Uncovering Factors Influencing Interpersonal Health Communication

Communicative Objectives

When interacting with others, people always pursue one or more objectives or goals (Clark & Delia, 1979). In that sense, interpersonal communication can be seen as reasoned, goal-oriented behavior (Southwell & Yzer, 2007, 2009); Clark and Delia (1979) identified three types of objectives that can explicitly or implicitly be distinguished in every communicative situation: (a) instrumental objectives, which focus on “the task of the communicative situation”; (b) interpersonal objectives, “involving the establishment or maintenance of a relationship with the other(s)”; and (c) identity objectives, “in which there is management of the communication situation to the end of presenting a desired self-image for the speaker and creating or maintaining a particular sense of self for the other(s)” (p. 200).

Clark and Delia (1979) indicated that multiple objectives can be prevalent in the same communicative situation. In Goldsmith’s (2001, 2004) “normative theory,” it is assumed that within a certain context, people often have multiple objectives at the same time that can conflict. This can create a complex communication situation (O’Keefe, 1988). How the hierarchy of different types of communication objectives is organized is not always clear-cut. Sometimes one has to weigh the need of communicating something effectively against the likelihood of damaging the relationship with the other person (DeTurck, 1985; Sillars, 1980). In interactions, the concept of face, or “the public self-image that every member [of a society] wants to claim for himself” (Brown & Levinson, 1987, p. 61), is particularly relevant. When making requests, for instance, people want their request to be efficacious, but they also want to maintain the face of the conversation partner, as well as their own face (Dillard, 1990).

Goffman (1959) compared participants in interaction with actors on stage, who are constantly aware of the presence of an audience in the things they do and say. He described how individuals in interaction engage in “impression management,” to create a desired impression, or face, of themselves, and also how individuals in interaction work as a team to help each other maintain face (Goffman, 1959, 1967); participants in interaction are thus continually doing “face work” to protect their own face and that of the other participants (Goffman, 1955). Dillard, Segrin, and Harden (1989) indicated that in a communicative situation, one might pursue interaction goals, concerned with social appropriateness, impression management, and avoiding face threats to all participants in the interaction. The concept “face” can be of importance for both interpersonal objectives, concerned with the relationship between the participants of the interaction, and identity objectives, concerned with managing the self-image of the speaker.

Objectives in Interpersonal Health Communication

The distinction between instrumental, interpersonal, and identity objectives discussed above can also be applied to interpersonal health communication. One might, for instance, want to instruct a child how to put on sunscreen, or wish to persuade a friend to quit smoking. In these examples, instrumental objectives are important: The main objective of the communicative act is to help the other person improve his or her health. Furthermore, in interpersonal health communication, objectives concerning the self-image or the relationship might be at play, which can conflict with the instrumental objective of, for example, persuading someone to change his or her smoking behavior. When addressing sensitive health issues, like safe sex, for instance, one might believe it is more important to maintain one’s own face and that of the conversation partner, thus preventing possible damage to the relationship, rather than effectively bringing up the health topic (Allen, Emmers-Sommer, & Crowell, 2002). In other words, in some cases, people might believe it is more important to maintain a good relationship over the short term than to prevent health risks over a longer term (Cline, Freeman, & Johnson, 1990).

Research Question

As described above, we aimed in the present study to explore factors that influence interpersonal health communication of people before they have been exposed to a health campaign. We did not have a strict hypothesis, and therefore speak of an “explorative study” in this article. We aimed to gain more knowledge about the kinds of conversations people have about health issues and the reasons they give for (not) having these conversations, for the purpose of providing greater insight into both health communication research and practices regarding factors that should be taken into account when designing health messages that aim to trigger conversations. As Southwell and Yzer (2007) have stated, “To harness motivations [for conversations] for campaign purposes, we need frameworks with which to predict conversational occurrence.” With the current article, we attempt to contribute to such a framework. To that end, we formulated the following research question:

Participants

In this study, we aimed to get a broad view on (self-reported) communication behavior. To that end, we selected 12 Dutch participants varying in sex, age, and level of education: Six participants were men and six were women; six participants were younger than 25 and six were older than 50; six participants had a low level of education and six had a high level of education. ¹ With this composition, we could make comparisons between maximally varying groups of participants in our data analysis. We used no specific criteria for participant selection. We recruited participants through a snowball method, starting from our personal network, and in this way, we composed a convenience sample. We contacted participants personally by email or telephone, and asked whether they wanted to participate in the study. All received a financial compensation of 10 euros (about US$11) for their participation, and provided informed consent prior to their participation.

After conducting and analyzing 12 interviews, we identified four types of communication behavior, which are the main focus of the rest of this article (see the “Results” section). These four types of communication behavior were confirmed in the rest of the interviews, indicating thematic saturation.

