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INOCULATION AS A RISK AND HEALTH COMMUNICATION STRATEGY IN AN EVOLVING MEDIA ENVIRONMENT
Bobi Ivanov, Kimberly A. Parker, and Lindsay L. Dillingham
Introduction
Communication continues to be at the center of risk and health promotion management strategies (Ivanov, 2012; Ivanov et al., 2016; Pfau, 1995) as many of the processes associated with these activities are “inherently communicative” (e.g., O’Hair & Heath, 2005, p.4). Garnett and Kouzmin, for example, argued that “Hurricane Katrina was and continues to be as much a communication crisis as a natural disaster” (2007, p. 171). As a result, these researchers, in concert with other social scientists (e.g., Degeneffe, Kinsey, Stinson, & Ghosh, 2009; Ivanov, 2012; Pfau, 1995), have called for the design and introduction of effective communication messages to be used as strategic tools in the effort to prevent and manage risk and health issues and crises.
A message strategy that has emerged as an effective tool in managing risk and health promotion is based on the principals of inoculation theory (Compton, 2013; Compton & Pfau, 2005; Ivanov, 2012; Ivanov, in press). As a two-sided message strategy, inoculation has proven to be an effective approach in mitigating the negative effects of politically motivated acts of violence (e.g., Ivanov et al., 2016), underage smoking (e.g., Pfau, Van Bockern, & Kang, 1992; Pfau & Van Brockern, 1994; Szabo & Pfau, 2001), alcohol consumption (e.g., Godbold & Pfau, 2000; Parker, Ivanov, & Compton, 2012), vaccine avoidance (e.g., Wong & Harrison, 2014), and unprotected sex (e.g., Parker et al., 2012), thus prompting Ivanov to render the “application of the strategy boundless” in the risk and health communication context (Ivanov, 2012, p. 77; Ivanov, in press).
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Yet, despite its research longevity spanning over five and a half decades, inoculation scholars have dedicated limited attention to the potential moderating role of communication modality. With very few exceptions that compared traditional media outlets (e.g., Pfau, Holbert, Zubric, Pasha, & Lin, 2000), inoculation has treated modality largely “as a ‘neutral’ conduit of message content” (Pfau, 1990, p. 195; Dillingham & Ivanov, 2016a). Thus, research on the impact of different traditional and emerging modalities on the process of inoculation and its subsequent message efficacy is largely underdeveloped. In a rapidly evolving multimedia landscape (Dholakia et al., 2010) that features online socializing and digitization of modalities (Zemmels, 2012), for inoculation to remain a relevant strategy in general, and in risk and health promotion and management in particular, scholars have to consider the impact of evolving media on the effectiveness of inoculation as a communication message strategy.
This chapter begins with an introduction of the theory of inoculation. More specifically, the chapter opens with a summary of inoculation’s conception and logic, as well as original and newly identified theoretical mechanisms, variables, processes, and boundaries. It then focuses on inoculation’s strategic application in risk and health promotion management by reviewing the extant inoculation studies conducted in these contexts. The chapter continues with an examination of the role that modality has played in previous inoculation research and concludes with considerations for future risk and health, but also general inoculation research in an evolving media environment.
Origins and Mechanisms of Inoculation Theory
Eagly and Chaiken labeled inoculation the “grandparent theory of resistance to attitude change” (1993, p. 561). In contrast to reactive strategies that can potentially restore—rather than protect—attitudes, inoculation is a preemptive strategy that works to reduce the effect of future persuasive attempts by motivating individuals to reinforce established attitudes. Inoculation messages are used to strengthen the conviction with which current attitudes are held and prepare individuals for future attacks (McGuire, 1961). The roots of inoculation theory can be found in Lumsdaine and Janis’ (1953) seminal study, which examined the persuasive effectiveness of one-sided (i.e., presenting only favorable arguments on one side of the issue) and two-sided (i.e., presenting arguments on both sides of the issue) messages. While both types of messages influenced attitudes and behaviors, two-sided messages emerged as the superior strategy when seeking to generate resistance to future persuasive attacks.
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To explain this finding, McGuire (1964) used a biomedical analogy arguing that attitudinal inoculation confers resistance in much the same way as human immunization is stimulated via vaccination. He cleverly observed that through the process of immunization, humans are made resistant to diseases by offering a weakened form of the virus, which stimulates the immune system. The immune system then begins the work of building up resistance to a future viral attack. McGuire (1964) stated that the dosage of the immunization is key to effectiveness; if it is too weak, it may fail to stimulate the immune system and if it is too strong, it may overwhelm it and cause the very disease the immunization aimed to prevent.
Developing his logic from the aforementioned process of immunization, McGuire (1964) argued that attitudinal inoculation can create more resistant attitudes by using persuasive messages designed to threaten, or “shock” (McGuire, 1961, p. 185), the confidence in the established attitude, thus motivating defense preparation. McGuire believed that counterarguing—the process of raising and refuting potential forthcoming attitudinal challenges—is a key component in the defense process, providing practice and confidence in the ability of individuals to withstand attitudinal pressures. As such, McGuire (1964) identified threat and counterarguing as the key mechanisms of inoculation-conferred resistance.
Unleashing the inoculation process necessitates effective message design, which has traditionally consisted of two message components, explicit forewarning and refutational preemption (see Ivanov, 2012). The purpose of the explicit forewarning is to demonstrate to individuals that their attitudes are not infallible; but, rather, likely to be challenged and potentially overwhelmed. The refutational preemption component of the message presents individuals with weakened challenges to the current attitudes, and then strongly refutes those relevant challenges. Threat is generated by both message components. While the explicit forewarning does so directly and overtly, the refutational preemption elicits threat more implicitly, or inherently, by introducing individuals to potential forthcoming challenges, thus rendering the danger of attitudinal pressures real. Counterarguing is stimulated by the generated threat and inspired by the guided practice of how to refute forthcoming challenges presented in the refutational preemption component of the inoculation message. According to McGuire (1964), inoculation messages elicit threat, both explicitly and implicitly, which motivates the process of counterarguing—supported by the guided counterarguing practice exemplified in the message—which in turn enhances attitudinal resistance.
