Original Research

The power of narrative health communication: Exploring possible effects of first-hand experiential stories on cancer awareness amongst university students

Karabo Sitto, Elizabeth Lubinga, Molemi Geya

Received: 06 Jan. 2021; Accepted: 21 July 2021; Published: 27 Sept. 2021

Copyright: © 2021. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Narrative health communication has the potential for effective health promotion about cancer amongst youth from low- and middle-income countries such as South Africa. Sub-Saharan Africa experiences a rising cancer-related disease burden with predicted increase of over 85% by 2030. Whilst promotion through communication, of cancer prevention strategies targeting 18–29 year olds remains scanty, it is crucial for cancer prevention behaviour before the disease develops. The study aimed at examining how narrative storytelling can create cancer awareness amongst students at the University of Johannesburg. A qualitative approach was adopted. During October 2019, an awareness session that formed part of a month-long health campaign involving various activities for students, promoted preventative behaviour leading to early cancer detection. Campus Health Services in collaboration with other University departments invited six cancer survivors and experts to share stories about their various cancer experiences with students and staff. Many of the participants aged between 18 and 49 years, indicated that they did not know how to engage in self-examination of their bodies and had never taken any cancer tests. Most of the participants expressed a willingness to engage in frequent self-examination and visiting health facilities to receive regular professional tests as a result of storytelling. Results may assist health promotion organisations with the construction of effective cancer health messaging especially for hard-to-reach groups such as youth in developing countries.

Keywords: spoken narratives; cancer awareness; South African University; young South Africans; cancer survivors.

Introduction

Narratives can serve as important interventions in health-related communication. Narratives have the potential to become an effective public health communication strategy for behaviour change.¹ Narratives have acted as strategies for health communication and have proved to influence health-related matters ranging from human behaviour to policies.² Narrative health communication is defined as a form of persuasive communication in which a health message is presented in the form of a fictional or non-fictional story, as opposed to being presented as statistical evidence or arguments to promote health-related behaviours.³ Research has yet to establish the most effective modality, content and format regarding the use of narratives for cancer-related health communication. In terms of content, a meta-analysis of 153 experimental studies on the use of narratives for health communication⁴ indicates that narratives proved to be more effective when they involved the use of highly emotional content. Specifically, regarding narrative content and emotional effects, narrative warnings are capable of generating transportation and identification,⁵ both of which relate directly to perceived effectiveness through the emotion of sadness. Identification involves audiences taking on ‘the protagonist’s goals and plans’, which results into the audience ‘experiencing emotions when these plans go well or badly’.⁶ Transportation theory defines what happens when individuals immerse themselves into a story or get transported into a narrative world where they may show effects of the story on their real-life beliefs.⁷ Narratives involve people’s experiences or transportation of audiences into narrators’ lived-experiences.⁸ Narratives elicit emotional responses in audiences and forge strong and memorable experiences based on the experiences of the main character(s).⁹ Given the threatening nature of cancer, it may be impossible for messages to achieve behavioural change goals without intentionally or unintentionally arousing their audiences’ emotions.¹⁰ Dillard and Nabi¹⁰ proposed six emotional reactions that people may have to cancer-related messages as surprise, fear, anger, sadness, happiness and contentment.

Yet narrative strategies do not operate at one level. In addition to emotional depth, they usually encompass many facets with varying modalities and format, length and complexity of the plot form part of narrative strategies.⁸ For health-related narratives, healthy behaviour rather than unhealthy behaviour leading to negative consequences could better be associated with effects on intentions to change health-related behaviour.⁴ These authors posit that the diversity of narrative characteristics and effects that have been found in experimental studies make it imperative for research efforts to continue, to determine which characteristics lead to effects. Five types of narrative communication are identified for different communication purposes.¹¹ Firstly, official stories can be constructed in order to tell an innocuous version of events or the position of a group. Secondly first-hand experiential stories can be told mostly by survivors. Thirdly, second-hand stories of others can be retold. Fourthly, culturally common stories that are generalised and pervasive in a cultural environment can be told. Lastly, invented or fictitious stories can be made up for purposes of identifying influences on targeted audiences.¹¹ This article specifically examines effects of first-hand experiential stories told by cancer survivors and experts amongst university students. The article attempts to examine effects of narrative storytelling by assessing audience emotional responses to each narrator’s story.

