The Effects of Different Types of Counterfactual Thinking in Narrative Persuasion: A Case Study of Using Animated Narratives to Persuade Peritoneal Dialysis Patients to Adhere to Antiseptic Regimens

End-stage renal disease (ESRD) is a chronic, progressive, and debilitating medical condition resulting from impaired kidney function. For ESRD patients in Hong Kong, common kidney replacement therapy is Peritoneal Dialysis (PD). Although PD treatment provides many benefits to ESRD patients, such treatment is associated with great responsibilities and demands on the patients because it is a whole regimen that they must follow. Noncompliance with the regimen can potentially cause infectious complications. Peritonitis is the most frequent bacterial infectious complication (Davenport, 2009) and is accounted for about 20% of infection-related mortality in Hong Kong (Ho et al., 2013). Research has shown that suboptimal adherence to the aseptic regimen (e.g., not wearing a face mask, not washing hands) is an important risk factor for peritonitis (e.g., Mawar et al., 2012). To increase PD patients’ understanding of peritonitis and improve their adherence to the aseptic regimen, health communication researchers suggest that narrative persuasion (Hinyard & Kreuter, 2007) has the potential to change patients’ attitude and behavior. To enhance its persuasiveness, Tal-Or et al. (2004) further argue to incorporate counterfactuals into narratives.

Counterfactual thinking is a pervasive form of thinking in which one imagines alternative outcomes, as opposed to the real outcome (Roese, 1997). For example, when people encounter an event with an unfortunate ending, they are likely to imagine “how things could have happened otherwise.” A story accompanied by a counterfactual is likely to be more persuasive, because people who view the story may experience negative emotions, such as regret, and have counterfactual thoughts similar to the person’s in the narrative (Tal-Or et al., 2004). When people encounter an event similar to the one in the narrative, after viewing the narrative, those negative emotions and counterfactual thoughts associated with the narrative easily come to mind, and prompt them to engage in behavior to minimize the chance of experiencing these negative emotions in reality (2004). Although Tal-Or et al.’s research provided initial evidence on counterfactuals in narrative persuasion, the influence of different types of counterfactuals on persuasiveness remains unknown. Therefore, we propose a psychological experiment to address this research gap.

Counterfactuals are often conditional statements that involve antecedents (i.e., “If only I had done X”) and an outcome (i.e., “Y never would have happened.”) (Epstude & Roese, 2008). The antecedent can be divided into an additive or a subtractive type. The outcome can be framed in terms of promotion focus or prevention focus, according to self-regulatory theory (Higgins, 1998). Therefore, counterfactual thinking can be in different combinations of antecedents and outcomes. As such, the effect on narrative persuasion is likely to vary. Our proposed study will address the research question: How narratives that are accompanied by different types of counterfactuals may influence the narrative’s persuasiveness on PD patients’ adherence to the aseptic regimen and understanding of peritonitis.

To examine the influence of different types of counterfactuals, we propose a 2 (Antecedent in Counterfactual: Additive versus Subtractive) by 2 (Outcome in Counterfactual: Promotion-framed focus versus Prevention-framed focus) between-subject design experiment. With assistance from the renal patients’ self-help groups, we will recruit patients under PD treatment to take part in our experiment. To match the patients’ advanced age and low literacy level of the patients (Ho et al., 2013), we choose computer animation to deliver the health story. That is, patients will be randomly assigned to watch an animated narrative accompanied by one of the four counterfactuals. After watching the animated narrative, we will evaluate the patients’ knowledge about peritonitis, their attitude toward the aseptic regimen, and their adherence behavior. Our research will not only enhance our theoretical understanding of the process of narrative persuasion but also develop a theory-driven animated narrative to PD patients for health communication practice.