Yet, Insko (1967) suspected that the process of inoculation, as originally conceptualized, was incomplete. As such, more recent research has focused on uncovering additional mechanisms to better explain the intricacies and complexities of the inoculation process (see Compton, 2013; Ivanov, 2012; Ivanov, in press). The results have shown that, in addition to, or in combination with, generating threat and counterarguing, inoculation elicits greater levels of issue involvement (e.g., Pfau et al., 2004), self-efficacy (e.g., Farchi & Gidron, 2010; Ivanov et al., 2016; Jackson, Compton, Whiddett, Anthony, & Dimmock, 2015; Pfau et al., 2009), and affect (e.g., Compton & Ivanov, 2014; Ivanov et al., 2012a, 2012b; Miller et al., 2013). Inoculation also boosts attitude accessibility (Pfau et al., 2003, 2004), strengthens the associative networks of those inoculated (e.g., Pfau et al., 2005), and bolsters attitudinal certainty (e.g., Pfau et al., 2004; 2005), all of which enhance attitude resistance. As a result, inoculation messages seem to offer a promising approach to designing successful risk and health promotion strategies.
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Theoretical Boundaries
As a theory-based strategy, inoculation functions within specified boundaries. These boundaries are both theoretical and practical. This chapter briefly addresses the three boundaries most relevant to risk and health communication and message design: initial attitudes, issue involvement, and cross-protection.
Initial Attitudes
Ivanov and colleagues suggested that “McGuire’s (1964) use of the biological analogy was not merely stylistic, it was explanatory” (2015, p. 220). Inoculation is used to immunize healthy individuals. Conversely, individuals who have already succumbed to the disease are not good candidates for preventive inoculation. Consequently, mirroring the biological analogy, attitudinal inoculation should only be used on individuals with “healthy” (i.e., established) attitudes. Using inoculation as anything but a preventive strategy would diverge from the theoretical undergirding of the biomedical analogy (Ivanov et al., 2016). Yet, from a pragmatic standpoint, a robust message strategy that can simultaneously reinforce desirable established attitudes, but also sway neutral attitudes and influence undesirable established attitudes, may present a preferred message approach to a strategy only designed to protect attitudes.
An inoculation-based strategy can in fact do all of the above (e.g., Ivanov et al., 2017; Wood, 2007). More specifically, the strategy serves an inoculating, preventive function consistent with the tenets of inoculation theory; it also serves a persuasive, rather than resistance, function as it helps create new, and augment-opposing, attitudes (e.g., Ivanov et al., 2017; Wood, 2007). It does so better than a traditional supportive (bolstering or one-sided) strategy (Ivanov et al., 2017), thus providing a strong alternative message approach for usage in risk and health prevention and management.
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Issue Involvement
The importance of the topic, or the involvement with the issue, was previously considered the “key to inoculation’s terrain” (Pfau et al., 1997, p. 210). Pfau and colleagues first advanced the idea that an inoculation strategy is most effective with topics or issues that are of moderate importance to individuals. The authors reasoned that highly involving issues would render the effectiveness of this strategy limited as individuals would have already fortified their attitudes due to their importance. Conversely, issues eliciting limited interest and involvement, Pfau and colleagues (1997) reasoned, would fail to motivate individuals to enhance their attitudinal defenses. As a result, moderately involving issues should provide the best opportunity for inoculation’s success. These findings-supported assertions suggesting a curvilinear relationship between inoculation’s effectiveness and issue involvement—although logically sound and empirically supported in Pfau and colleagues’ study—did not receive meta-analytic support (Banas & Rains, 2010). Although the unstandardized beta coefficients were in the hypothesized direction, no linear or curvilineal relationship was discovered (Banas & Rains, 2010). Hence, the potential confounding role of issue involvement in the process of inoculation should be considered with caution.
Cross-Protection
Threat-motivated defense building is at the heart of inoculation’s success (Pfau et al., 1997). McGuire (1964) contended, and evidenced, that the motivation to shore up defenses allows individuals to extend the attitudinal protection veil beyond the counterarguing content provided in the refutational preemption of the inoculation message. Stated differently, the effectiveness of inoculation messages extends beyond the message-presented arguments by potentially creating an umbrella (or blanket) protection over all arguments within the issue domain (Compton, 2013; Compton & Pfau, 2005; Ivanov, 2012; McGuire, 1964).
Recently, however, Parker and colleagues (2012, 2016) have argued that the umbrella protection may extend beyond the issue domain by creating cross-protection for related attitudes as well. Their results, as well as that of others (Ivanov et al., 2015; Ivanov et al., 2016), have provided early confirmation for the possibility of cross-protection.
The review of the boundaries shows the possibilities of inoculation-based strategies. Inoculation offers the opportunity for design and implementation of effective risk and health communication strategies for reinforcing, creating, and changing both targeted and related beliefs, attitudes, and behaviors.
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Application of Inoculation in Risk and Health Communication Settings
In the fifty-five year history of the theory, inoculation-based strategies have been applied, mostly with success, to numerous contexts including: politics (e.g., Pfau & Burgoon, 1988; Pfau et al., 1990), mass media (Pfau et al., 2006, 2008), commerce (e.g., Ivanov et al., 2009; Ivanov et al., 2017), corporate communication (Dillingham & Ivanov, 2015; Haigh & Pfau, 2006), public relations/crises (Burgoon, Pfau, & Birk, 1995; Wan & Pfau, 2004; Wigley & Pfau, 2010), interpersonal communication (Sutton, 2011), cross-cultural communication (Ivanov et al., 2012b), and education (Compton & Pfau, 2008). An additional context that has received significant attention from inoculation scholars is that of risk and health communication. Consequently, the rest of the contextual focus of this chapter will be placed on specific risk and health related attitudes (or behaviors) and policies featured in previous inoculation research.
Smoking Prevention
Preventing smoking onset with young adolescents has generated inoculation interest and research. Using inoculation strategy in a two-year study, Pfau and colleagues (Pfau et al., 1992; Pfau & Van Bockern, 1994) were successful in protecting anti-smoking attitudes and intentions of at-risk middle school students with low self-esteem. Banerjee and Greene (2006, 2007) organized anti-smoking intervention workshops with the same population and also discovered positive inoculation effect.
Drinking Prevention
Duryea (1982, 1983) advocated for inoculation to be employed as an alcohol education prevention strategy. Since then, studies have explored the efficacy of inoculation in this role. Godbold and Pfau (2000) tested the effectiveness of normative inoculation messages in combating the false, inflated perception regarding the number of adolescent peers consuming alcohol. By creating a more realistic perception of the true number of peers who consume alcohol, inoculation was able to help protect adolescents from subsequent pressures to consume alcohol by peers who cited the behavior as normative.
Focusing on a different population, Parker and colleagues (2012) tested cross-protection effects of inoculation on binge drinking attitudes. More precisely, these authors discovered that inoculating college students against the dangers of unprotected sex indirectly created cross-protection that spanned over a related attitude toward another risky behavior. More precisely, the results showed greater resilience of negative attitudes toward binge drinking.
