
content.
Another possible explanation for why memorable messages are associated with
negative emotional arousal and decreased behavioral intent can be culled from the EPPM
(Witte, 1992), which theorizes that emotional and cognitive processes occur simultaneously
and that fear appeals can induce both emotional fear as well as an adaptive cognitive
response (Leventhal, 1970). However, as Witte (1992) explains, fear appeals are only
persuasive when the message also indicates how the receiver can adapt their behavior to
avoid the threat. In the context of the present study, it might be that some memorable
messages overwhelmed hearers’ ability to process and adapt to the threat posed by the
message, leaving them in a state of fear-induced inaction. For example, memorable messages
about the pain of birth might only induce behavioral change if the message provides advice
for how to avoid a painful labor. This advice must also be something that the woman feels
she is capable (i.e., self-efficacious) of achieving (Witte, 1993). Future studies of pregnancyrelated memorable messages should consider examining the extent to which these messages
promote fear over efficacy as one possible explanation for their varied effectiveness.
Health Self-Concept, Emotional Arousal, and
Behavioral Intent
Women’s health self-concept before pregnancy was not significantly associated with
pregnancy-related behavioral change induced by a memorable message. Control theory posits
that when a message causes dissonance between a woman’s self-concept and her current
behavior, the program level cognitive processing should motivate her to negate this
dissonance by changing her behavior; see Figure 1 for theoretical model of control theory in
childbirth memorable messages (Carver & Scheier, 1982). Thus far, the use of control theory
40
as a theoretical framework to understand how people enact health protective and maintenance
behaviors in response to a memorable message has been useful (e.g., Ellis & Smith, 2004;
Miczo et al., 2013; Smith & Ellis, 2001). However, the fact that the two self-concepts were
not significantly associated may indicate that women’s non-expectant health concept and
pregnancy self-concept are so disconnected that childbirth messages do not interact with the
mother’s previous health identity. While this is not theoretically supported, childbirth might
potentially signal a separation from a woman’s previous health self-concept such that she is
redefining her health behaviors for her new pregnant identity. Fremgen (2001) explains that
pregnancy is a psychological process of reorganizing self-representations into a maternal
identity. The neurological and psychological process that occurs during pregnancy makes
birth a healthcare context where negating identity might be inconsistent with other health
contexts using control theory. Even though the degree of actual behavioral change based on
previous health self-concept was a not significant, as aforementioned this study found
significant associations between message features and behavioral intentions.
STRENGTHS, LIMITATIONS, AND CONCLUSIONS
This study presents a number of strengths and limitations that should be given
consideration. First, this study adds to the growing body of research on the influence of
memorable messages on healthcare-related behaviors by investigating how memorable
messages are influencing childbirth expectations. Second, this study furthers the theoretical
development of memorable messages by offering measures that can potentially by used to
capture underlying message constructs in a variety of contexts. When investigating the
structure of memorable messages, such as rule based content or topicality, measuring the
messages personal relevance to the receiver is relatively rare despite the fact that studies
(Holladay, 2002; Kranstuber et al., 2012) have demonstrated the degree of personal relevance
significantly influences negative or positive emotional arousal. Since memorable messages
can be either general or specific to the receiver, it is important that future memorable
message research measure the degree to which personal relevance determines effectiveness
of a memorable message at inducing behavioral change.
One of the most significant contributions of the present study to MM research is the
validation of message-related measures of memorable message effectiveness. The memorable
41
messages collected in this study were categorized based on source, content, context, and
form, which have previously lacked valid measures. This study expanded Miczo et al.’s
(2013) three dimensions of influential health messages and retested their relevance in the
context of pregnancy- and childbirth-related memorable messages. Previous studies have
primarily used interpretative methods to identify sources, perceived intent of the sender,
topic, and response to the message (Barge & Schlueter, 2009; Ellis & Smith, 2004; Holladay,
2002; Smith & Ellis, 2001; Smith et al., 2009). Although quantifying how the components of
memorable messages might induce behavioral change, Miczo et al. (2013) reported the
reliability of their message-related measures as a limitation of their study. By combining the
items recommended by Miczo et al. (2013) with additional measures to develop the argument
strength dimension, the revised scales captured facets of memorable messages that further
our understanding of how these variables interact with emotional arousal, behavioral
intention, and health self-concept. The three overarching message dimensions affectively
implement what we currently know about persuasive messages and interpersonal
communication. By retooling Miczo et al.’s (2013) message dimensions into a self-report
format instead of a coding scheme, this study offers future researchers the opportunity to
continue working on validating scales that reliably measure memorable message
characteristics in a variety of different health contexts.
