Improving Health Literacy Responsiveness: A Randomized Study on the Uptake of Brochures on Doctor-Patient Communication in Primary Health Care Waiting Rooms.

Presenting attractive and useful health education materials in waiting rooms can help improve an organization's health literacy responsiveness. However, it is unclear to what extent patients may be interested in health education materials, such as brochures. We conducted a three-week field study in waiting rooms of three primary care centers in Groningen. Three versions of a brochure on doctor-patient communication were randomly distributed, 2250 in total. One version contained six short photo stories, another version was non-narrative but contained comparable photos, and the third version was a traditional brochure. Each day we counted how many brochures were taken. We also asked patients (N = 471) to participate in a brief interview. Patients who consented (N = 390) were asked if they had noticed the brochure. If yes (N = 135), they were asked why they had or had not browsed the brochure, and why they had or had not taken it. Interview responses were categorized by two authors. Only 2.9% of the brochures were taken; no significant association with brochure version was found. Analysis of the interview data showed that the version with the photo narrative was noticed significantly more often than the non-narrative version or the traditional version. These results suggest that designing attractive and comprehensible health materials is not enough. Healthcare organizations should also create effective strategies to reach their target population.

Using Photo Stories to Support Doctor-Patient Communication: Evaluating a Communicative Health Literacy Intervention for Older Adults.

Older adults often have limited health literacy and experience difficulties in communicating about their health. In view of the need for efficacious interventions, we compared a narrative photo story booklet regarding doctor-patient communication with a non-narrative but otherwise highly similar brochure. The photo story booklet included seven short picture-based stories about themes related to doctor-patient communication. The non-narrative brochure had comparable pictures and layout and dealt with the same themes, but it did not include any stories. We conducted two Randomized Controlled Trials (RCTs) among older adults with varying levels of health literacy: one RCT in Germany (N = 66) and one RCT in the Netherlands (N = 54); the latter one was followed by an in-depth interview study among a subset of the participants (81.5%; n = 44). In the RCTs, we did not find significant differences between the photo story booklet and the non-narrative brochure. In the interview study, a majority of the participants expressed a preference for the photo story booklet, which was perceived as recognizable, relevant, entertaining and engaging. We conclude that photo story booklets are a promising format but that there is room for improving their effectiveness.

"Hey, that could be me": The role of similarity in narrative persuasion.

Stories are often used in health communication because of accumulating evidence of their potential to affect people's attitudes and health behavioral intentions. Similarity between the reader and the story's protagonist appears to positively influence narrative persuasion, but the exact role of similarity on persuasive outcomes is debated, as some research finds clear effects of similarity manipulations whereas others do not. Possibly, these mixed results were found because the similarity manipulations were not always relevant to the topic of the story. We conducted an experiment (N = 582) in which we varied the age and gender of the protagonist, features that were of central relevance to the story's topic, namely breast cancer versus testicular cancer. There were two groups of participants: 324 students (mean age: 21.46 years) and 258 older adults (mean age: 56.83 years). Age similarity (but not gender similarity) had an effect on identification with the protagonist, transportation (i.e. the experience of being absorbed into a story), and the intention to donate, but only for students. For older adults, age or gender of the protagonist did not seem to matter, as nearly no differences in persuasive measures were found. As far as the underlying mechanism is concerned, the results of structural equation modeling showed that the concept of 'perceived similarity' would be a relevant addition to models of narrative persuasion, as it was significantly related to the narrative processes of transportation and identification, which, in turn, predicted attitudes and behavioral intentions, both directly-in the case of transportation-or indirectly, via the emotion of compassion. We conclude that both manipulated and perceived similarity are important for narrative persuasion, and that it should be kept on the research agenda of health communication.

Sweet Temptations: How Does Reading a Fotonovela About Diabetes Affect Dutch Adults with Different Levels of Literacy?

Recent studies suggest that health-related fotonovelas-booklets that portray a dramatic story using photographs and captions-may be effective health communication tools, especially for readers with a low level of literacy. In this experiment, effects on knowledge and behavioral intentions were assessed of a fotonovela originally developed for a Latin-American audience. Dutch readers from a low literacy group (N = 89) and a high literacy group (N = 113) were randomly assigned to one of three conditions: a fotonovela condition (all captions translated into Dutch), a traditional brochure condition (also in Dutch), and a control condition. On knowledge about diabetes, participants in the fotonovela condition outperformed participants in both other conditions. This finding was consistent across literacy levels. On behavioral intentions, however, readers of the fotonovela did not score significantly higher than participants in the other conditions. We also evaluated hypotheses proposed in the Entertainment Overcoming Resistance Model (EORM; Moyer-Gusé, 2008) on the possible mechanisms underlying persuasion through narratives. No support was found for the mechanisms proposed in the EORM. The outcomes of this study suggest that a fotonovela may be a valuable health education format for adults with varying levels of literacy, even if it was developed for a target group with a different cultural background.