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Unprotected Sexual Engagement
Parker and colleagues (2012) conducted a study to test the ability of inoculation to decrease the possibility of college student engagement in the risky practice of unprotected sexual intercourse. These authors designed an inoculation-based message aimed at protecting the positive attitudes toward condom use. The results were encouraging as the message not only protected the targeted attitudes, but as aforementioned, the effect extended to related ones as well, i.e., the negative attitudes toward binge drinking.
Vaccination
In a recent study, Wong and Harrison (2014; also see Wong, 2016) explored the ability of inoculation messages to protect positive attitudes toward HPV vaccinations. In their experiment they tested two different inoculation message approaches. In the first one, they presented participants with inoculation messages designed to directly protect the attitudes toward HPV vaccinations. In the second approach, the messages were not specific to HPV vaccination, but instead focused on the general practice of vaccination. Both approaches were successful in protecting attitudes toward HPV vaccination. These findings are significant as they show that not only is inoculation an effective risk and health strategy in directly defending favorable HPV vaccination attitudes, but also that inoculation can indeed generate umbrella protection. As the results showed, inoculating general pro-vaccination attitudes generated protection for specific attitudes as well, such as those about HPV vaccination. This outcome suggests that targeting global risk and health-related attitudes (e.g., impaired driving) may have a positive effect on multiple specific attitudes (e.g., drinking and driving, prescription drug usage and driving, and even texting and driving).
Risk and Health Policy
Industry-sponsored, anti-policy messages have been effective in subverting efforts to galvanize support for pro-health policies (Niederdeppe, Heley, & Barry, 2015). In order to buffer attitudes toward pro-health policy, Niederdeppe and colleagues (2015) tested the efficacy of inoculation in combating the effectiveness of anti-policy messaging. More specifically, these authors applied inoculation as a strategy to protect against the effect of industry anti-policy messages designed to decrease support for policies aimed at reducing obesity, cigarette use, and painkiller addiction. The results were encouraging. The findings indicated that inoculation messages had both immediate and delayed success as the messages were effective both instantly, i.e., after their presentation, and a week later.
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Inoculation scholars have found equivalent success in their attempts to protect attitudes in support of numerous government policies related to risk and health such as restrictions on televised violence, gambling, marijuana legalization, and sale and distribution of hand guns (e.g., Miller et al., 2013; Pfau et al., 1997, 2005). In fact, these messages have proven equally effective in protecting both sides of the issues above-listed.
Additional Risk and Health-Related Topics
The effectiveness of inoculation-based strategies is certainly not limited to the already-introduced topics and policies. McGuire’s (1964) original research, for example, focused on the protection of different health-related beliefs such as: the belief in regular teeth brushing; the belief in the benefits of penicillin; the belief in annual x-ray exams to detect for tuberculosis symptoms; and the belief in annual doctor’s visits for regular checkups. His inoculation messages were successful regardless of the belief protected.
In addition, Rosenburg (2004) suggested that inoculation may be a suitable strategy to curb verbal aggression in schools. Matusitz and Breen believed that inoculation may be a promising strategy to help lower the rates of criminal recidivism (Matusitz & Breen, 2013). These authors also proposed that inoculation may assist in deterring young people from joining gangs (Breen & Matusitz, 2008). In addition, Kingsley Westerman and colleagues recommended using inoculation messages to aid safety training for emergencies (Kingsley Westerman, Margolis, & Kowalski-Trakofler, 2011).
Numerous other health and risk prevention topics remain that could be well-served with an inoculation-based strategy, some of which include the promotion and protection of healthy eating habits, positive attitudes toward mammograms, colonoscopies, breastfeeding (see Ivanov, 2012), and regular exercise (see Compton & Ivanov, in press). Inoculation can also be used as a strategy to prevent relapse in individuals recovering from substance abuse (see Ivanov, in press). Furthermore, it can potentially be used as a strategy to promote healthy sunscreen practices, attitudes, and behaviors (see Ivanov, in press).
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Beyond Risk and Health Prevention
Although most of the inoculation research in the area of risk and health communication has focused on prevention application, an inoculation-based strategy is not limited to prevention (Ivanov et al., 2017; Wood, 2007). For example, Ivanov, Burns, and colleagues (2016) used inoculation as a risk and health management, rather than purely preventative, strategy. These authors did not use inoculation-based strategy exclusively with individuals with already established desirable beliefs. Instead, they successfully applied the strategy irrespective of the initial belief valence. In their study, the authors used the strategy to enhance the general public beliefs in the ability of the US government agencies to both prevent and minimize the negative effects of a politically motivated act of violence, such as the intentional downing of a commercial airliner on US soil. In addition, using an inoculation-based strategy, the authors were able to enhance the perceived ability of individuals to cope with the aftermath of such an act while at the same time lowering the perceived intensity of the experienced fear elicited by the politically motivated act of violence. Thus, inoculation-based messages offer a promising strategic approach in risk and health communication management, not just prevention.
Application of Inoculation Using Different Modalities
As addressed in the preceding section, health and risk messages employing an inoculation theory-based design have shown consistent efficacy in conferring resistance to persuasion (see Parker et al., 2012, 2016). However, inoculation research focused on understanding the role of communication modality in the inoculation process has been neither as abundant nor as clear with regard to results (Dillingham & Ivanov, 2016a; Pfau et al., 2000). When considering the relatively “boundless” (Ivanov, 2012, p. 77) potential of inoculation theory to inform applied risk and health message strategy, the question of modality becomes paramount. Stated simply, when inoculation messages leave the controlled experimental environment, can practitioners and scholars have confidence that these messages will perform (i.e., create and sustain resistance to persuasion) in a real-world multimodal communication environment?
Inoculation theory designs featuring print-only messages have largely dominated the previous five decades of research (Dillingham & Ivanov, 2016a). In the words of the late inoculation scholar Michael Pfau, modality has been treated as a “neutral conduit of message content” (1990, p. 195) within the boundaries of inoculation theory. Therefore, much of the empirical support demonstrating the superiority of inoculation messages as compared to both supportive and control messages has been founded on comparing participant sentiment after exposure to a print treatment message (inoculation, supportive, or message/no message control) and a subsequent print attack message (Compton & Pfau, 2005).
