Barriers to health appeals

This is my summary/translation of the article Abwehrreaktionen auf Gesundheitsappelle: Forschungsstand und Praxisempfehlungen by Hastall, 2012.

Against threatening or disturbing messages we have defensive processes, in order not to get thrown into a (unhealthy) state of frenzy every time we encounter one. These defensive processes are understood as motivated reactions, responses to health-appeals that take up resources when three criteria are met (Hastall, 2012).

  1. The response follows directly after contact with the message
  2. The response is based on defensive measures; it is meant to reflect an anticipated threat (e.g. threats to feelings of self-worth or emotional well-being)
  3. The response is aimed directly or indirectly at avoiding the message or attacking the content of the message

We can distinguish four different groups of defensive responses that might inhibit effective health marketing/communication:

  1. Avoiding or minimising contact with threatening messages
  2. General psychological ego-defence mechanisms
  3. Attacking the content of the message or the messenger
  4. Increased health-damaging behaviour

Modern man has developed advanced avoidance strategies for online marketing messages of any kind to such a degree that we completely miss the advertisements on a website (a concept known as banner-blindness) and we install ad-blocking software, spam filters and the like to assist us in avoiding unsolicited content. Modern psychoanalysis and clinical psychology defines defence mechanismsas unconscious processes meant to protect an individual from fear and recognition of internal or external burdens and threats. A defence mechanism does this by regulating the response of the individual to emotional conflict and external burdens (Wittchen/Hoyer, 2011). Over 40 such processes have been discerned and are commonly and continually applied by individuals in their daily lives (Cramer, 2008). The mechanisms of denial, repression and rationalisation seem especially important in the health domain (Hastall, 2012).  For example; illusory superiority bias describes the constant overestimation of our positive aspects and the subsequent underestimation of our negative aspects. Combining this bias with unrealistic optimism and false consensus bias leaves many well intended health messages unattended to, because they are deemed ‘not relevant’ to us.

Table: Health marketing defence mechanisms (Hastall, 2012)

Avoiding or minimising contact with threatening messages
Selective message avoidance Complete avoidance of messages or turning away the attention after brief/short and unconscious contact
Banner blindness Selective advertisement avoidance specific to websites. While visually scanning the site, the anticipated  advertisements are visually faded out
Technical defence Using technical solutions to avoid contact with unwanted messages, such as AdBlock or a spam filter
Legal defence Prohibiting advertisements or joining a revocation list e.g. Robinson-list
General psychological ego-defence mechanisms
Denial Not considering or denial of aspects in reality that threaten ones’ existence, such as health risks
Repression Displacing threatening aspects of reality in ones’ subconscious
Rationalisation Inventing seemingly reasonable explanations to justify threatening thoughts, feelings or behaviours
Illusory superiority effect Overestimating ones’ positive qualities in comparison to others, while simultaneously underestimating ones’ negative qualities
Unrealistic optimism Believing that one will be affected less by negative occurrences and more by positive occurrences than other people
False consensus effect Overestimating the proportion of people that share ones’ viewpoint on a certain topic
Attacking the content of the message or the messenger
Selective interpretation Reinterpreting the content of the message in such a way that it harmonises with ones’ views and beliefs
Counter arguments Generating arguments that counter the propositions of a message and the recommendations made e.g. by looking for information stating the opposite
Source devaluation Devaluating the source of a message e.g. by insinuations of incompetence or unreasonable intentions
Aggression Verbal or physical  attacks on the messenger, the message or the medium carrying the message e.g. tearing down health related placards
Advantageous social comparison Comparing oneself to person who are worse off or are behaving worse than you in order to feel better about oneself and to diminish the necessity of a behaviour or attitude change
Social validation Looking for persons with similar attitudes and behaviours and emphasizing the high number of corresponding people
Heightened attractiveness of critical aspects Health damaging behaviours are seen as more attractive after contact with the message than before contact with the message
Increased health-damaging behaviour
Boomerang effect Message provokes the opposite of the intended goal e.g. smoking more after contact with a anti-smoking message
Taking psycho-active substances Taking alcohol, nicotine, drugs or medication after contact with the message in order to pacify oneself or shift thoughts

Should a possibly threatening message get through the first line of defence mechanisms and manage to get itself consciously considered, attack strategies might come into play. Findings that confirm this course of thought and action are aggregated from research into cognitive dissonance (Festinger, 1957), psychological reactance (Brehm, 1966; Dillard & Shen, 2005) and resistance (Jacks & Cameron, 2003).