Using a narrative to spark safer sex communication.

OBJECTIVE: College students are a group at risk for contracting sexually transmitted infections (STIs). While they are generally well informed about STIs, they do not consistently use condoms. An important element in preventing STIs is safer sex communication, especially with a sexual partner. This may be difficult, however, because of a lack of experience in talking about safer sex or because of the absence of suitable role models. In this study, a narrative intervention was tested that was developed to provide receivers with a social script for safer sex communication. DESIGN: An experiment was conducted among college students (N = 225) who were exposed to either a narrative intervention or a non-narrative (brochure) intervention, followed by a post-test questionnaire. In the narrative condition, part of the participants completed a pre-test questionnaire before being exposed to the intervention. RESULTS: Compared to pre-test scores, the narrative positively influenced safer sex communication intentions. The results show no significant differences between post-test scores of the narrative and the non-narrative condition. Mediation analyses showed that narrative processes (identification and transportation) were positively related to safer sex communication. CONCLUSION: In this study, we investigated both the effects of a narrative intervention on safer sex communication intentions, and the mechanisms of narrative processing underlying these effects. The narrative turned out to be as effective as a brochure version with the same information. Our mediation analyses suggest that narratives can be made more persuasive by increasing the reader's involvement with the story as a whole, and with one of the characters in particular.

Uncovering Factors Influencing Interpersonal Health Communication.

Talking to friends, family, or peers about health issues might, among other things, increase knowledge of social norms and feelings of self-efficacy in adopting a healthier lifestyle. We often see interpersonal health communication as an important mediating factor in the effects of health campaigns on health behavior. No research has been done so far, however, on factors that influence whether and how people talk about health issues without being exposed to a health campaign first. In this exploratory study, we interviewed 12 participants about their communication behavior concerning six different health themes, like smoking and exercising. The results suggest that at least four types of interpersonal health communication can be distinguished, each influenced by different factors, like conversational partner and objective of the conversation. Future research should take this diversity of interpersonal health communication into account, and focus on designing health campaigns that aim to trigger dialogue within target populations.

A Neurocomputational Model of the N400 and the P600 in Language Processing.

Ten years ago, researchers using event-related brain potentials (ERPs) to study language comprehension were puzzled by what looked like a Semantic Illusion: Semantically anomalous, but structurally well-formed sentences did not affect the N400 component-traditionally taken to reflect semantic integration-but instead produced a P600 effect, which is generally linked to syntactic processing. This finding led to a considerable amount of debate, and a number of complex processing models have been proposed as an explanation. What these models have in common is that they postulate two or more separate processing streams, in order to reconcile the Semantic Illusion and other semantically induced P600 effects with the traditional interpretations of the N400 and the P600. Recently, however, these multi-stream models have been called into question, and a simpler single-stream model has been proposed. According to this alternative model, the N400 component reflects the retrieval of word meaning from semantic memory, and the P600 component indexes the integration of this meaning into the unfolding utterance interpretation. In the present paper, we provide support for this "Retrieval-Integration (RI)" account by instantiating it as a neurocomputational model. This neurocomputational model is the first to successfully simulate the N400 and P600 amplitude in language comprehension, and simulations with this model provide a proof of concept of the single-stream RI account of semantically induced patterns of N400 and P600 modulations.

Development of a Communication Intervention for Older Adults With Limited Health Literacy: Photo Stories to Support Doctor-Patient Communication.

Successful doctor-patient communication relies on appropriate levels of communicative health literacy, the ability to deal with and communicate about health information. This article aims to describe the development of a narrative- and picture-based health literacy intervention intended to support older patients with limited health literacy when communicating during their primary care consultations. We performed a formative evaluation that included a review of the literature and interviews with stakeholders on relevant health literacy issues, qualitative studies with the target group, intervention planning, and a small-scale evaluation. Cocreation with the target group was a major component. Seven photo stories were developed incorporating principles from narrative and social learning theory and covering communication themes and strategies identified during focus group discussions and role-play exercises. The intervention was developed in 3 different formats: 1-page photo stories, narrated video clips using the original photo story pictures, and interactive video clips covering participation and communication during primary care consultations. In our small-scale evaluation, older adults considered the cocreated intervention appealing and comprehensible. The intervention shows promise for improving the health of older adults but needs further evaluation. This study provides a rigorous template for the participatory development of health literacy interventions.