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To date only two studies (Dillingham & Ivanov, 2016a; Pfau et al., 2000) have explicitly explored the role of modality in the inoculation process. However, several authors have embraced the interchangeable modality concept posited by Pfau (1990) and, as a result, used video messages (rather than or in addition to print) in the course of their respective studies. Yet, the purported neutrality of communication modality in the inoculation process is perplexing when reviewing these studies in tandem. For example, when exploring the potential of inoculation theory to deter adolescent alcohol abuse, Godbold and Pfau (2000) overwhelmed the protection created by a video inoculation message with a video attack message. Yet, unlike Godbold and Pfau, Burgoon and colleagues (1978) used a video inoculation/video attack design, but found evidence of inoculation’s effectiveness.
To review, inoculation messages have thrived in a print treatment/print attack environment (see Compton & Pfau, 2005), with the results being mixed in studies that have paired a video treatment with a video attack (Burgoon et al., 1978; Godbold & Pfau, 2000). Some researchers—perhaps due to the assumed interchangeability of modalities—have mismatched video and print treatments within an inoculation study, or paired a print inoculation message with video attack or vice versa (e.g., An & Pfau, 2004; Banas & Miller, 2013). While the majority of these studies support print as the more robust medium, the results are not conclusive. For example, An and Pfau’s (2004) video attack message reduced the resistance generated by a print inoculation message. In contrast, the print inoculation messages of both Banas and Miller (2013) and Lim and Ki (2007) showed success when faced with a video attack message. The Banas and Miller (2013) work is particularly notable due to the salience of the video attack. They offered that “the movie had the advantage of imagery, narration, music, and length” (2013, p. 198), and also lasted 40 minutes. Nonetheless, the print inoculation message created sustained resistance. More recently, and in the health context, Wong (2016) combined print and video formats in the pro-vaccination inoculation message and the generated resistance sustained persuasive attack presented through video. And, while Pfau, Van Bockern, and Kang (1992) did not include an attack phase in their study, the authors were able to inoculate low self-esteem middle school students against smoking initiation using video inoculation messages.
While scholars have noted (see Dillingham & Ivanov, 2016a) that some of the aforementioned studies (e.g., An & Pfau, 2004; Godbold & Pfau, 2000) demonstrate the potential for video to overwhelm the resistance created by print inoculation treatments, other work has demonstrated differences not just in the presence/absence of multimodal formats (i.e., video), but also in the evocative or engaging nature of the video messages. Nabi (2003), in the context of animal experimentation, explored whether or not inoculation messages presented by a “talking head” (p. 202) news anchor would impact participants as strongly as a video inoculation message that incorporated animal cruelty images. When faced with a video attack message, participants in Nabi’s (2003) study showed increased resistance following exposure to the visually evocative inoculation message.
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Further support for the strength of imagery was provided by Pfau and colleagues (2006, 2008) who found participants to be more affected (i.e., reporting negative feelings toward war) by a video featuring war footage compared with a video comprised of only news anchor reporting. The impact of video war footage was so salient, in fact, that Pfau and colleagues (2006) did not have success inoculating those participants against anti-war sentiment. Meanwhile, the anchor-only video attack group retained its inoculation-generated resistance, even in the face of a purportedly strong video attack (e.g., An & Pfau, 2004; Godbold & Pfau, 2000). It should be noted that Pfau and colleagues (2006) used print inoculation treatments with both (i.e., footage-inclusive and anchor-only) video attack messages. In a 2008 follow-up study about evocative visuals, Pfau and colleagues found that resistance created by neither print-only nor print-with-photograph inoculation messages could withstand a footage-inclusive video attack.
Despite the aforementioned ancillary findings that modestly suggest the strength of video messages compared to print and, more specifically, the enhanced salience achieved through use of evocative or engaging imagery, the two studies (Dillingham & Ivanov, 2016a; Pfau et al., 2000) that have systematically investigated modality-induced differences in inoculation message processing have not reflected these nuances. When comparing and contrasting the two efforts, Dillingham and Ivanov (2016a) and Pfau and colleagues (2000) share failed hypotheses about the strength of one modality over the other (video versus print) while using engaging (i.e., not news anchor–only) video footage in direct comparison to a print-only message. In both studies, video performed slightly better than print, but fell short of statistical significance. By way of contrast, Pfau and colleagues (2000) explored the impact of varied modality in the inoculation message, while Dillingham and Ivanov (2016a) compared print and video attack messages. The two author groups also hypothesized in different directions (i.e., in favor of a different modality).
Largely based on medium theory’s (see Meyrowitz, 1994) supposition that print is a more engaging media form because reading requires active, central processing while television content can be passively (i.e., peripherally) processed, Pfau et al. (2000) hypothesized that participants who read an inoculation message would achieve an enhanced inoculation effect (i.e., greater resistance to persuasion) compared to those who viewed a video inoculation message. Dillingham and Ivanov (2016a), disparately, predicted that a video attack message would damage print-induced resistance in inoculated individuals more than a print attack message. The authors based their hypothesis on video-enhanced findings of Godbold and Pfau (2000), Nabi (2003), and An and Pfau (2004). As both studies (Dillingham & Ivanov, 2016a; Pfau et al., 2000) noted, the failed prediction that modality would alter the inoculation process, while not inherently good for the studies themselves, is actually quite positive for the advancement of inoculation theory. Not only is a large body of inoculation research that has employed a print-only research design still applicable to modern theorizing, as both author groups note, the seeming modality-neutral environment inherent in the inoculation process boosts the applied value of the theory. After all, practitioners using this strategy can only control the format of the inoculation message—and even then both video (Pfau et al., 1992; 2000) and print (Dillingham & Ivanov, 2016a) inoculation messages have withstood subsequent persuasive attack—but intervention designers cannot control or perfectly foresee what attack modalities their target population could face.
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To summarize, when directly addressing the issue of modality, Pfau et al. (2000) and Dillingham and Ivanov (2016a) offer support for Pfau’s (1990) original suggestion that modalities are interchangeable and simply a “neutral conduit of message content” (p. 195) in the inoculation message. These findings potentially explain consistent confounding results within video and print inoculation experiments and help diffuse empirical hints (e.g., Godbold & Pfau, 2000) that video might alter the inoculation process. The lessened sensitivity to modality suggested by inoculation research (Dillingham & Ivanov, 2016a; Pfau et al., 2000) seems to persist when an interpersonal component is introduced during the process. In addition to the burgeoning literature on post-inoculation talk (PIT) (see next section), where resistance generated via print has protected against persuasive attack even after the participant has discussed the issue within his or her social networks, a recent study (Jackson et al., 2015) showed the efficacy of a health oriented print inoculation treatment even when the persuasive attack was delivered verbally and in-person to a group of research participants by a confederate.