Effectiveness and benefits of narratives for cancer-related messaging

Sub-Saharan Africa is experiencing a rising proportion of an overall disease burden attributable to cancer, with the region predicted to have a greater than 85% increase in cancer burden by 2030.¹² Persuasive health communication could play a positive role in mitigating cancer burden amongst targeted audiences. As a result of under-preparedness on the part of health systems and bodies, particularly in developing and underdeveloped countries, many individuals live with cancer undetected for dangerously long periods of time.¹³ This predicted cancer burden requires exploration of more effective methods and early communication to enable the reduction of cancer as a cause of death, particularly amongst younger people.

There are numerous benefits accruing from using narratives to communicate about cancer, including the reduction of fear and resistance, help with easier processing of new or complex information, building stronger attitudes and behavioural intentions and providing role models for changed behaviour.¹⁴ The main role players play a pivotal role in the attitudes of recipients audiences, particularly in terms of how similar or different they are to themselves.^9,14 Role players may be fictional or non-fictional. Conversely, the effectiveness of narratives may be negated through social distance. Social distance describes the perceived social difference between the main character and the recipient of the story.¹⁵ Narratives may create social distance. When a person listens to a story and perceives themselves to be distant from the main character, then the effectiveness of the narrative is diminished.⁹

The power of using narratives to deliver messages effectively² generally lies in the fact that they are easy to understand and are memorable to targeted audiences. Specifically, in using narratives to communicate cancer,¹ two factors are found that make narrative persuasion effective: whether characters live or die and whether they encounter key barriers. First person narratives or testimonials, particularly positively influenced participant, need to search for more knowledge about colon cancer screening and behavioural intentions to go for screening.¹⁶ The effect of those first person narratives or testimonials lay in the vividness of the message to the participants. Narratives are effective methods of persuasion by demonstrating experience of main characters and behaviour,⁹ especially for a complex disease such as cancer. Narrated stories are powerful, motivating and can make important contributions to empowering both message recipients and main characters.¹⁷

Challenges of communicating about cancer to the youth

Amongst youths aged 18–29 years, little attention has been given to cancer prevention strategies, yet it is important to promote cancer prevention behaviour before cancer develops.¹⁸ Globally, particularly in disadvantaged communities and amongst the youth, large disparities in the occurrence and death from cancers such as cervical cancer remain.¹⁴ The most alarming growth in the number of cancer diagnosis globally lies amongst the youth and more especially young women.¹⁹ This age group, amongst which university students fall, represents a critical developmental period that can provide a foundation for the formation of mindsets and worldviews that will ultimately shape future health habits and lifestyles.²⁰ Early communication is important considering that some of the risk factors for cancer directly relate to prevailing lifestyles such as binge drinking, which amongst adolescents has been widely studied globally.²¹

Spreading the message about cancer especially amongst young people remains a difficult communicative task.¹³ In many communities, particularly in low- and middle-income countries, young people contend with health knowledge gaps because issues of health are closely guarded as a result of people’s beliefs and norms.²² Language is also a challenging barrier, driven by the use of technical terms that are untranslatable for cancer treatments and diagnoses, making it difficult for persons diagnosed to understand and trust.²³ Cancer communication and messaging requires innovation and reconfiguration to improve early detection and survival rates, particularly amongst young people in developing countries. Although more than half of all cancers are not preventable, early screening actions including mammography and bowel cancer screening help to ensure that cancers are diagnosed and addressed in early stages, which can result into better survival outcomes for patients.²⁴ There is a paucity of cancer messaging that specifically targets young people. Communication about cancer is often too generic and is likely to present as irrelevant to young and healthy individuals.

Cancer communication targeted at young people that is overt in its effort to be ‘youthful’ can miss the mark and make intended recipients feel distanced from the message. In using narratives, perceived similarity to the narrators leads to transportation, that is, closeness, makes recipients ‘see’ themselves through the storyteller’s perspective. ‘Individuals appear to more readily adopt behaviours demonstrated by models they consider similar to themselves’.¹⁴ These similarities may include obvious physical characteristics such as gender, race, ethnicity and age.¹⁴ Amongst students,⁵ it was found that age similarity, but not gender similarity, had an effect on identification with the protagonist, yet neither seemed to matter for older adults.