Comprehensibility of Health-Related Documents for Older Adults with Different Levels of Health Literacy: A Systematic Review.

A systematic review was conducted to assess the available evidence for the effectiveness of interventions aiming to improve the comprehensibility of health-related documents in older adults (≥50) with different levels of health literacy. Seven databases were searched (2005 forward), and references in relevant reviews were checked. The selection procedure was conducted by 2 independent reviewers. Data extraction and assessment of the quality of the resulting studies were conducted by 1 reviewer and checked for accuracy by a 2nd reviewer. A total of 38 intervention studies had a study population of older adults (n = 35) or made an explicit comparison between age groups, including older adults (n = 3). Inconsistent evidence was found for the importance of design features to enhance the comprehensibility of health-related documents. Only for narratives and multiple-feature revisions (e.g., combining revisions in textual and visual characteristics) did the included studies provide evidence that they may be effective for older adults. Using narrative formats and/or multiple-feature revisions of health-related documents seem to be promising strategies for enhancing the comprehensibility of health-related documents for older adults. The lack of consistent evidence for effective interventions stresses the importance of (a) replication and (b) the use of standardized research methodologies.

When correction turns positive: processing corrective prosody in Dutch.

Current research on spoken language does not provide a consistent picture as to whether prosody, the melody and rhythm of speech, conveys a specific meaning. Perception studies show that English listeners assign meaning to prosodic patterns, and, for instance, associate some accents with contrast, whereas Dutch listeners behave more controversially. In two ERP studies we tested how Dutch listeners process words carrying two types of accents, which either provided new information (new information accents) or corrected information (corrective accents), both in single sentences (experiment 1) and after corrective and new information questions (experiment 2). In both experiments corrective accents elicited a sustained positivity as compared to new information accents, which started earlier in context than in single sentences. The positivity was not modulated by the nature of the preceding question, suggesting that the underlying neural mechanism likely reflects the construction of an interpretation to the accented word, either by identifying an alternative in context or by inferring it when no context is present. Our experimental results provide strong evidence for inferential processes related to prosodic contours in Dutch.

Referential choice across the lifespan: why children and elderly adults produce ambiguous pronouns.

In this study, children, young adults and elderly adults were tested in production and comprehension tasks assessing referential choice. Our aims were (1) to determine whether speakers egocentrically base their referential choice on the preceding linguistic discourse or also take into account the perspective of a hypothetical listener and (2) whether the possible impact of perspective taking on referential choice changes with increasing age, with its associated changes in cognitive capacity. In the production task, participants described picture-based stories featuring two characters of the same gender, making it necessary to use unambiguous forms; in the comprehension task, participants interpreted potentially ambiguous pronouns at the end of similar orally presented stories. Young adults (aged 18-35) were highly sensitive to the informational needs of hypothetical conversational partners in their production and comprehension of referring expressions. In contrast, children (aged 4-7) did not take into account possible conversational partners and tended to use pronouns for all given referents, leading to the production of ambiguous pronouns that are unrecoverable for a listener. This was mirrored in the outcome of the comprehension task, where children were insensitive to the shift of discourse topic marked by the speaker. The elderly adults (aged 69-87) behaved differently from both young adults and children. They showed a clear sensitivity to the other person's perspective in both production and comprehension, but appeared to lack the necessary cognitive capacities to keep track of the prominence of discourse referents, producing more potentially ambiguous pronouns than young adults, though fewer than children. In conclusion then, referential choice seems to depend on perspective taking in language, which develops with increasing linguistic experience and cognitive capacity, but also on the ability to keep track of the prominence of discourse referents, which is gradually lost with older age.

A time and place for language comprehension: mapping the N400 and the P600 to a minimal cortical network.

We propose a new functional-anatomical mapping of the N400 and the P600 to a minimal cortical network for language comprehension. Our work is an example of a recent research strategy in cognitive neuroscience, where researchers attempt to align data regarding the nature and time-course of cognitive processing (from ERPs) with data on the cortical organization underlying it (from fMRI). The success of this "alignment" approach critically depends on the functional interpretation of relevant ERP components. Models of language processing that have been proposed thus far do not agree on these interpretations, and present a variety of complicated functional architectures. We put forward a very basic functional-anatomical mapping based on the recently developed Retrieval-Integration account of language comprehension (Brouwer et al., 2012). In this mapping, the left posterior part of the Middle Temporal Gyrus (BA 21) serves as an epicenter (or hub) in a neurocognitive network for the retrieval of word meaning, the ease of which is reflected in N400 amplitude. The left Inferior Frontal Gyrus (BA 44/45/47), in turn, serves a network epicenter for the integration of this retrieved meaning with the word's preceding context, into a mental representation of what is being communicated; these semantic and pragmatic integrative processes are reflected in P600 amplitude. We propose that our mapping describes the core of the language comprehension network, a view that is parsimonious, has broad empirical coverage, and can serve as the starting point for a more focused investigation into the coupling of brain anatomy and electrophysiology.