Strategies to lessen the resistance

There are two neurological systems working in parallel: BIS and BAS (e.g. Carver et al. 2000; Gray, 1982). The Behavioural Inhibition System; looking for potential threats and possible dealing with them through various defence mechanisms – and the Behavioural Activation System; looking for cues for potential positive experiences. BIS concerns itself with (our protection from) negative emotions. Any message that intends to trigger certain health behaviours would do well to address both systems, simultaneously trying to minimize BIS while maximizing BAS (Knowles & Linn, 2004) Minimizing the threat– All health related sciences tend to take the perspective of the ‘Natural model’ of health vs. disease and mainly focus their efforts on the physical. However, a health related message can be perceived as threatening on more levels than just as it relates to our physical manifestation. All the possible levels of threat must be discerned if they are to be minimized.

Table: Threats by health marketing (Hastall, 2012)
Target of threat Anticipated health relevant conditions
Reading messages on health risks Anxiety of health risks Execution of the recommended protective behaviour
Body Physical discomfort when reading the message Pain, reduced capabilities, death Physical strain; side effects
Cognition Worry about the likelihood of the disease Worry about the likelihood of healing Worry about the effectiveness of the protective behaviour
Emotion Fear or dread at reading the message Sorrow about those concerned; fear Feelings of shame or uncertainty
Self-worth “Manipulation” by marketing messages Dependent on outside help; passive layman Self-perception as vulnerable or overanxious
Social status Non-compatible role expectations Loneliness; Blaming others as accomplices Being ridiculed or rejected by others
Resources Time or expenses looking for more information Time or expenses for necessary treatment Time or expenses for protective behaviour


Brehm, J. W. (1966): A Theory of Psychological Reactance, New York: Academic Press. Carver, C. S., Sutton, S. K., & Scheier, M. F. (2000). Action, emotion, and personality: Emerging conceptual integration. Personality and social psychology bulletin26(6), 741-751.
Cramer, P. (2008): Seven Pillars of Defense Mechanism Theory, in: Social and Personality Psychology Compass, 2, 5, S. 1963-1981
Dillard, J. P./Shen, L. (2005): On the Nature of Reactance and Its Role in Persuasive Health Communication, in: Communication Monographs, 72, 2, S. 144-168.
Festinger, L. (1957): A Theory of Cognitive Dissonance, Stanford: Stanford University Press.
Gray, J. A. (1982). The neuropsychology of anxiety: An enquiry into the functions of the septo-hippocampal system. New York: Oxford University Press.
Hastall, M. R. (2012). Abwehrreaktionen auf Gesundheits-appelle: Forschungsstand und Praxisempfehlungen. In S. Hoffmann, U. Schwarz & R. Mai (Eds.), Angewandtes Gesundheitsmarketing (pp. 281-296): Springer Fachmedien Wiesbaden. Jacks, J. Z.
Cameron, K. A. (2003): Strategies for Resisting Persuasion, in: Basic & Applied Social Psychology, 25, 2, S. 145-161 Knowles, E. S.
Linn, J. A. (2004): Approach-Avoidance Model of Persuasion: Alpha and Omega Strategies for Change, in: Knowles, E. S./Linn, J. A. (Hrsg.): Resistance and Persuasion, Mahwah: Psychology Press, S. 117-148.
Wittchen, H.-U./Hoyer, J. (2011): Klinische Psychologie & Psychotherapie, Berlin: Springer.

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Greater self-efficacy

Self-efficacy is a persons’ belief in their capability to perform any task. When looking at self-efficacy we are not so much loooking at how correct this assesment is, but rather we are interested in the belief of the person.


We can enhance our sense of self-efficacy in four ways (Bandura, 1994, 2004, 2006b):

Mastery experience,
Social models,
Social persuasion and
Reappraisal of somatic and emotional state.

Our success experiences build up our sense of self-efficacy while experiencing failure lowers our self-efficacy. However, if our successes are too easily achieved our built up self-efficacy collapses at the first unexpected setback. A robust sense of self-efficacy comes from the experience of overcoming obstacles; good mastery experiences require effort.