The purpose of this study was to examine how first-hand experiential narratives person stories could influence cancer awareness amongst a group of university students in South Africa. The intention of organising a session by cancer survivors, which involved the narration of their experiences, was to influence the university students’ intention, as recipients of the messages contained in the narratives, to make behavioural changes with respect to their health. The article attempted to establish which narrative source (public figure, peer, celebrity, gender, expert) appealed to the audience the most through the emotions that the audience experienced and to determine audience intentions to engage in cancer prevention behaviour after the awareness session.

Theory

To answer these questions, two theories, the source credibility model (SCM) and the health belief model (HBM) were applied. Whereas the two models differ, in terms of their origins, they agree in terms of the effectiveness of message sources. It may be argued that SCM is one that is implicitly based in rhetoric studies, whereby a communication is intentionally constructed in order to achieve a desired effect. However, the awareness session upon which the article is based, was set up with an intention of influencing audience members to engage in cancer preventative behaviour – specifically self-examination in order to achieve early detection of cancers. This approach makes the SCM and the HBM relevant to the study.

Source credibility model

The SCM has its roots in marketing, conceptualised by Hovland et al.²⁵ The focus of the model is on the effectiveness of the message by evaluating how credible recipients perceive it to be. The original authors observed expertise and trustworthiness as two critical factors affecting persuasion in marketing messages’ influence.²⁵ Attractiveness was proposed by Ohanian²⁶ as a third factor of credibility, further developing the concepts into a theoretical model. Credibility refers to a person’s perception of the truth of a piece of information²⁷ as working definition for this study.

Source credibility considers the targeted audience of the message, the author of the message and the contents of the message in assessing credibility of communication. This message includes narratives as communicative tools for conveying ideas and persuading audiences. The three key elements of trustworthiness, expertise and attractiveness hold the following definitions:²⁷

Expertise: The extent to which a communicator is perceived to be a source of valid assertions

Trustworthiness: The degree of confidence in the communicator’s intent to communicate the assertions he considers most valid

Attractiveness: The attraction aspects of the communicator that he or she generates, which are consistently liked more and have a positive impact on products with which they are associated. (p. 5)

Throughout communication history, the power of messaging proves to be stronger and more credible when it comes from sources that people trust directly. The power of word of mouth is unquestionably stronger than any other channel of information dissemination. This holds true even for health communication, where testimonials or narratives of people living in communities hold more weight than any prepared messages from other sources. In an undifferentiated environment, such as cancer communication, testimonials can be used to differentiate messages.²⁸ Attractiveness, expertise and especially trustworthiness are important in a testimonial strategy²⁸ because all three factors play a role in the recipient’s perceptions of the message shared. Health communication when successful in delivering effective messages can influence behavioural intentions of recipients as an outcome.

Testimonials are a form of narratives, sharing non-fictional experiences of narrators with audiences. First-hand experiential narratives are testimonials because they are a narration of individuals non-fictional experiences. In many instances, particularly with respect to health communication narratives about cancer, non-fictional experiences are believed to possibly lend more credibility to the stories.¹⁴ The factor of attractiveness in the SCM is about how drawn recipients are to the message, that is, the perceived similarity to narrators they find similar to themselves.¹⁵ The narrator has to consider the relevance of their story to the recipients, as well as packaging how they tell their story, based on their experiences, in this case, with cancer. Expertise as a factor is concerned with how knowledgeable the narrator is perceived to be and considers themselves to be about the subject, for example, often perceived as having authority on the subject matter, in the case of cancer either as a healthcare professional, a survivor or a person living with cancer. The trustworthiness factor of the message or story rests on the authenticity of the narrator, their narrated experience and their connection with the recipients of the message. The trustworthiness is concerned with not only the contents of the narrated story, but who is telling it, the context in which they are doing so and how they deliver it. The success of cancer narratives in terms of achieving cognitive, affective and behavioural intention are affected by existing audience health beliefs. The narratives, the narrators and their credibility may be external to recipients’ attitudes and beliefs with respect to health, specifically cancer amongst youth.

