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Health Care for Women International

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Does Culture Matter?: A Cross-National Investigation of Women's Responses to Cancer Prevention Campaigns
Kyoo-Hoon Han & Samsup Jo
a a a

Department of Communication, Sookmyung Women's University, Seoul, South Korea Available online: 12 Dec 2011

To cite this article: Kyoo-Hoon Han & Samsup Jo (2012): Does Culture Matter?: A Cross-National Investigation of Women's Responses to Cancer Prevention Campaigns, Health Care for Women International, 33:1, 75-94 To link to this article: http://dx.doi.org/10.1080/07399332.2011.630117

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Health Care for Women International, 33:7594, 2012 Copyright Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2011.630117

Does Culture Matter?: A Cross-National Investigation of Womens Responses to Cancer Prevention Campaigns
KYOO-HOON HAN and SAMSUP JO
Department of Communication, Sookmyung Womens University, Seoul, South Korea

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We examined how culture inuences the persuasive effects of health campaigns that promote early screening for cancers that occur in women. Two message dimensions were included: individualistic vs. collectivistic appeal and gain vs. loss frame. A total of 955 females from three countriesthe United States, South Korea, and Japanparticipated in the experiment. From the results, we found that message framing alone did not signicantly inuence the effectiveness of public campaigns for womens cancer prevention; and this tendency was similar across the three countries. Gain-framed messages are likely to be more persuasive when combined with a collectivistic appeal, however, whereas loss-framed messages tend to be more effective when combined with an individualistic appeal in both the United States and South Korea; but this result was not the case for Japan. Based on the ndings, we suggested theoretical and managerial implications as well as several directions for future research. While the importance of early screening has been increasingly noted as an effective way to prevent cancer (American Cancer Society, 2010), early detection is particularly signicant for cancer prevention in women (Kalager, Zelen, Langmark, & Adami, 2010; Warren et al., 2006). For instance, compared with most European countries, the United Sates has a higher breast cancer incident rate yet a lower breast cancer mortality rate. These patterns
Received 10 October 2010; accepted 4 October 2011. This research was supported by the SRC Research Center for Womens Diseases of Sookmyung Womens University. Address correspondence to Kyoo-Hoon Han, Department of Communication, Sookmyung Womens University, Chungpadong-2ga, Yongsan-gu, Seoul, South Korea. E-mail: hanque@sm.ac.kr 75

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are consistent with more aggressive breast cancer screening in the United States (Howard, Richardson, & Thorpe, 2009). To persuade women of the importance of early screening, administrators and practitioners have employed a variety of cancer prevention campaigns over the years. Consequently, there have been considerable efforts to investigate the effect of cancer prevention messages that target women specically (e.g., McCaul, Branstetter, Schroeder, & Glasgow, 1996; Pearlman, Clark, Rakowski, & Ehrich, 1999; Ramirez, Suarez, Laufman, Barroso, & Chalela, 2000). Few researchers, however, have explored the persuasive effects of cancer communication from a cross-cultural perspective. Considering the need for such research, we examined how health messages promoting early cancer screening might be more or less effective for women across culture types and message frames in multiple countries. We expected that this examination would reveal meaningful theoretical and managerial implications to enhance the effectiveness of cancer prevention campaigns on both national and global scales.

LITERATURE REVIEW
People grow up in particular cultures and become accustomed to the value systems, beliefs, and perceptual processes that are congruent with their cultural background (Zhang & Gelb, 1996). Due to differences in culturally established tradition, taste, experience, and so on, individuals in a particular cultural environment tend to hold a set of values and preferences that are more or less distinct from what others might hold in different places (Aaker, 2000; De Mooij, 1998). For this reason, culture has received wide critical attention over the years as an important determinant of reactive outcomes. Culture has been a signicant factor, particularly in communication research because scholars have believed that culture has the potential to shape the persuasiveness of messages by inuencing how they are understood and interpreted (De Mooij, 1998; Miracle, Chang, & Taylor, 1992; Uskul, Sherman, & Fitzgibbon, 2009). Among many cultural dimensions identied in previous cross-national studies, Hofstedes (1980, 1991) typology has been tremendously inuential and highly applicable to multicultural research; moreover, most subsequent studies have supported his propositions that national cultures vary substantially over a wide range of factors (e.g., Albers-Miller & Gelb, 1996; De Mooij, 1998; Fernandez, Carlson, Stepina, & Nicholson, 1997; Moon & Franke, 2000). In particular, his individualism-collectivism dimension has received considerable attention as a major domain of cultural variability addressed by scholars across disciplines (e.g., Cho, Kwon, Gentry, Jun, & Kropp, 1999; Cutler, Erdem, & Javalgi, 1997; Han & Shavitt, 1994; Taylor, Miracle, & Wilson, 1997; Triandis, 1990; Zandpour et al., 1994). Individualism is dened as a social pattern that consists of loosely linked individuals who view themselves as independent of collectives (e.g., family, coworkers, tribe, nation), whereas