Inoculation Modality and Post-Inoculation Talk (PIT)
To this point, the discussion of the chapter has focused on a modality-controlled distribution of the risk and health strategic inoculation message, or what Rogers (1995) referred to as the linear model of communication. Stated differently, in our discussion the message content, format, timing, and dispersion vehicle were controlled by the strategic communication specialist and flowed one way, directly to the intended message receiver. This process is consistent with the traditional understanding of the mechanisms that elicit and facilitate the inoculation-based effects. To remind, risk and health inoculation messages generate motivation to shore up attitudinal defenses. The motivation is bolstered by the presentation of counterarguing material and guided practice designed to enhance the ability of the individual to counterargue forthcoming attitudinal challenges (McGuire, 1964). The motivated counterarguing practice is credited with the added skill or ability of the individual to withstand challenges (Compton, 2013; Compton & Pfau, 2005; Ivanov, 2012). Until recently, this counterarguing practice was considered to be entirely an internal process (Ivanov, Parker, & Dillingham, 2013), “as though one is having an intrapersonal dialogue with the anticipated attack message source” (Ivanov et al., 2012a, p. 704). Indeed, Brandt (1979) has suggested that counterarguing is “presumed to be [a] subvocal, psychological process” (p. 324). Therefore, if internal counterarguing exists solely, no further dispersion of the risk and health inoculation message is likely to occur and the inoculation process may truly be linear, where the inoculation message information is shared one way—from the strategic communication specialist to the message receiver—which motivates an internal defensive process.
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However, in a seminal inoculation essay, Compton and Pfau (2009) theorized that the process of counterarguing is not exclusively intrapersonal, as once anticipated (e.g., Brandt, 1979); but instead, it is interpersonal as well. They suggested that inoculation message recipients may talk with others about the message content and topic for the purposes of reassuring and/or advocating their own attitudinal positions. If so, the process of risk and health inoculation message diffusion may not exclusively fit the linear model of communication (Rogers, 1995). Instead, the process of inoculation may also fit the convergence model, in which communication participants create and share information in an effort to reach mutual understanding (Rogers & Kinkaid, 1981). Recent inoculation research has provided evidence that the process of counterarguing may be both subvocal and vocal as inoculation message receivers talk to others in an effort to reassure and advocate their positions (Dillingham & Ivanov, 2016b; Ivanov et al., 2015). More specifically, by examining the communication content, Ivanov and colleagues (2015) found evidence that inoculated individuals not only shared the content contained in the inoculation message, but they also introduced novel arguments not present in the inoculation message. The conversations, termed post-inoculation talk, or PIT (Ivanov et al., 2012a), centered on both the topic at hand, as well as related topics, a practice which is closely associated with both the traditional and modern understanding of the inoculation process. Thus, the recent PIT findings suggest that, contrary to previous conceptualizations, inoculation message strategy relies, at minimum, on a dual process of message diffusion. The first is a traditional (linear) one-way controlled diffusion of information in which the message strategist disperses a controlled, prepared-in-advance inoculation message using the desired modality and timing of message transmission (Rogers, 1995). Yet, inoculation may also be diffused as information-exchange among receivers and non-receivers of the inoculation message, a process outside of the communication strategist’s control (Rogers & Kinkaid, 1981).
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Extant inoculation research that has focused on the traditional or linear process of inoculation message diffusion evidences the effectiveness of one-way communication in shoring up attitudes and combating attitudinal challenges (Compton, 2013; Compton & Pfau, 2005; Ivanov, 2012). However, what effect, if any, does the secondary diffusion process—inoculation as an information-exchange—have on the effectiveness of the inoculation process?
The first and most obvious added effect of PIT is the interpersonal diffusion of inoculation messages along social networks. As research shows (e.g., Ivanov et al., 2015), the content of the information shared via PIT contains the original message components, thus dispersing the intended inoculation message content to individuals not reached by the original presentation of the message. This outcome increases the practical utility of the inoculation-based message strategy due to its increased reach. In addition, in circumstances that provide only limited opportunity for one-way traditional dispersion of messages (e.g., natural or man-made disasters impacting traditional and/or electronic channels of communication), an interpersonal dispersion of the risk and health inoculation message via social networks may prove to be an invaluable asset to a communication specialist. For example, in a country such as Nigeria where per capita distribution of television sets, cellular phones, and other technological devices is low (“Compare Countries,” n.d.), the ability to interpersonally diffuse an inoculation message about an Ebola outbreak and management strategies via social networks may be quite useful to a risk and health communication strategist.
The fact that inoculation messages are diffused interpersonally through social networks is quite beneficial for the purpose of risk and health message distribution; however, what effect does the PIT have on the interlocutors? After all, should the inoculation effect be eroded as a result of PIT, then the benefit gained from the process of interpersonal message diffusion would be offset by the diminished inoculation effect. To date, little is known about the effect of the inoculation message on the individuals receiving the message via PIT for the first time. What is clear is that non-recipients of the initial, traditionally distributed inoculation message may receive the inoculation message by talking to inoculated others (e.g., Dillingham & Ivanov, 2016b; Ivanov et al., 2012b, 2015). What effect inoculation has on these individuals is far less clear as, to date, no research has investigated the effect of inoculation when diffused through social networks. This remains an important empirical question.
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More is known about the effect of PIT on the initial inoculation message recipients. Ivanov and colleagues (2012b) investigated the attitudinal impact of PIT. Their results suggested that PIT has the ability to enhance attitudes. More specifically, they discovered that inoculation generates threat, which motivates anger against current attitudinal challengers and challenges. Both threat and anger inspire PIT, which enhances the target attitude. Dillingham and Ivanov (2016b) conducted a more nuanced comparison of attitudinal impact of inoculation messages both in the presence and absence of PIT. Their findings indicated that traditional inoculation using subvocal counterarguing moved the attitudes in the desired direction. PIT, on the other hand, enhanced the certainty or conviction with which those attitudes were held. Taken together, the above studies show that PIT not only benefits the strategy by increasing its reach, but also by enhancing the target attitudes.
As traditionally conceptualized, the dispersion of the risk and health inoculation message was considered to be a one-way linear diffusion of a strategist-controlled message. Recent research (e.g., Dillingham & Ivanov, 2016b; Ivanov et al., 2012b, 2015) has suggested that the process of inoculation message distribution may be two-tiered. Risk and health inoculation messages are initially dispensed with a communication strategist–selected modality or modalities using a precise message presented at desired times, frequency, and to a predetermined target audience. In addition, inoculation is also spread via PIT, which is not under direct control of the risk and health communication strategist. Thus, inoculation can be diffused using multiple modalities and, at minimum, in two ways: by direct, controlled, one-way transmission from source to receiver and also as information-exchange among the participants of the PIT process (Rogers, 1995; Rogers & Kinkaid, 1981). The outcome is an overall greater rate of risk and health message diffusion and stronger inoculation effects experienced by the initial message recipients.