Health belief model

The HBM is widely used to evaluate, explain and predict individual health-related behaviours with respect to taking up of health services. In the case of cancer, the main features of the messaging are early detection and lifestyle interventions to lower or prevent diagnosis. The HBM centres on the individual and factors that may affect individuals’ actions in relation to their health. The variables in the model are broadly categorised into three types: (1) modifying factors, (2) individual beliefs and (3) action.²⁹ The modifying factors include demographic variables such as age, gender and social class, as well as psychological characteristics such as personality.³⁰ The individual beliefs include the individual’s perceptions in relation to the disease,³¹ in this instance, cancer. The action factors are premised on the perceived benefit of taking action, driven by the cues to action, or triggers for an individual to act, which may be internal and/or external.²⁷

The perceptions held by individuals are driven by their beliefs, which are informed by the information they receive, its source and its credibility. The credibility is multidimensional, including credibility of the source and credibility of the message as perceived by the recipient. The more credible a narrative is about health, the more certain the perceptions are of recipients of the health message and ultimately, their actions in relation to interventions for their health. Their personal beliefs in relation to health messages include their perceived susceptibility to the disease, perceived severity of the issue, health motivation and their perceptions of the benefits and barriers of taking action.^27,29,30,31 With respect to healthcare narratives, the more relevant recipients find the stories, the lower they demonstrate social distancing behaviour¹³ with respect to the message and/or narrator.

The credibility of the message is directly linked to behavioural intentions in the SCM,²⁶ which can be compared with the cues of triggers to action in the HBM.³¹ Source credibility predicts public attitudes and determines the effectiveness of the communication on recipients of the message.³² This is because the message recipient is critical in forming attitudes about the message and its sender too.²⁷ The source of the message tells their narrative by sharing/narrating their story with the recipient.²⁸ For the receiver to take action, they need to perceive that there is truth contained in the message²⁸ particularly the narrated testimonial of an individual about their health-related experience, whether personal or professional.

Methodology

Research approach

This study took a cross-sectional qualitative approach. A descriptive design involved a narration of personal experiences by a panel made up of cancer survivors to a group of approximately 100 University staff and students. A total of 50 students voluntarily participated in the study. In October 2019, the students and staff attended a university library talk about cancer awareness as part of the activities of cancer awareness month run by the University Primary Health Division in collaboration with other departments. All campaign communication and messaging fell under the themes #SaveYourLife #ProtectYourAssets with the intention by the Campus Health division to educate students about early detection and the importance of self-examination.

Procedure

A panel was selected to address university students and staff about cancer awareness activities by a multidisciplinary team at a South African university consisting of health professionals, radiology specialists, academics, leaders of the student representative body and event project managers and executive management. The main drawcard for cancer awareness meeting was the public figure, a prominent South African government minister who is a cancer survivor. The mix of panellists depended on the factors of credibility and social similarities, that is, expertise (through training or experience), trustworthiness (personal experience) and similarity and attractiveness (age, status), which would make the quality of their narratives relevant to the event attendees as recipients.

The underlying intention was for the selected speakers to provide narratives, which could be non-threatening, yet give a realistic and relatable perspective of cancer to young people. Other considerations in selecting the speakers for the panel were diversity of experiences, age, background, expertise, gender and types of cancer the survivors had been diagnosed with, to enable the likelihood of similarity with the target population. The single all-encompassing criteria for all panel members were that they had to have experienced close encounters in dealing with cancer. Panel members were not prompted in terms of how or what stories to tell, enabling relay of unscripted stories. The event was hosted at the main campus library, to allow for ease of travel, access for students to attend the seminar and familiarity of environment.

The first speaker was a prominent South African government minister, female, aged over 60 years, who survived breast cancer. The second speaker was a young female in her mid-thirties who had survived breast cancer after being diagnosed at the age of 30. The third speaker was a male radiology technician who had experience with diagnosis amongst cancer patients. The fourth speaker was an experienced male medical doctor, who had consulted with cancer patients in his community engagement work. The fifth speaker was a male upcoming musician aged 25 years who survived multiple bouts of leukaemia between the ages of 19 and 23. The sixth and final speaker was a female activist and social media influencer aged 25, whose non-governmental organisation is involved in creating awareness about cancer and who survived skin cancer.

At the cancer awareness session, the first author who chaired the panel, introduced each panellist by name and title and then invited each of them to share their stories about cancer. They each had 10 min to narrate their experience with cancer, as well as offer up some advice. Once all the panellists had spoken, the session moved into a question and answer session, where audience members could ask questions directed to the different narrators.

Qualitative data collection tool

At the end of the session, audience members were invited to complete a self-administered reflective questionnaire. Qualitative data collection tools such as reflective questionnaires enable customisation to the specifics of a study.³³ The reflective questionnaires were handed out at the beginning of the event, to enable attendees to pay attention to participant information in order for them to fill in the correct information for each of the sources. They contained a section for biographical details, followed by six open-ended questions soliciting opinions about the narratives they had heard on the day. The questions assessed perceptions about the most influential narrative, source of the narrative’s credibility, possible knowledge gained and possible action to be taken to change behaviour.