We can judge what effort we expect to lead to what results in our own behaviour, by observing the behaviour of others. This social modelling depends highly how similar we judge the people we are looking at to ourselves. The more alike we think we are, the more our self-efficacy shifts depending on the efforts and results of the other. We look for social models that display the skills we desire and try to learn ways to achieve such skills from them.

Psychological boosts by social persuasion are easily deflated by reality and do not provide any resilience over time. However, persuading people that they are capable can create just enough of an increase in effort and commitment that it might lead to a successful mastery experienceSocial persuasion is most successful when it focuses on teaching how to structure situations to maximize the chance of success and by prompting to measure success in terms of self-improvement instead of comparison to others.

We often interpret our physical responses and our mood-state as related to our capabilities in a negative way while this need not be the case. Persons with a high sense of self-efficacy can interpret a state of arousal as a motor to action whereas persons with a low sense of self-efficacy can interpret the same state as an obstacle to action, or even an indication to cease all efforts (Brooks, 2013). Learning to Reappraise your somatic or emotional state from negative (I am anxious) to positive (I am excited) can increase self-efficacy. Read more on reappraisal here: Keep your arousal high

Bandura, A. (1994). Self‐efficacy: Wiley Online Library.
Bandura, A. (2004). Health promotion by social cognitive means. Health education & behavior, 31(2), 143-164.
Bandura, A. (2006a). Guide for constructing self-efficacy scales. Self-efficacy beliefs of adolescents, 5(307-337).
Bandura, A. (2006b). Toward a psychology of human agency. Perspectives on psychological science, 1(2), 164-180.
Brooks, A. W. (2013). Get Excited: Reappraising Pre-Performance Anxiety as Excitement.

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Different theories on humour

Aggression, incongruity, and arousal-safety are the three explanatory mechanisms that most humour theories rely on.

When a joke attacks an individual or group, this is considered an aggression based joke. These kind of jokes usually contain a lot of stereotypes that are considered to be funny and popular (Zillmann & Cantor, 1976). Jokes of this nature have two important goals: one is to gain solidarity of the joker with the audience and the second one is to exclude a (victimized and ridiculed) target group (Norrick, 2003). Even when an aggressive element is clearly present, the social “meaning” of the joke is often to be found at a deeper level (Ritchie, 2005).

Giora’s (2003) salience hypothesis provides a more detailed account of humourous incongruity. According to Giora people access the most salient meaning first. Humour exploits this tendency by providing an account consistent with a highly salient interpretation; the punch line forces us to revisit initially activated but still contextually suppressed concepts. A crucial feature of Giora’s account is the prediction that jokes involve not merely a surprise ending, but active suppression of the original interpretation.

Yus (2003) also mentions the punch line of a joke as being the most salient. It’s about discovering the congruous elements. The tension and the relief will come after the meaning of the joke is figured out. This is called the arousal-safety theory. This theory explains the relief of  ‘getting it’. But what is the humourous effect in this? Sperber and Wilson (1986) argue that according to relevance theory, searching a relevant context ceases with the first interpretation that provides an adequate balance of effects for efforts.  The punch-line at the end  makes this initial interpretation go away and activates a new interpretation, based on an entirely different context (Giora, 2003).Yus suggests that the realization that one has been fooled by the joker, coupled with “a positive interaction of the joke with the addressee’s cognitive environment” helps explain the humourous effect.

Reasons to laugh

Laughing is not always a result of humour; according to relief theory, people sometimes laugh because they need to reduce physiological tension (Meyer, 2000). Relief theory assumes that laughter and mirth result from a release of nervous energy.

According to superiority theory, people laugh because they feel some kind of triumph over others or feel superior to them (Meyer, 2000). From this perspective humour has a primarily emotional function, helping the humourist to build confidence and self-esteem (Buijzen & Valkenburg, 2004). Laughter and mirth appear when one feels a certain superiority towards the other who is inferior, weak and defeated. Ridicule and making fun of those who are less fortunate, are typical themes of humour covered by superiority theory (Buijzen & Valkenburg, 2004).