Questions left unanswered: how the brain responds to missing information.

It sometimes happens that when someone asks a question, the addressee does not give an adequate answer, for instance by leaving out part of the required information. The person who posed the question may wonder why the information was omitted, and engage in extensive processing to find out what the partial answer actually means. The present study looks at the neural correlates of the pragmatic processes invoked by partial answers to questions. Two experiments are presented in which participants read mini-dialogues while their Event-Related brain Potentials (ERPs) are being measured. In both experiments, violating the dependency between questions and answers was found to lead to an increase in the amplitude of the P600 component. We interpret these P600-effects as reflecting the increased effort in creating a coherent representation of what is communicated. This effortful processing might include the computation of what the dialogue participant meant to communicate by withholding information. Our study is one of few investigating language processing in conversation, be it that our participants were 'eavesdroppers' instead of real interactants. Our results contribute to the as of yet small range of pragmatic phenomena that modulate the processes underlying the P600 component, and suggest that people immediately attempt to regain cohesion if a question-answer dependency is violated in an ongoing conversation.

Comprehension of marked pronouns in Spanish and English: object anaphors cross-linguistically.

Previous research on pronoun resolution has identified several individual factors that are deemed to be important for resolving reference. In this paper, we argue that of these factors, as tested here, plausibility is the most important, but interacts with form markedness and structural parallelism. We investigated how listeners resolved object pronouns that were ambiguous in the sense of having more than one possible antecedent. We manipulated the form of the anaphoric expression in terms of accentuation (English: Experiments 1a and 2a) and morphology (Spanish: Experiments 1b and 2b). We looked at sentences where both antecedents were equally plausible, or where only one of the antecedents was plausible. Listeners generally resolved toward the (parallel) grammatical object of the previous clause. When the pronouns were marked due to accentuation (English) or use of specific morphology (Spanish), preference switched to the alternative antecedent, the grammatical subject of the previous clause. In contrast, when one of the two antecedents was a much more plausible antecedent than the other, antecedent choice was almost wholly dictated by plausibility, although reference form prominence did significantly attenuate the strength of the preference.

Processing polarity: ERP evidence for differences between positive and negative polarity.

The goal of the present study was to investigate event-related potential (ERP) responses to Dutch negative and positive polarity adverbs of degree presented in licensed and unlicensed contexts with negative and affirmative particles directly preceding the polarity item. To control for effects of the processing of negation as such, neutral adverbs were also presented in negative and affirmative contexts. The results did not show any significant effect of negation for the non-polar adverbs, allowing context effects for polarity items to be interpreted as being due to the appropriateness of the context. Negative polarity violations elicited an N400 response that might reflect the lack of semantic congruity of the negative polarity item in an affirmative context. In contrast, processing positive polarity items in context of negation resulted in a positive effect resembling the P600, which may be considered as a marker of a different sort of integration difficulty caused by violation of licensing conditions and/or a search for a licensor in the wider discourse context. The study presented here is the first to show an unambiguous dissociation between responses to negative and positive polarity violations. This dissociation argues for different mechanisms underlying the processing of these two types of polarity; we propose that positive polarity items are sensitive to wider discourse context, while negative polarity items are more sensitive to local lexical context.

Less is not more: neural responses to missing and superfluous accents in context.

Prosody, particularly accent, aids comprehension by drawing attention to important elements such as the information that answers a question. A study using ERP registration investigated how the brain deals with the interpretation of prosodic prominence. Sentences were embedded in short dialogues and contained accented elements that were congruous or incongruous with respect to a preceding question. In contrast to previous studies, no explicit prosodic judgment task was added. Robust effects of accentuation were evident in the form of an "accent positivity" (200-500 msec) for accented elements irrespective of their congruity. Our results show that incongruously accented elements, that is, superfluous accents, activate a specific set of neural systems that is inactive in case of incongruously unaccented elements, that is, missing accents. Superfluous accents triggered an early positivity around 100 msec poststimulus, followed by a right-lateralized negative effect (N400). This response suggests that redundant information is identified immediately and leads to the activation of a neural system that is associated with semantic processing (N400). No such effects were found when contextually expected accents were missing. In a later time window, both missing and superfluous accents triggered a late positivity on midline electrodes, presumably related to making sense of both kinds of mismatching stimuli. These results challenge previous findings of greater processing for missing accents and suggest that the natural processing of prosody involves a set of distinct, temporally organized neural systems.