The Interviews

All 12 interviews were conducted, audio-recorded, and transcribed verbatim (following, for example, Edwards, Donovan-Kicken, & Reis, 2014) by the same trained interviewer. The interviewer conducted all interviews in the homes of the participants. The interviews were semistructured and contained questions regarding when, why, and with whom participants actually talked, or would talk, about the health themes: “(drinking) alcohol,” “healthy eating,” “exercising,” “smoking,” “safe sex,” and “safe tanning.” We deemed these themes relevant to a wide audience when talking with different conversation partners, such as friends, family, or romantic partners. Alcohol, for instance, is a theme that can be discussed among adolescents when drinking together, but also between parents and children when talking about the dangerous consequences of excessive drinking.

In every interview, we addressed a number of questions for each health theme: “Do you ever talk about this theme? Why, with whom, and in which situations?” and “Would you talk about this theme? Why, with whom, and in which situations?” In this way, we ensured that we addressed both the self-reported communication behavior and the intentions of participants to talk about health issues. ² Furthermore, we asked follow-up questions that picked up on answers that participants gave, to gather more information on their communication behavior. An example of a follow-up question was, “And did people talk to you about this afterward?” in response to a participant sharing an anecdote about drinking too much alcohol when going out. During the interviews, the interviewer invited the participants to talk about the issues addressed in the interview in their own words and manner. In a few cases, participants needed some encouragement from the interviewer to talk more extensively about a theme.

We removed any information linking to the identification of participants, for example, names, from the transcripts. The mean duration of the interviews was 28 minutes (SD = 9 minutes). Each health theme was addressed separately in each interview, resulting in a total of N = 72 “interview sections” that could be analyzed. We conducted the interviews in Dutch and translated the examples discussed in the rest of this article into English. ³

Analysis of the Interview Data

We analyzed the interview data using basic elements of grounded theory (Strauss & Corbin, 1998). Two coders were involved in each of the coding steps. ⁴ The interview data were first divided into codable information units, consisting of the response of each participant to each interview question or each follow-up question, to preserve the context and meaning of participants’ utterances (cf. Helme et al., 2011). Next, in the “open coding” step, the information units were labeled according to the information they contained. Examples of labels were “easy topic of conversation” or “afraid to address drinking behavior of friend.” The final dataset consisted of N = 462 labels, which were then categorized in the “axial coding” step. This coding step was performed by discussing and comparing labels in multiple meetings over a period of several weeks, resulting in six categories and their definitions, discussed in the “Results” section. After defining the categories, both coders separately categorized the labels according to those definitions, which resulted in a substantial agreement (kappa = .75). ⁵ Labels that both coders did not agree on were discussed, until full agreement was reached.

We secured the credibility of the findings by systematically comparing observations within and across study participants before finalizing the categorization of the data (Charmaz, 2006; Thomas & Magilvy, 2011). We continued this process until thematic saturation was reached, and no new categories emerged from the data. Furthermore, multiple coders were involved in each step of the coding process, each of whom was to reach full agreement in the labeling and categorization before moving on to the next step. Finally, the two coders searched for representative examples of the categories across the interview data (Yeshua-Katz & Martins, 2013), which we discuss in the next section of this article.

Admonishing

The first type of communication behavior that we distinguished was admonishing, which occurs when someone urges a conversation partner to change his or her health behavior, for example, when telling someone they should not drink alcohol. Admonishing mainly seemed to serve instrumental objectives, that is, “getting something done” through the interaction. Participants admonishing someone appeared to feel “obliged” to communicate their message, even if this did not improve their own health outcomes: They not only indicated that they admonished a smoker who smoked in their proximity, which would improve their own health outcome, but also admonished parents who did not put sunscreen on their small child, which would not improve their own health outcome. Furthermore, in a more subordinate position, admonishing appeared to serve interpersonal and identity objectives. When admonishing the conversation partner, he or she may experience this as a face threatening act which could possibly lead to damage to the relationship. Admonishing the conversation partner could also result in the face of the self being threatened because of the risk of being seen as a nuisance. Still, participants seemed to feel a moral obligation to admonish other people rather urgently, as evidenced by the many instances of “admonishing” in Table 1.