Limitations
This study is limited by the cross-sectional nature of the data, longitudinal data would
be able to measure how the effect of memorable messages change from the beginning of a
woman’s pregnancy until immediately after giving birth. It is possible that a longitudinal
design might show that women become immune to memorable messages and advice giving
as they advance in their pregnancy. Having during and post-pregnancy information might
also allow the data to capture a woman’s changing self-concept, to observe whether selfefficacy increases or negative attributes of childbirth decrease. In addition, the nature of cross
sectional data means that how recently a woman has heard the memorable message may
influence the intensity of her response to it. To see if a woman’s most memorable message
changes several time throughout her pregnancy is impossible with cross sectional data.
Furthermore, some challenges with collecting data from a hard-to-reach population should be
42
addressed as well the resistance of health professionals in assisting with research and data
collection. This study sought a diverse population of participants, however, despite efforts to
post on childbirth forums associated with each individual state, ethnic diversity was not
achieved. The results of this study are limited to a mostly Caucasian population. In addition,
since limited demographic information was collected, the effects of socio-economic status on
the relationship between behavioral intent and perceived self-efficacy to enact behavioral
changes is unknown. An additional factor that limited the socio-economic diversity of this
sample was the refusal of non-profit medical offices and clinics to allow the placement of
recruitment fliers in the waiting areas. Data collection was successful largely because of the
cooperation of private practices who allowed fliers in the waiting area; a partnership with a
large retail store that allowed the study to be presented in several prenatal education classes;
and a local yoga studio where the owner personally agreed to announce the study at the
beginning of prenatal yoga classes. Attempts to work with other local professionally-trained
prenatal educators at community centers such as the YMCA were not successful.
Conclusions
Whereas some memorable message studies focus on the measurement of current
behavior (Ellis & Smith, 2004; Smith et al., 2009), this study focused on two dimensions—
one current, one future—of pregnancy-related memorable messages: how a woman should
prepare for birth to meet her expectations and how messages are influence her projected selfconcept. Although there is some methodological criticism of measuring behavioral intent
versus enacted behavior, in the context of healthcare, this study used the theory of planned
behavior which is an established theory used to predict and explain behavioral change in
response to health conditions (including childbirth) where the nature of the condition is
temporary or fluctuating (Ajzen, 2002; Godin & Kok, 1996). In addition, if we can
understand what women’s intentions are, we will know what behaviors are impressionable
with the least amount of intervention. Assessing behavioral change intention as a tipping
point toward a set of behaviors can help illustrate which behaviors might be the easiest to
persuade mothers to engage or not engage in.
43
Implications for Health Practitioners
Within a healthcare context, practical application of this research can improve the
ways in which practitioners address patients by helping conversations begin from a place of
understanding based on the messages that women received before or during prenatal care.
Knowing that memorable messages are recalled for a long period of time with great accuracy
(Knapp et al., 1981), practitioners might consider how engrained the beliefs and values
presented in this research are within a woman’s self-concept. Two ways practitioners might
attempt to prevent undesirable prenatal expectations are to address common memorable
messages and follow up with patients after childbirth. In terms of addressing common
memorable messages, when women are presented with faulty or flawed information about
pregnancy and/or childbirth, educating these women with more accurate information might
help to dispel some of their concerns. In terms of after-birth follow up, taking the time to
discuss the birthing process with women might prevent future misguided memorable
messages about the experience. The experience of childbirth varies between individuals, but
social influences can propagate fear and anxiety that is important to address before a woman
gives birth (Fremgen, 2001; Hofberg & Ward, 2003). Information that can help create a birth
environment that decreases fear, anxiety and stress has important implications for perinatal
outcomes. If memorable messages can be reframed to reduce expectations of pain,
powerlessness, and disembodiment in the mother’s conceptualization of labor, we can bring
childbirth literature one-step closer to the idealized birth experience.
44
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