Ethical considerations

The reflective questionnaire provided for informed consent in which participants were provided with the details of the session. Anonymity was ensured by marking each questionnaire with a number prior to the event and requesting the participants not to sign their names. Voluntary participation was ensured by informing attendees that by choosing to fill in the reflective questionnaire, they consented to participation. Some of the attendees chose not to participate. Even though more than 100 people attended the session, only 50 forms were completed, translating into a response rate of close to 50%. The University Registrar of Students and the Faculty of Humanities Ethics Committee (ethical clearance number: REC-01-116-2019), gave permission to the authors to conduct the study.

Analysis

The questionnaires were collected immediately after the event and the responses were captured using a Google form. The responses were coded and then analysed thematically. Results reflected perceptions regarding narratives, which proved to be the most credible, reasons for credibility and potential trigger for participants to take action towards changing personal behaviour regarding individual health.

Results and discussion

The purpose of the study was to examine how first-hand experiential narratives created cancer awareness amongst university students. Thematic analysis was conducted to find out what the most emergent themes were, in terms of selection of the most credible sources and why, lessons learnt from the cancer awareness talk and behavioural intentions.

Descriptives

Amongst the 50 attendees who participated in the study, 30 were male and 20 were female. The participants were aged between 18 and 49 years, with the majority aged between 21 and 25 years old. Four participants, two each were aged 18 and 19 years. Amongst the participants in the 20s, which cover the most common ages amongst university students, there were no participants aged between 26 and 27, with only three aged 20. There was only one participant each for ages 28, 32, 34, 36 and 49 (see Figure 1).

FIGURE 1: Study participants by age (n = 50).

Age is an important aspect of this study, which intended to examine how narratives would relate to cancer awareness amongst young South Africans.

Sources and credibility

In terms of the sources and perceptions of credibility in line with the SCM, a variety of themes emerged.

Source credibility and perceived similarity

The source that appeared to have been considered most credible and whom most of the participants choose was the male budding musician aged 25, who had survived cancer between the ages of 19 and 23 years. Most participants could identify with the source leading to perceived similarity. A number of participants (n = 20) specifically selected the peer source and his narrative because the experience happened to the speaker at a young age and that they could relate to a young person who went through the experience.

‘The age at which he was diagnosed and how easy it is for us to ignore things because we think they’ll go away.’ (Participant 4, female, aged 25)

‘… because he was diagnosed at 19…touched me because I realised it could happen to me ….’ (Participant 10, female, aged 23)

‘That he was diagnosed at a very young age, this shows how anyone at any age is vulnerable to getting cancer and that we should take it very seriously.’ (Participant 14, male, aged 21)

‘Neo’s story because he was young when he was diagnosed, which is a reality slap that even young people can get cancer.’ (Participant 18, female, aged 21)

‘It goes to show us that cancer can affect anyone (healthy or sick) at any age and when it is left unattended because of ignorance or in denial it can have severe consequences that would end up being long term.’ (Participant 20, male, aged 24).

‘He was young at the time of his diagnosis, which proves that cancer is not an issue of age. It affects everyone.’ (Participant 22, male, aged 21)

‘It is about a young man who was diagnosed with cancer at a very young age.’ (Participant 26, male, aged 20).

‘I’m also around that age and it could happen to me.’ (Participant 30, male, aged 22).

‘I really felt touched by the fact that he had cancer 3 times whilst he was very young.’ (Participant 25, female, aged 19)

‘The fact that he was diagnosed [sic] with cancer at the same age.’ (Participant 34, male, aged 18).

