Language Matters: Effects of Linguistic Agency Assignment on HPV Prevention Advocacy in Chinese Public Health Education Materials

"It is...possible that the use of agentic language may be an important element in a wide range of health promotional materials and in many different linguistic and cultural contexts, including locations where individuals are not well-informed about a particular disease or infection."

Studies on public knowledge and awareness of cervical cancer, human papillomavirus (HPV), and HPV vaccines in Mainland China indicate the need to raise awareness about HPV prevention. Researchers studying the design of health-related educational materials have looked at "linguistic agency", or points of view in narrative health messages. Because language is strongly associated with cultural and societal features, it is possible that the persuasive effects of linguistic agency may be affected by cultural beliefs and societal attitudes. The current study examines the effects of linguistic agency assignment on HPV prevention advocacy in Chinese public health education materials. Based on the findings, recommendations are provided for the design of public health-related materials to help promote education about HPV.

The assessment of the potential effects of agentic language is based on the extended parallel process model (EPPM), which includes four elements of effective health message design: threat severity; personal susceptibility; self-efficacy; and response efficacy. As the EPPM suggests, when individuals perceive efficacy to be high, they are likely to engage in danger control responses by adopting the behavioural changes designed to protect them from the threat.

As discussed in the literature on agentic language, people tend to perceive that a health threat is an active entity and that its associated risks are beyond their control. Consistent with this argument, assigning threat agency to a virus or pathogen was shown to lead to higher levels of perceived severity, susceptibility, and fear arousal compared with the assignment of agency to human factors. Individuals may feel less capable of managing the threat by themselves when the disease is perceived as an active predator. Thus, it is possible that fear may propel individuals to seek protection by choosing a vaccine or other recommended solution rather than relying on their own abilities.

The participants (n = 481) - native Chinese speakers residing in China - were asked to read one of four versions of a 2-page article about the HPV infection. All stimulus materials were translated and back-translated into Chinese. The threat agency in the articles described HPV transmission in one of two ways: (1) by human factors (e.g., "people can contract HPV in a single act of unprotected intercourse"); (2) by the virus (e.g., "HPV can take advantage of a single act of unprotected intercourse"). In the immunisation agency, the HPV vaccine was attributable to either human factors (e.g., "people can effectively guard themselves with vaccines") or to vaccines (e.g., "vaccines can effectively guard people").

Almost 90% (n = 430) reported they had not been vaccinated for HPV at the time of the study, and a majority of the participants had not talked with a doctor about HPV in the past (92.7%, n = 446). (Many participants (73.4%, n = 353) reported they were more interested in receiving the HPV vaccine after they read the article that was part of the study.) During the data collection process, the researchers received several anonymous emails from participants who stated their concerns about HPV. Examples are as follows: "I had never heard of HPV before", and "I had no idea HPV could cause cancer". Their comments confirmed researchers' concerns about the low literacy level about HPV in China.

Echoing previous research, the study found that a health threat was considered more consequential when it was assigned to the virus rather than to human factors. In other words, when the threat agency was ascribed to HPV rather than human factors, the participants reported higher levels of fear arousal after reading the educational materials, which may have led to higher levels of the perceived effectiveness of the HPV vaccine and a more positive attitude toward vaccination. This finding is consistent with the EPPM, which assumes that the cognitive appraisal of a health threat is important for individuals to accept messages.

Some cross-cultural issues are discussed. For example, because HPV infection is a type of sexually transmitted infection (STI), there may be public concerns that vaccinating adolescents is seen as encouraging early sexual activity and promiscuity. Chinese culture is deeply rooted in Confucianism, whose teachings point out that excessive sexual desire leads people to lose their relational behaviour, resulting in the collapse of their family as well as the collapse of society. Furthermore, sex is a culturally sensitive topic in Confucianism. However, based on collectivist cultural values, it is possible that individuals would become less likely to worry about the guilt and shame associated with discussions about topics related to sex if they understood the serious potential consequences of HPV and if individual behaviour became herd behaviour based on mandatory vaccinations.

In conclusion, the findings of this study may contribute to the health communication literature by explaining the persuasive power of language and demonstrating that the concept of linguistic agency assignment is applicable across cultures for the promotion of public health education.