The Future of Inoculation as a Risk and Health Communication Strategy in an Evolving Media Context
Different Modalities
While, as previously mentioned, extant research supports the notion that modality does not substantially impact the inoculation message outcome (Dillingham & Ivanov, 2016a; Pfau et al., 2000), some unanswered questions remain. The modality-neutral inoculation environment is encouraging for practitioners, but remains perplexing for scholars. Almost unanimously, leading mass communication theorists (see McQuail, 2010) advance the idea that medium and message have an inextricable interplay, even to the point of McLuhan’s (1964) legendary assertion that “the medium is the message” (p. 1). How, then, can inoculation theory ostensibly deviate from this norm?
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One potential explanation is that print and video inoculation messages generate the same overall outcome (i.e., resistance to persuasion), but do so via different processes. Potentially, differences in processing moderate generated resistance in ways that have yet to be explored. Pfau and colleagues (2000) suggested processing differences in their initial study of modality and inoculation, citing abundant support for dual-process models, namely the Elaboration Likelihood Model (ELM) (see Petty & Cacioppo, 1986). More specifically, the authors considered print messages a modality that required central processing and argued that video messages could be processed peripherally. As such, they argued, the print-generated resistance should bear the positive traits of central processing, such as more deeply rooted and longer lasting attitudinal resistance. While the authors’ subsequent hypothesis that a print inoculation message would generate resistance beyond the capability of video was not supported, their idea deserves reconsideration in light of the findings addressed in this chapter. Possibly, the print inoculation message did generate longer-lasting and more thoughtful, or intentional, resistance, but those nuances were not captured in the Pfau et al. (2000) analysis.
Pfau and colleagues (2000) measured attitude toward the attack as the primary dependent variable. As such, video and print inoculation messages did not show significant differences. However, could these results have differed if certainty about the attitude had been measured? Studies (see Dillingham & Ivanov, 2015, 2016a, 2016b; Pfau et al., 2005) that have measured attitude or belief certainty have done so as a separate outcome variable. If Pfau and colleagues’ (2000) suggestion that modalities engage different processes to arrive at the same outcome holds merit, possibly print could increase certainty in a way video does not, even though both print and video generate overall resistance. Results from the other study, which explicitly studied modality in inoculation message processing (Dillingham & Ivanov, 2016a), do not dampen the idea that print could encourage central processing while video leaves the opportunity for peripheral processing. Dillingham and Ivanov found that participants reported higher levels of beliefs and certainty in those beliefs when their print-generated resistance was attacked with both print and video messages. As such, print inoculation messages could have been processed centrally and yielded enhanced certainty.
Also, as previously discussed, save the work of An and Pfau (2004), several studies that have mismatched print and video messages have demonstrated the strength of print inoculation treatments. These studies do not confound the idea that print leads to central processing and video to peripheral. Banas and Miller (2013), Lim and Ki (2007), and Wong (2016) all failed to erode print-generated resistance with a video inoculation message. In addition, while their study primarily concerned metainoculation (i.e., inoculating against an inoculation treatment), Banas and Miller also suggested the possibility of heuristic and central processing in the inoculation process. Based on their findings, the authors noted that “inoculation . . . can work heuristically as well as through mindful processing” (2013, p. 200). The disparate video inoculation/video attack study results (Burgoon et al., 1978; Godbold & Pfau, 2000) also make more sense when viewed through the lens of processing differences. If video is a modality that is processed peripherally within inoculation theory, then various cues such as imagery, color, or sound, could alter the level of generated resistance. Future studies should explore the central and peripheral processing possibilities within inoculation theory as well as measure attitudinal certainty following print-generated inoculation treatments.
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Multimedia Campaigns
The lack of hindrance from modality concerns points to an intriguing future for multimedia risk and health-based inoculation campaigns. As research has shown (Pfau et al., 2000), both print and video inoculation messages can generate resistance, and future research may point to print engaging central processing. If central and peripheral processing are at play, practitioners have an even greater advantage as a print-based inoculation message is more easily controlled and precisely theoretically grounded (see Ivanov, 2012) and, presumably, distributed in a more cost-efficient manner via pamphlets, paper, email, websites, or other text-based media. Also encouraging for practitioners is the resilience of text-based inoculation messages to video attack (Banas & Miller, 2013; Dillingham & Ivanov, 2016a). While gaps in literacy could be an obstacle for practitioners using print-based inoculation risk and health campaigns, research has demonstrated that video inoculation messages can also generate resistance, thereby protecting pro-health attitudes (Burgoon et al., 1978; Pfau et al., 2000).
The notion that modalities can be mixed (in the inoculation message) and matched (with various attack formats) with relative confidence of the overall strategy effectiveness has empirical support (Dillingham & Ivanov, 2016a; Pfau et al., 2000). Video could also accompany the print component similar to the work of Wong (2016). While studies have explored mismatched (print inoculation and video attack and vice versa) treatment effects, to our knowledge Wong has pioneered combining modalities within the treatment condition. The efficacy demonstrated in his study is encouraging for practitioners. The video message does not seem to overwhelm or distract from the print inoculation message; rather, the two seem to work in unison. Future research should explore the impact of multimedia (i.e., combination video and print) attack messages to ascertain the impact of mixing media types in both the inoculation and attack message. Furthermore, in contrast to the modality-neutral results (Dillingham & Ivanov, 2016a; Pfau et al., 2000), support for integrating evocative visuals in inoculation video treatments as a strengthening mechanism is consistent (Nabi, 2003; Pfau et al., 2006, 2008).
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Practitioners can assert a reasonable degree of confidence that venturing beyond the traditional format of inoculation message design (see Ivanov, 2012)—i.e., using a degree of creativity in designing the audiovisual components that accompany the inoculation message—would not sacrifice message effectiveness. While at this point suggesting supplanting the print inoculation message with video is unwarranted (Banas & Miller, 2013; Pfau et al., 2000), when working with media-saturated populations such as adolescents, the use of evocative and memorable video should not derail inoculation-generated resistance (Wong, 2016). While still images have not been studied, the modality flexibility evidenced via video study (Dillingham & Ivanov, 2016a; Pfau et al., 2000) could translate to text-accompanied photographs. A recent non-inoculation study (Dixon, 2016) about two-sided (pro and against) health messages demonstrated greater recall and higher risk perception related to negative behavior when photos accompanied text that explained the pros and cons of vaccination. Continued applied experimentation with print, video, photo, and even interpersonal communication is warranted based on the findings here reviewed.