A factor influencing the occurrence of admonishment was the health theme. The results in Table 1 indicate that participants most often admonished someone when it concerned the health theme of “safe tanning.” The results in Table 1 furthermore indicate that participants most often did not admonish someone when it concerned the health theme of “exercising,” followed by “smoking.” Participants did not think that “safe tanning” was a very difficult topic about which to admonish someone, as is shown in the following example:

I think this is one of the easier things, because then you can eh, without directly, when someone is too fat, then they could feel hurt or something about it, but like . . . “Don’t sit in the sun too long, don’t you know that’s not good for you?” “Dry skin, shouldn’t you put something on that?” All examples of how to say something about this. (Participant 12)

For “exercising,” the person admonished might feel attacked about his or her weight or looks. Admonishing someone about his or her exercising behavior is thus more direct and perhaps more sensitive, in which case interpersonal and identity objectives might be more prevalent than instrumental objectives.

The occurrence of admonishment furthermore seemed to be influenced by the conversation partner, that is, the person being admonished. The results in Table 1 suggest that participants most often admonished friends and that they most often did not admonish strangers. This indicates that, for admonishing, the social proximity of the conversation partner plays a role. It may be more appropriate to admonish someone in a socially proximate relationship, such as a friend, than to admonish someone in a socially distant relationship, such as a stranger.

Another factor influencing the occurrence of admonishment appeared to be participants’ characteristics. In Table 2, we show participants’ self-reported communication behavior on health themes arranged according to participant characteristics. The results in Table 2 indicate that older participants more often than younger participants do not admonish someone, as in the following example concerning “alcohol,” in which an older participant expresses a fear of reprisal:

. . . Nowadays you can get hit easily. Then they say: “What’s it to you?” So you don’t bring it up. It’s like when someone is destroying something, that you’d say “Don’t do that.” “What’s it to you?” Because people are different than they used to be of course. They hit other people more easily. . . . Or they get angry. That they say: “Hey oldy, mind your own business!” (Participant 7)

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Table 2.

Number of Information Units in Which Participants Differing in Characteristics Mentioned Talking About Health Issues or Not Talking About Health Issues (Number Between Brackets), Categorized by Type of Communication Behavior.

Participant Characteristics	Admonishing	Casual Talk	Educating	Negotiating	Total
Gender
Men	32 (52)	50 (57)	9 (8)	4 (2)	95 (119)
Women	28 (54)	60 (38)	7 (6)	3 (0)	98 (98)
Age
Younger participants	31 (45)	47 (47)	0 (0)	5 (0)	83 (92)
Older participants	29 (61)	63 (48)	16 (14)	2 (2)	110 (125)
Level of education
Low education	23 (55)	56 (35)	3 (4)	2 (0)	84 (94)
High education	37 (51)	54 (60)	13 (10)	5 (2)	109 (123)

The results in Table 2 furthermore suggest that participants with a high level of education admonish someone about their health behavior more often than participants with a low level of education. The participants’ gender did not seem to be related to the occurrence of admonishment.

Casual Talk

For casual talk, like gossiping, small talk, or casual exchange of information, the main concerns of the participants did not seem to be with instrumental objectives, as with admonishing behavior. Rather, casual talk appeared to arise from interpersonal and identity objectives; that is, it concerned maintaining a good relationship with the conversation partner and maintaining a positive self-image. In several cases, for instance, we found that participants thought it was easier or more pleasant to talk with like-minded people about a specific health theme. The example below, on the theme of “smoking,” illustrates that the main objective of the participant is to maintain a positive self-image, by being among like-minded people and thus likely not to violate social norms, and to maintain a good relationship with the conversation partner(s) by gossiping about an out-group.

The occurrence of casual talk appeared to be influenced by the health theme that was the topic of communication. In Table 1, we see that participants most often indicated a willingness to talk, but also to not talk (e.g., with a different conversation partner) casually about the health theme “safe sex.” Furthermore, participants appeared to talk casually about “safe tanning,” and not to talk casually about “exercising.” In the following example, a participant refers to casual talk about “safe sex”:

Another factor that was found to influence the occurrence of casual talk is the conversation partner. As we can see in Table 1, participants most often (do not) seem to talk casually with friends. Whereas participants indicated that they talked casually with friends about some health topics, they indicated they did not talk casually with friends about other health topics, as in the following example, where a participant mentions not talking casually with friends about “safe tanning”:

. . . getting sun burnt, that’s something for the short term, so everybody takes this . . . into account. But I never talked about this with friends, like: “Then I might get cancer in the far away future.” (Participant 5)

Participants furthermore appeared to talk casually with family and acquaintances, and not with strangers. This suggests that participants might mainly talk casually with conversation partners with whom they wanted to maintain a good relationship, that is, someone they already know.

Furthermore, the occurrence of casual talk seemed to be influenced by participant characteristics. The results in Table 2 show that older participants more often than younger participants indicated that they talked casually about health issues. Furthermore, the results in Table 2 suggest that participants with a high level of education indicated that they did not talk casually about health issues more often than participants with a low level of education. Moreover, the results in Table 2 suggest that women participants talked casually more often than men participants, whereas men participants mentioned not talking casually more often than women participants.