One of the participants found the same source credible, but from a slightly different angle. The participant felt that she could identify with the source not only because he was diagnosed at a young age but also because the type of cancer was similar to the one that her father suffered:

‘His cancer was similar to the one my father was diagnosed with. I was touched by the fact the he was diagnosed at a very young age, and he managed to conquer the cancer.’ (Participant 40, female, aged 22)

These findings are in line with the existing literature about the effectiveness of perceived similarity in ensuring credibility of stories, with the more credible narratives relying on attractiveness based on the way the stories are told and personal experiences.¹³ In this case, given that the majority of participants were aged between 21 and 25 years old, they could identify with the narrator who falls within the same age, but underwent the experience at a younger age. The fact that they could have been in the same position by virtue of their age, lends credence to that particular narrative. It is noteworthy that only one of the participants in the 30s+ years age group selected the narrative by the peer source and it was on the basis of not having identified the illness as cancer rather than based on the fact that he was young. Furthermore, the narrative evoked emotions of sympathy amongst participants who by comparison (to themselves) considered the ‘tender’ age (younger than themselves) at which the peer source experienced cancer. It was also memorable to the participants, that the narrator together with his parent in the know about his illness, took painkillers for a year out of ignorance, unbeknown to both that he was faced with a more severe disease.

Range of emotions

A range of emotions emerged from the responses representing what appealed to the participants about the testimonials. The emotions ranged from sympathy to fear and admiration.

Sadness

Apart from the peer source selected as number one, the second source was the public figure, who is also a government minister. From the responses, the participants appeared to be affected by her narrative whereby she had to go through multiple experiences of losing a child, being diagnosed with and undergoing cancer treatment, whilst having to attend to her duties simultaneously. The emotion of sadness represents loss and tends to lead to failure to meet goals.⁹ Participants said:

‘Regardless of an occupation/title/status, it is actually true that cancer is out there and it is really devastating.’ (Participant 1, male, aged 24)

‘Lost kid whilst being diagnosed.’ (Participant 6, male, aged 25)

‘I had someone who was also diagnosed (sic) with breast cancer before and I do understand the basic pain that she went through.’ (Participant 17, male, aged 25)

‘… panellist went through cancer after she lost her child, had a lot to deal with.’ (Participant 32, male, aged 23)

‘The fact that she had just lost a child, and sadly as a leader she must have been through an emotional trauma.’ (Participant 35, female, aged 25)

‘The pressure of paying attention to the state matters/problems and dealing with cancer treatment after one of the members of her family….’ (Participant 42, male, aged 23)

The source who was placed third in terms of selection and seems to have garnered sadness combined with contentment from the participants was the 30-year-old female who had undergone a double mastectomy. Contentment creates satisfaction that aspirations have been met.¹⁰ For this source, participants seemed to sympathise with her from the detail of her narrative and the experience that she went through:

‘The detail and the experience she went through.’ (Participant 13, female, aged 23)

‘The process of dealing with it both emotionally and financially straining.’ (Participant 23, male, aged 23)

‘… cancer survivor who had a bilateral [sic] mastectomy, she spoke about support, we take for granted other peoples feeling and she opened my mind to the fact that we need to be more compassionate and supportive to our friends/family who are going through this journey.’ (Participant 37, female, aged 19).

For yet another source, contentment arose out of one participant being able to identify with the contextual circumstances:

‘She grew up fatherless, like I did. I know what it’s like to go through a traumatic experience and not have your other parent there.’ (Participant 48, male, aged 23)

Contentment

Some participants selected all or two of the survivors concurrently, based on perceptions of courage and bravery arising out of their experiences. Dillard and Nabi¹⁰ broke down the emotion of contentment into a cognitive antecedent of satisfaction that aspirations have been met:

‘They both didn’t understand what was happening, which always happens and even after they found out they stood and continued even @ their young age.’ (Participant 3, female, aged 22)

‘The courage and bravery of the survivor, not giving up and surviving the terrible cancer.’ (Participant 33, female, aged 21)

‘She is a motivator, she embraces the traumatic experience, she combines [sic] to teach about cancer.’ (Participant 39, male, aged 21)

‘The conquerus [sic] experience. The lived experiences of the cancer survivor on treatment.’ (Participant 41, male, aged 25)

‘That after the chemotherapy and its side effects, a person can actually regain their strength even though some effects can still remain with them in the long run.’ (Participant 44, female, aged 23)

Fear

Some of the information offered in the narratives created fear amongst the participants, partly because of lack of prior knowledge, but also novelty and perceived susceptibility:

‘Auto penisectomy [sic]: It scared me. The fact that the patient had to wait till it happened and only consulted after.’ (Participant 11, male, aged 36)