One modality concern not addressed by inoculation research, though probable in a real-world health campaign, is the effectiveness of audio-only messages presented through media such as radio or podcast. Particularly in natural disasters (see Kingsley Westerman et al., 2011), radio waves could be the lone form of communication during the early stages of relief. Could inoculation messages be dispersed via radio that advise victims to follow safety recommendations despite fear or temptation to flee and/or crowd public spaces? Inoculation research has demonstrated the efficacy of one-modality messages, though print has been dominant (Compton & Pfau, 2005). Perhaps the one-modality effectiveness could extend to audio inoculation messages. Future research should explore this possibility to boost use in health and risk contexts.
Social Media
An uncharted territory of inoculation research is continued efficacy in interactive media environments, both synchronous and asynchronous. The modality-neutral likelihood, alongside growing support for the idea that interpersonal conversation can complement, rather than supplant, the internal inoculation process (Dillingham & Ivanov, 2016b) certainly does not discourage the idea that people using the Internet as a communication tool can (co-)create and possibly share inoculation effects. The research and applied potential is considerable. Can a person share an inoculation message on Facebook, for example, have the message attacked via comments, and demonstrate generated resistance with a counter-comment? Can witnessing the entire inoculation attack cycle serve as a threatening—and potentially resistance-instilling—mechanism for standby social media observers? Likewise, can a Twitter retweet of an inoculation message serve the same strengthening function as a PIT conversation (see Dillingham & Ivanov, 2016b)? These and other questions should be addressed with further research. In addition, when considering the possibility of dispersing inoculation messages using social media, the length of messages becomes a key question. More specifically, inoculation messages used in research have tended to be longer than those allowed (e.g., Twitter’s 140-character limit), or reasonably expected, in social media environments.
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Terse messages. The emergence of new communication technologies and social media are requiring risk and health inoculation scholars to reconsider both the inoculation message structure and delivery (see Compton & Ivanov, 2013). Traditionally, inoculation messages have favored print or audiovisual formats, delivered via traditional modes (e.g., television, newspaper, etc.) and featured extended message length. For example, Parker and colleagues (2012) designed a successful inoculation message aimed at boosting condom use among sexually active college students. The length of that message was 1,378 words. With the emergence of texting and social media as methods of communication that require a terse way of communicating (e.g., Twitter is limited to 140 characters), the question risk and health inoculation scholars face is whether inoculation messages can be adapted to take full advantage of media specialized in dispensing these short message forms. This need is especially pronounced in the context of risk and health communication where emergency alert systems (EAS) distribute important messages using 90 characters or less (Wimberly, 2015). Yet, relatively little data-driven research exists informing effective message design for these media in general, and in the context of health-related warning messages dispersed by public safety officials in particular (Sutton, League, Sellnow, & Sellnow, 2015). So, can risk and health inoculation messages be “fitted” to be applicable with short-form message dissemination media forms?
Compton and Ivanov (2013) suggested that the length of inoculation messages can be considerably reduced without losing their effectiveness. Similar to their political communication example, consider the following health promotion message aimed at recovering addicts and designed to prevent relapse: “They’ll tell u 2 use. It might feel good. But, u use even once & u r back on the bottom. Broke. Helpless. Fight back. Don’t give in.” (132 characters). This message, suitable for distribution via text or Twitter, has all of the features an inoculation message should have. First, it provides threat. It does so explicitly by submitting a forewarning (e.g., “They’ll tell u 2 use”). It then proceeds to offer additional threat implicitly (or inherently; McGuire, 1970) by presenting the receivers with real challenges they are likely to encounter in the future (e.g., “It might feel good”). To clarify, threat is a required requisite of inoculation, not explicit forewarning (Compton, 2009). Threat can be elicited explicitly via a forewarning, but also implicitly through the presentations of counter-attitudinal arguments as applied in the above example. Thus, even though a forewarning was used in the example, it is not required for the inoculation-based process to be unleashed and can be omitted should message length become an issue. For example, the same message can be pared down to fit the 90-character length used in risk and health EAS messages by dropping the forewarning (e.g., “Using may feel good. But, u use once. U r back on bottom. Broke. Helpless. Don’t give in.” [89 characters]).
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The risk and health terse message exemplified in the previous paragraph also provides receivers with a refutational preemption, by refuting the benefits of performing the behavior (e.g., “But, u use even once. U r back on the bottom. Broke. Helpless.”). The message ends with an encouragement to continue to defend the attitude or behavior (e.g., “Don’t give in”).
Overall, the example terse message provides its recipients with the motivation to bolster their ability to defend their positive attitudes toward, and/or behavior of, staying sober by showing individuals that their newfound sobriety is likely to be assailed. It then provides them with guided practice of how to counterargue attacks on their sobriety. But this example represents just one way that inoculation can take advantage of short format risk and health message dispersion media. The message can be augmented by inserting a hashtag, which could lead the message receiver to additional refutational or attitude consistent information. Furthermore, the risk and health inoculation message could be designed to provide only an explicit forewarning in the terse message with a link that would take the reader to the full-length refutational component of the message. Using the same topic as above, the inoculation message may be worded in the following way “It’s been tough. But, U r sober & in recovery. Yet b wary of pride and old habits. U r not safe. Test is coming. Can u pass it? Find out here.” (140 characters). The above message provides a forewarning suggesting that despite the person’s recent success aimed at long-term recovery, the hard work is at stake. The forewarning is designed to motivate the recipient to press on the link (i.e., represented by the underlined word “here”) where the refutational component of the message can be presented in its full length whether as text, audio, video, or a combination thereof.
Consequently, as exemplified in this section, risk and health inoculation messages could be adapted to take full advantage of short text dispersion media. Their rate of success is an empirical question that necessitates further investigation. However, in a modern environment where individuals rely of their technologies, such as smart phones, tablets, and computers, for information gathering and processing, for inoculation to continue to be a relevant risk and health message strategy, its method of dispersion and presentation has to fit the audience preferred modalities and formats of message reception.