From the perspective of incongruity theory, people laugh at unexpected or surprising happenings. According to this theory, it is the unexpected that comes up which provokes humour in the mind of the receiver. Rather than focusing on the physiological (relief theory) or emotional (superiority theory) function of humour, incongruity theory emphasizes cognition. It assumes that the cognitive capacity to note and understand incongruous events is necessary to experience laughter or mirth. The main themes here are absurdity, nonsense, and surprise.


Excerpt from Humour theories: Schadenfreude in the media. Literature review, 2008.

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Another interesting distinction in game genres or game types is that of Exergames. Broadly speaking ‘exergames’ are all games that are controlled by bodily movement. Think of a game of virtual tennis, bowling or raft racing (Wii) and games like Dance Dance Revolution.

“Recently videogames that use physical input devices have been dubbed “exergames” — games that combine play and exercise.” (Bogost, 2005)

There was – and sometimes still is – concern that playing all these videogames is making us less physically active. Video games over the years have moved from the arcades of the 1970’s and 1980’s to desktops or game consoles in our living rooms, as well as to mobile platforms in our pockets. This means that we went from playing games (mostly) while standing up, slamming on big buttons and rattling a joystick to playing games (mostly) while sitting down and manipulating smaller buttons or keys with our fingertips (Bogost, 2005). By adding to our screen-time and our sedentary lifestyle, gaming was thought to be bad for our health and especially the health of our young people (Vandewater, Shim, & Caplovitz, 2004). In a time when the problem of child-obesity is of epidemic proportions, these concerns seem relevant. So eyes and hopes were turned to promoting a different method of game interaction; still on a screen but obliging the player to move around in order to control the game. Exergaming seems like a promising solution to the threat of sedentary gaming.

In order for all exergaming to work, some sort of sensoring is required. Sensors that can capture our bodily movements became more advanced and cheaper – making their way from research and therapeutic settings into peoples’ homes. Exergames are now used voluntarily in many living rooms, where the physical interaction is not viewed as ‘exercise’ but the whole game experience is viewed as entertainment.

Interacting with an exergame requires a certain expenditure of energy – more than a sedentary screen based interaction would – but not to the same amount as the original physical interaction that is being mimicked in the game environment (Daley, 2009).

Bogost, I. (2005). The rhetoric of exergaming. Proceedings of the Digital Arts and Cultures (DAC).
Vandewater, E. A., Shim, M.-s., & Caplovitz, A. G. (2004). Linking obesity and activity level with children’s television and video game use. Journal of adolescence, 27(1), 71-85.
Daley, A. J. (2009). Can exergaming contribute to improving physical activity levels and health outcomes in children? Pediatrics, 124(2), 763-771. doi: 10.1542/peds.2008-2357

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DEAL WITH IT / Serenity

One of the things out there that can give us more insight into coping by breaking a few things down is the structure of Primary and Secondary Appraisal (Chesney, Neilands, Chambers, Taylor, & Folkman, 2006). These are the two connected processes of looking at a situation to see if it is stressful and then deciding how to deal with it (being of aware of these two processes and being able to purposefully direct them would be meta-cognition).

Primary Appraisal is where we ask ourselves “Do I care?”. If we think that yes, this does matter to us and that this might take a lot of resources than the situation is judged as possibly stressful.

If so, secondary appraisal begins by asking “What can I do about it?”. Immediately tapping into your sense of control – or not – and your sense of self-efficacy – or not. It matters here that you value yourself and your skills and you recognize the abilities you have and foresee yourself applying them with vigour. It also matters that you see the situation for what it is and make a realistic judgement about how much of it can be changed. By you or by anyone else.

Secondary Appraisal continues into “What am I going to do about it?”. The answer to this question is your selected coping strategy – and more effort is not always the right answer. Sometimes in life there is really not much we can change about a situation. You would be better of trying to deal with it differently instead of trying to change it. There is no predetermined right or wrong coping strategy because it always depends. Mostly it depends on how much control you can have and how many resources you have available, emotional or otherwise.

When you choose a coping strategy that matches the amount of control you have, we call this ‘adaptive coping’ and this leads to fewer negative psychological symptoms than ‘maladaptive coping’ (Park, Folkman & Bostrom, 2001). Adaptive coping might mean that you select to do nothing because there is nothing that can be done, except deal with how you feel about it.