In line with the existing literature, the aspects that participants mentioned as having affected them most, involved strong emotions as shown here, emphasising that highly emotional narratives are effective.^4,10 It is important to note that whereas the given studies involved constructed stories and took a quasi-experimental approach, the results were similar to this study in which participants spontaneously related their experiences without being scripted. Three strong emotions arose out of the narratives, that is, sadness, contentment and fear. What is worth noting is that even though some participants singled out particular narrators, there were others who pointed out multiple narratives because of admiration of the speakers undergoing difficult experiences, yet emerging as strong people who could tell their stories. The narratives provided a human angle and a positive outcome to a dreaded disease, from stories that participants could relate to. From what some participants stated, the stories of victory illustrated to them that if detected early, cancer can be beaten. The narrative by the radiology expert not only created fear but also shocked participants into the knowledge that if cancer is left unattended, fearful consequences could arise. For those participants who identified it as most effective, they also said that they were willing ‘to perform regular checks and to consult as early as possible to ensure early detection’.

New knowledge

To another group of participants, the vividness of the narratives lay in new knowledge acquired and what was perceived to be dramatic. One of the experts in radiology diagnostics narrated how some patients waited for too long to consult about cancer-related problems until they developed devastating side effects.

The dramatic

‘The guy whose penis was cut / because of cancer, I did not know it was possible for someone to get cancer of the penis or….’ (Participant 7, male, aged 25)

‘Side effects of chemotherapy. That radiation literally burn off your skin and it falls of, penis and also undergo surgery to cut off both breast. something i had no idea on [sic].’ (Participant 28, female, aged 20)

‘story … about a man who had autopenectomy. What touched me was that the patient waited for a long time before he actually went to see a doctor.’ (Participant 49, male, aged 24)

Novelty

To other participants, it was the novelty of acquiring knowledge about which they had no prior exposure, which made some sources credible:

‘… she mentioned that there are different types of cancers. 1 in 4 people are diagnosed with cancer.’ (Participant 38, female, aged 22)

‘All the stories. The breast lump, breast health. The stem cell cancer – the 1st time I heard about it.’ (Participant 24, female, aged 49)

Narratives were also memorable in terms of providing hitherto unknown information to the participants. This finding contributes to the argument about whether narratives are effective because of their cognitive value or are a result of relation to experiences.⁹ From this finding, it is a combination of both factors. The fact that the participants could relate to the experiences of the narrators also made the new information provided through the personal narratives of these authors more vivid. This is in spite of the fact that cancer-related information is commonly available in the media and at health facilities yet young people often ignore it.

Lessons learnt from first-hand experiential narratives

Participants mentioned that they learnt the importance of knowing their bodies (n = 14) and as part of that, a deep knowledge of personal well-being. Some participants stated that it was important to go for health checks (n = 11), whilst others said that it was important to prioritise health (n = 8), part of which involved engaging in a healthy lifestyle. Participants underscored the need to take care of themselves (n = 5) whilst others said that they learnt how to engage in self-examination or to engage in regular self-examination (n = 5). Each of the participants acknowledged the need to go for early treatment, to talk to survivors and mentioned that support from important others is important.

Participant information about the lessons learnt from the narratives provides some pointers about the effects of this message format. Perhaps to a youthful audience, information about cancer is better disseminated through narratives. Narratives may be effective because when audiences listen to stories about people’s experiences, they can relate to them making the information tangible and accessible rather than often-existing perceptions that such information is abstract, made up of scientific jargon. Pre-existing perceptions are evidenced from responses by some of the participants who did not know that children or black people can get cancer too or the fact that men can get breast cancer.

Behavioural intentions

Following the cancer awareness session, participants stated intentions to engage in a variety of preventative activities. The preventative activities proposed by the participants mainly fell into four categories, although some of them mentioned more than one activity.

Self-examination

Most of the participants (n = 20) mentioned that they would be engaging in regular self-examination of their bodies in a bid to try and detect any unusual aspects that they were not aware of. Part of the process of self-examination, they said, would be to acquire intimate knowledge of their bodies in order to know what is normal for them. Some of them mentioned that they are now more aware of how to examine themselves and they know what to search for, for example, unusual lumps in breasts. They also mentioned that they would engage in regular self-examination, some stating that they would specifically examine their breasts or testicles ‘every morning, every day in the shower, every month’.

Screening at health facilities

Other participants (n = 13) said that they intended to visit health facilities to get examined and tested by professionals. Some stated that they would not test for cancer alone, but for health issues in general. A few mentioned that the reason why they would visit health facilities would be to ensure that if they have cancer, it would be detected early. Others were of the view that rather than just engaging in testing at health facilities, they would do regular self-examination first, then go to health facilities if they felt anything unusual on their bodies. Of note was a sole participant who mentioned that they will go to the University Health Centre for a check-up.