Getting real about semantic illusions: rethinking the functional role of the P600 in language comprehension.

In traditional theories of language comprehension, syntactic and semantic processing are inextricably linked. This assumption has been challenged by the 'semantic illusion effect' found in studies using event related brain potentials. Semantically anomalous sentences did not produce the expected increase in N400 amplitude but rather one in P600 amplitude. To explain these findings, complex models have been devised in which an independent semantic processing stream can arrive at a sentence interpretation that may differ from the interpretation prescribed by the syntactic structure of the sentence. We review five such multi-stream models and argue that they do not account for the full range of relevant results because they assume that the amplitude of the N400 indexes some form of semantic integration. Based on recent evidence we argue that N400 amplitude might reflect the retrieval of lexical information from memory. On this view, the absence of an N400-effect in semantic illusion sentences can be explained in terms of priming. Furthermore, we suggest that semantic integration, which has previously been linked to the N400 component, might be reflected in the P600 instead. When combined, these functional interpretations result in a single-stream account of language processing that can explain all of the Semantic Illusion data.

Fill the gap! Combining pragmatic and prosodic information to make gapping easy.

Two studies investigated the effects of prosody and pragmatic context on off-line and on-line processing of sentences like John greeted Paul yesterday and Ben today. Such sentences are ambiguous between the so-called 'nongapping' reading, where John greeted Ben, and the highly unpreferred 'gapping' reading, where Ben greeted Paul. In the first experiment, participants listened to dialogues and gave a speeded response as to which reading of an ambiguous target sentence first comes to mind. In the second experiment, they also responded to a visual probe that was presented during the presentation of the ambiguous target. The results show that context and prosody have independent and strong effects on both on-line processing and off-line interpretation of gapping; in the right combination they can make gapping as easy as the normally preferred nongapping reading.

Semantic ambiguity processing in sentence context: Evidence from event-related fMRI.

Lexical semantic ambiguity is the phenomenon when a word has multiple meanings (e.g. 'bank'). The aim of this event-related functional MRI study was to identify those brain areas, which are involved in contextually driven ambiguity resolution. Ambiguous words were selected which have a most frequent, dominant, and less frequent, subordinate meaning. These words were presented in two types of sentences: (1) a sentence congruent with the dominant interpretation and (2) a sentence congruent with the subordinate interpretation. Sentences without ambiguous words served as a control condition. The ambiguous words always occurred early in the sentences and were biased towards one particular meaning by the final word(s) of the sentence; the event at the end of the sentences was modeled. The results indicate that a bilaterally distributed network supports semantic ambiguity comprehension: left (BA 45/44) and right (BA 47) inferior frontal gyri and left (BA 20/37) and right inferior/middle temporal gyri (BA 20). The pattern of activation is most consistent with a scenario in which initially a frequency-based probabilistic choice is made between the alternative meanings, and the meaning is updated when this interpretation does not fit into the final disambiguating context. The neural pattern is consistent with the results of other neuroimaging experiments which manipulated various aspects of integrative and context processing task demands. The presence of a bilateral network is also in line with the lesion and divided visual field literature, but contrary to earlier claims, the two hemispheres appear to play similar roles during semantic ambiguity resolution.

Processing the noun phrase versus sentence coordination ambiguity: thematic information does not completely eliminate processing difficulty.

When faced with the noun phrase (NP) versus sentence (S) coordination ambiguity as in, for example, The thief shot the jeweller and the cop ..., readers prefer the reading with NP-coordination (e.g., "The thief shot the jeweller and the cop yesterday") over one with two conjoined sentences (e.g., "The thief shot the jeweller and the cop panicked"). A corpus study is presented showing that NP-coordinations are produced far more often than S-coordinations, which in frequency-based accounts of parsing might be taken to explain the NP-coordination preference. In addition, we describe an eye-tracking experiment investigating S-coordinated sentences such as Jasper sanded the board and the carpenter laughed, where the poor thematic fit between carpenter and sanded argues against NP-coordination. Our results indicate that information regarding poor thematic fit was used rapidly, but not without leaving some residual processing difficulty. This is compatible with claims that thematic information can reduce but not completely eliminate garden-path effects.