Another influencing factor regarding the occurrence of casual talk was the conversation context or, more specifically, the presence of someone in the communicative situation whom the topic personally concerns. In Table 3, it is indicated in n = 54 cases that it matters whether a person whom the topic personally concerns is present in the communicative situation and that this determined whether or not participants talked casually about a health issue. In n = 181 cases, this did not seem to matter in determining whether or not to talk casually about a health issue. An example on the health theme “healthy eating” when the presence of a person whom the topic personally concerns does matter is as follows:

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Table 3.

Number of Information Units in Which Participants Indicated That It Does or Does Not Matter Whether Someone Is Present in the Communicative Situation Whom the Topic Personally Concerns, Categorized by Type of Communication Behavior.

	Admonishing	Casual talk	Educating	Negotiating	Total
Matters	120	54	5	6	185
Does not matter	62	181	30	4	277
Total	182	235	35	10	462

This example indicates that the presence of a person whom the topic personally concerns might matter when this personal relevance is obvious or visible, such as when this person is obese. It might be more difficult to estimate whether a person has an alcohol addiction or has skin cancer, for instance.

Educating

For educating, as for admonishing, the main concern of participants appeared to be with instrumental objectives, that is, with getting the conversation partner to perform healthy behavior. Although this objective is the same as for admonishing, educating might occur more indirectly, that is, through providing the conversation partner with information on which to base his or her decision to adapt or not to adapt health behavior. Furthermore, educating seemed to be used preventively, whereas admonishing seemed to be used when the conversation partner was already performing unhealthy behavior. Again, as with admonishing someone, interpersonal and identity objectives were found to play a role, creating a struggle between the wish to be effective and the wish to prevent damage to the relationship, and damage both to own identity and that of the other person. In the following example, a participant talked about his wish to educate his children effectively on “safe sex,” even if they felt uncomfortable talking about this issue:

. . . I think it’s easier to talk with my children about that than the other way around. That’s the way the relationship is defined. You don’t talk about sexuality with your parents, but your parents think they should talk about this with you . . . it’s better to have said this once too many than once too little. Better safe than sorry. (Participant 11)

A factor determining the occurrence of educating was the health theme. The results in Table 1 indicate that educating is most common for the health theme of “safe sex.” The results in Table 1 furthermore show that participants gave reasons to not educate someone about the health theme of “safe tanning,” as in the following example:

. . . I talked about this in the summer, with my wife. That you should protect yourself against that, against too many sunbeams. Not with my kids, they don’t listen anyway. (Participant 10)

Another influencing factor in the occurrence of educating was the conversation partner. The results in Table 1 indicate that participants mentioned educating only in the context of children. This indicates that whereas for casual talk the relationship between conversation partners was mainly horizontal, as between friends, for educating the relationship between conversation partners was vertical, as between parents and children. The following example describes a parent educating her children about “alcohol”:

. . . and I can tell my own kids, like: “Don’t drink so much!” Or: “You know that’s bad for you, your brains will be damaged, you’re not going to be fit, what you’re doing in the weekend will bother you for three days,” things like that. But it’s always in a kind of mother role of course, like eh, mothers always have something, right. That’s partly fear that something will happen to your kids, and in general of course. (Participant 12)

Furthermore, the occurrence of educating appears to have been influenced by participant characteristics. The results in Table 2 suggest that only older participants mentioned educating, which can be explained by the fact that the older participants all had a child or children, whereas none of the younger participants did. Furthermore, the results in Table 2 indicate that participants with a high level of education more often mentioned educating than participants with a low level of education. The gender of participants did not appear to influence the occurrence of educating behavior.

Negotiating

For negotiating, as for admonishing and educating, the main concern of participants appeared to be with instrumental objectives, in this case with getting both the self and the conversation partner to perform healthy behavior. Furthermore, as with admonishing and educating, interpersonal and identity objectives were found to play a role, for example, when negotiating about an issue increases the risk of damage to the relationship or to own identity.

A factor influencing the occurrence of negotiating was the health theme. The results in Table 1 indicate that participants only mentioned (not) negotiating about the health theme of “safe sex.” Another influencing factor in the occurrence of negotiating was the conversation partner. The results in Table 1 furthermore indicate that participants only mentioned (not) negotiating with their partner or sexual partner, as in the following example:

This health theme might be the only one in which both conversation partners stand to gain the same advantage from the communicative act: that is, maintaining their sexual health. This type of communication behavior, thus, only occurs with a conversation partner that is highly socially proximate, and with whom the relationship is horizontal: namely, the sexual partner. Participant characteristics did not appear to influence the occurrence of negotiation behavior.