Healthy lifestyle

A few participants (n = 7) observed that they would make lifestyle changes to prevent cancer. They mentioned specific measures that they will undertake such as intentions to ‘exercise more, decrease alcohol consumption, try to eat health or for others healthier food’. In terms of their lifestyle changes, some said that they would start ‘taking care of themselves, not take health-related things lightly, don’t take pains, lumps etc. for granted, be careful of minor pains in their bodies’.

Cancer activism

An unforeseen, yet emergent behaviour change intention by a few of the participants (n = 5) was their involvement in informing others about cancer. Three of the four participants mentioned that they would:

[E]ncourage society and others to take care of themselves, inform peers and family members about early detection of cancer, volunteer in cancer non-governmental organisations, ensure early detection and diagnosis of cancer for close members of family.

One of the participants said they would start offering support to patients.

The behavioural intentions mentioned by the participants are reflective of the narratives told by the various panellists. In their stories, most of the panellists narrated how they felt ill yet had not attributed the illnesses to cancer. One of the survivors said that he felt ill, but because he was young, he informed his parent who gave him painkillers for a whole year. He survived on painkillers before he went to a health facility for a check-up, where he was diagnosed with cancer. Other survivors said that they found lumps in their breasts through self-examination, whilst the radiology expert mentioned that apart from women examining their breasts, it was important for men to examine their testicles frequently. The unforeseen behavioural intention about engaging in cancer activism was a response towards one of the survivors who is a cancer activist. She narrated how after she went into remission, she became part of an organisation, which travels all over the country, raising funds to assist cancer patients.

Conclusion

This article attempted to explore possible effects of first-hand experiential stories of cancer survivors and experts examined, new knowledge accruing from stories and cancer prevention behavioural intentions through the emotions that they provoked. The effects of the narratives mostly lay in the emotions that were provoked amongst the participants, which are in line with literature.^4,9 Some responses by participants show that they were transported into the experiences of the speakers, thus making the narratives more memorable to them⁴ buoyed by the fact that the speakers live to tell their stories.¹ Reactions by students detailing the behavioural changes that they intend to make show that they did not merely listen to the narratives, but that they adapted them with the intention of making necessary changes to their lives. However, behavioural intentions, as researchers mention, do not always translate into actual behaviour because of intention–behaviour gaps.³⁴ Yet the formation of implementation intentions is crucial to promoting goal achievement. Thus, although people may have strong intentions to achieve a goal, some may succeed whilst others fail. Of importance is that theories such as the HBM bridge the gap through attempts to explain why some people succeed and others fail to act on health-related behaviour intentions. The panel session could be considered to have been successful, because participants gained awareness about different aspects of cancer and also expressed a willingness to engage in specific individual measures towards cancer prevention. The SCM calls audience members to action. Results indicate that in line with the SCM the theme of the event, was to motivate students to ensure early detection by engaging in frequent self-examination and visiting health facilities to receive professional tests. From the responses, some participants indicated that they would engage in frequent self-examination or go to the university clinic for professional examination. The session provided knowledge about cancer that most students were unaware of, such as the fact that there are different types of cancer and how to examine themselves. The session debunked myths amongst young South African university students, such as the fact that cancer is not contagious or transmissible and provided necessary factual information about risk factors that the students did not know, yet which are important in terms of awareness. In addition, some of the responses by the participants regarding behavioural intentions were related to the life experiences narrated by the cancer survivors and experts. There is a paucity of cancer prevention messaging targeting young people such as university students in South Africa. Whilst cancer prevention information is available at health facilities, there are no deliberate cancer-related health communication campaigns that engage young people. This study shows that even in developing contexts, narrative storytelling can yield positive effects on behavioural intentions. Based on narrators’ experiences, young people expressed a willingness to engage in self-examination. A limitation of the study was that there were few participants, yet positively, a qualitative approach allowed for the participants to express their individual perceptions. Future studies could utilise quantitative, experimental studies to ascertain cause–effect relationships between narratives and specific behavioural intentions. Such relationships cannot be assumed outside of a quantitative research design.

Acknowledgements

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article.

K.S., E.L. and M.G. all contributed equally to this research article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data are available from the corresponding author, E.L., upon request and dependent on permission from institution.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

References