In my opinion this Secondary Appraisal process is most eloquently expressed in the Serenity Prayer (Reinhold Niebuhr, 1892-1971), famously used by Alcoholics Anonymous:

God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.


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Rehabilitation thinking for games in health

Designing and researching games in health has underlayers of models we (unwittingly) hold on what rehabilitation should be  – and held within this our concepts of disability – driving our design decisions or the questions we ask.

Rehabilitation: all measures that aim to lessen bodily, mental or psychological disability or social isolation or the effects thereof and to guide those afflicted by it (back) into society

(Franke, 2010).

Following this definition every measure that was intended to lessen suffering should be thought of as rehabilitation. It would follow that any measure intended to rehabilitate someone is ‘rehabilitation’ regardless of the effect of such a measure, at the same time the definition does not leave room for measures that might not have been intended to rehabilitate but in effect lessen a person’s disability. Here we find the same hopeful designer-driven definition as we do in Serious Games versus the more effect driven definition of Serious Gaming (see my chapter Understanding Serious Gaming for more on this).

In the application of gaming in rehabilitation we can often recognise INTEGRATION and even SEGREGATION thinking. Supposedly, a subgroup of humans (the disabled) is in need of games that are different from games for ‘normal’ people. In this line of thinking segregation occurs for example when hard- and software platforms are especially built for the disabled. An integration approach would be to build different games for the disabled but using the same platform as ‘normal’ players.

When a game is prescribed as part of a therapy – when the game is on a device made exclusively for the disabled and the gameplay is entirely focused on rehabilitative action, than these games adhere to the MEDICAL or NATURAL MODEL. In this model of thinking disease is an opposite state to health and never the twain shall meet. The SALUTOGENESE MODEL views health and disease not as a dichotomy but as a gliding scale (Lindstrom, 2010). In this model every person at every moment in their lives is healthy to some extend and unhealthy to some extend. So even when we are diagnosed as diseased (by the medical model) there are parts of our lives in which we are healthy. Thinking within either the medical or the salutogenese model leads to a different approach of the player and possibilities for gameplay. One can approach the design as for the ‘disabled’ or for a ‘player with a disability’.

Some definitions of disability concern the limitations in the expression of individuality, normality, adaptation and differentiation (Franke, 2010). Games can allow for all different kinds of expression by their designers and by their players. They move in between the realms of art, exploration, creation and learning.  There are different ways in which mediated games could be used to bend limitations of expression that disabled people might struggle with. A game designed in such a way that the experience of a disabled person may be shared with any another human being connects the gameplay to the Right of Community and Participation (Franke, 2010).

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Keep your arousal high

We often think of the responses of our body and our emotional state as linked to our performance. “My heart is racing. I am terribly nervous because I am no good at…..”. However, this is not necessarily a valid conclusion. ‘Nervous’ is a combination of a physical state (aroused) and an emotional one (anxious) which is attached to a moral judgement of your behaviour (no good). Seems logical. But the response of our body could have been attached to a different judgement, accompanied by a different emotion and it would seem just as logical. “My heart is racing. I am all pumped up and ready to go rock this….”. You still have an aroused physical state but with a positive emotion (excitement) and the moral judgement turns the other way (all good).

One of the factors determining the likelihood of you going emotionally one way or the other is your sense of self-efficacy. People with a high sense of self-efficacy tend to see arousal as some extra push by their body, a trigger to ACT. People with a low sense of self-efficacy interpret the same arousal as an obstacle. A sign to stop and sit down until the arousal goes away or even worse, they take it as a sign that their capabilities are insufficient and that they cannot possibly do this.

The advice we get to combat nervousness and plummeting self-esteem often targets our level of arousal: sit down and take a few breaths – in through your nose, down to your belly button and out your mouth. Sound familiar? You could also, perhaps more effectively, leave your arousal where it is and try to change your emotional state by focusing on what is going to make this a positive experience for you. Connect it to some core value you have, play with it and shape it in some way you would actually enjoy experiencing it.

Most importantly focus on that which YOU believe you can do – connect it to where your self-efficacy is highest and start shaping it from there. Keep your arousal high and let it work for you. Your higher heart rate makes you more alert and gives all your senses a boost to perform at their best. It is the same experience of an athlete, crouched down and ready to race.

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