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Booster messages. Although the extant research has unequivocally shown inoculation to be an effective message strategy in general (Banas & Rains, 2010) and in the risk and health contexts in particular (e.g., Ivanov et al., 2016; Parker et al., 2012; Wong & Harrison, 2014), its effects erode over time (McGuire, 1962; Pfau, 1997; Pfau et al., 1990; Pryor & Steinfatt, 1978). This outcome is likely a result of message (Stiff & Mongeau, 2003) and motivation (Insko, 1967) decay. As Insko suggested, “induced motivation” to accumulate “belief-bolstering material” will decline over time following “the ordinary forgetting curve” (p. 316). To compensate, inoculation strategists have relied on booster shots, or message reinforcements, with some effectiveness (Pfau, 1997; Pfau & Van Bockern, 1994). The main challenges frustrating inoculation strategists when using inoculation boosters have dealt with the proper timing of the booster shots after the introduction of the initial inoculation message, as well as the proper form, length, and frequency (see Ivanov, in press; Ivanov, Parker & Dillingham, 2016).
The form and length of the booster shot is especially relevant when deciding on the modality of risk and health message distribution. With evolving traditional and social media technologies available to the message strategists, booster messages that can be quickly disseminated through these media should be of particular import and interest. These messages may take longer-length form, as traditionally constructed (Pfau, 1997; Pfau & Van Bockern, 1994), or may even be presented in a terse format. For example, a current risk and health intervention campaign using inoculation to combat the risk of relapse among recently sober addicts, as a follow-up to the inoculation message, is dependent on the use of short text messages to reinforce or boost sobriety.
Evolving media technologies in general, and social media in particular, allow for new ways of delivering booster messages that can be done with better timing and frequency (e.g., using preset triggers for text or e-mail messages). Inoculation messages have been shown to be effective in combating complacency and enhancing resilience (Ivanov et al., 2016). Boosters, which can help assail the threat of message and motivation decay, can play a significant strategic role by reaching message recipients quickly and frequently through different social media platforms and mobile devices (e.g., Twitter, mobile phones, Facebook, tablets, etc.). As such, risk and health inoculation strategists have the opportunity and responsibility to take full advantage of these new modes of booster message delivery.
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Post-inoculation talk. Up to this point, the chapter’s discussion regarding PIT has centered on the questions of whether inoculation message recipients, including those of risk and health messages, engage in such talk and for what reason (i.e., advocacy, reassurance, or both). However, what has received little consideration to date is the understanding of how individuals talk. Stated differently, over what conversational vehicle does the talk take place? Do individuals engage in PIT face to face, via telephone, on Twitter or Facebook, or do they use other and/or multiple modes of communication? The preliminary results of an ongoing study suggest that inoculated individuals talk to multiple others about the message topic and content. In some cases they use the same mode (e.g., in person or face to face) with multiple discussion partners, while in other cases they use different modes with different discussants. What is still unknown is whether individuals have multiple conversations with the same partner over different modes and whether the mode of conversation has an impact on, or is impacted by, the conversational channel.
Compton and Pfau (2009) suggested, and Ivanov and colleagues (2015) affirmed, the usage of PIT for the purposes of both reassurance and advocacy. In addition, Ivanov et al. (2015) discovered PIT in the form of advocacy to encounter greater numbers of counter-attitudinal challenges than PIT in the form of reassurance. Due to reduced normative pressures and inhibitions (Bordia, 1997), computer-mediated communication may be more conducive to social debate (Berger, 2014). If so, then social platforms may be better suited for advocacy-focused PIT, where such preference may not be present with reassurance-motivated PIT. As a result, the PIT channel used for message transmission may moderate the approach taken in the discussion (i.e., to advocate or to self-reassure). Alternatively, the primary purpose of the PIT (i.e., advocacy vs. reassurance) may influence the conversational channel selected. Moreover, inoculated people may choose different conversation channels with different individuals based on the primary purpose of the PIT. The referenced study in progress is designed to provide some answers to the above speculations, but more future research is needed to uncover the impact of modality on the purpose and content of PIT. The potential interaction between modality and the purpose of PIT (i.e., advocacy vs. reassurance) may have a significant impact on the effectiveness of risk and health message diffusion and desired outcomes. For example, faced with an Ebola crisis in affected areas lacking technological devices and platforms needed for computer-mediated communication, inoculation recipients may be counted on to advocate the proper risk and health prevention strategies. However, if these inoculated individuals are not likely to engage others face to face to propagate the message, then the social diffusion advantages of inoculation-elicited PIT will be negated.
Overall, PIT extends the utility of risk and health inoculation-based strategies as it boosts the attitudinal (or behavioral) defenses of target message receivers and aids message diffusion along social networks. However, the transmission channel and platform could potentially impact the process of PIT. As such, the impact of evolving technologies and media on the process of PIT must be considered by risk and health inoculation-based strategists.
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Conclusion
Effective message design continues to be an important component of successful communication approaches undergirding risk and health prevention and management strategies (Ivanov, 2012; Ivanov et al., 2016; Pfau, 1995). Due to their demonstrated effectiveness (e.g., Ivanov et al., 2016; Parker et al., 2012; Pfau & Van Brockern; 1994; Wong & Harrison, 2014), inoculation-based messages have gained interest and popularity as risk and health communication strategies (see Compton, 2013; Compton & Pfau, 2005; Ivanov, 2012, in press). However, for inoculation-based approaches to remain relevant, viable strategic options, and for them to continue to gain popularity, their practical application using traditional print and video modalities need to be aligned with multimodal realities of today’s digital and social media environment. This chapter provided a review of the robust nature of inoculation-based strategies when used with different traditional, single and mixed modalities. In addition, it featured specific suggestions on how risk and health strategists may be able to take advantage of the evolving media environment in order to enhance the effect and practical application of inoculation-based strategies. By providing examples, as well as direct and ancillary evidence, a call to action was extended to test the efficacy of the strategy in a multimodal, digital environment in order for strategists to take full advantage of the evolving communication technologies.
As a multi-level (i.e., linear and information-exchange) dispersion strategy, inoculation shows significant promise for risk and health prevention and management strategists. Its robustness across different modalities demonstrates the opportunity to deviate from inoculation’s standard modal form in order to capitalize on the greatest delivery and presentation prospects. As such, it presents a significant advantage as inoculation provides communication strategists with the potential to incorporate terse and booster messages in the campaign design, as well as take advantage of the ability of inoculation messages to be diffused over social networks.
Successful risk and health prevention and management will continue to depend on the effectiveness of communication strategies supporting these activities. Inoculation-based messages can provide the foundation on which such effective strategies can be built. With the potential to be dispersed across different modalities and forms, inoculation messages provide reliable and exciting strategic approaches that may help maximize the diffusion and intended effect of the targeted communication. Thus, if applied properly, the potential of inoculation-based strategies may be “boundless” (Ivanov, 2012, p. 77) in the rapidly evolving media environment supporting effective health and risk communication.
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