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collectivism is dened as a social pattern consisting of closely linked individuals who see themselves as parts of one or more collectives (Trandis, 1995, p. 2). Individualistic and collectivistic cultures are characterized by the distinct differences in peoples social perceptions and behaviors (Han & Shavitt, 1994). In general, members of individualistic cultures tend to hold an independent view of the self that emphasizes separateness, internal attributes, and personal achievement. In contrast, members of collectivistic cultures tend to hold an interdependent view of the self that emphasizes connectedness, relationships, and group harmony (Aaker & Maheswaran, 1997; Hofstede, 1980; Zandpour et al., 1994). As a result, marked differences in peoples attitudes and behaviors between an individualistic culture and a collectivistic culture may exist depending on to which culture an individual belongs. For example, values and attitudes congruent with independence are more likely to be acceptable to members of an individualistic culture, whereas values and attitudes congruent with interdependence are more likely to be favorable to members of a collectivistic culture (Aaker & Maheswaran, 1997; Zhang & Gelb, 1996). Hofstedes cultural dimensions can be of great use when it comes to analyzing a countrys culture, because he reported his study results by country. Scholars generally have supported that many countries are culturally similar or dissimilar in terms of the individualismcollectivism dimension (Cho et al., 1999; Frith & Sengupta, 1991; Miracle, Chang, & Taylor, 1992; Triandis, 1990). They conrmed Hofstedes basic nding that individualism is valued more in western countries, whereas collectivism is valued more in eastern countries. According to several studies that replicated Hofstedes country classication in the late 1990s, major countries at the extreme end of each dimension in their new classications were generally consistent with Hofstedes original report (Cutler, Erdem, & Javalgi, 1997; Fernandez et al., 1997). Further utility of the individualismcollectivism dimension is attributable to the fact that culture is also signicant in the domain of health communication. The underlying assumption is that health information targeted to a specic cultural group is likely to increase the possibility that receivers will understand the information and follow the suggested behavior. In other words, a successful health communication approach in a country might not be effective in another country that has different cultural characteristics. Barg and Grier (2008) found that people tend to construct meanings from breast cancer information based on their own cultural and social experiences. This nding suggests that any campaign for health promotion needs to consider the lived experiences and cultural backgrounds of their target audience. Accordingly, carefully designed health messages deploying cultural values, such as individualism or collectivism, are more likely to communicate effectively. More empirical evidence is required, however, to verify whether a tailor-made health message would enhance its communication effects within a specic culture.

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In addition to the idea that cultural differences can inuence the persuasive effects of health promotions, the role of message framing in public communication has been an area of academic interest over the years. Message framing is associated with cues that signal the positive or negative consequences of accepting or refusing to adopt a certain behavior (Rothman & Salovey, 1997). The underlying premises are that messages aimed at persuading individuals to perform a particular health behavior can be framed in different ways; and appropriate message framing is likely to appeal to the target audience more effectively (Martin & Marshall, 1999; Salovey & Williams-Piehota, 2004). There are two typical sorts of message framing in health campaigns: gain and loss. In health communication, gain-framed messages generally emphasize the benets of engaging in a certain behavior, whereas loss-framed messages tend to stress the harmful consequences of not following a suggested behavior (Chang, 2007; Cho & Boster, 2008). An oft-cited theoretical point regarding the effects of message framing in health communication is prospect theory (Salovey & Williams-Piehota, 2004). This theory postulates that individuals tend to be risk seeking when losses are salient but risk averse when gains are salient; that is, people respond differently to gain- and loss-framed messages (Kahneman & Tversky, 1979). Although prospect theory has been generally supported by later scholars, we discovered that the results of studies about the persuasiveness of each type of message frame were quite mixed. In their study on the message effects of breast self-examination, for instance, Meyerowitiz and Chaiken (1987) revealed that women who read loss-framed messages developed more favorable attitudes, stronger intent to take action, and greater condence to adopt preventive behavior than women who read gain-framed messages. Although many other scholars have also supported the notion that loss framing attracts more attention and induces greater effort for information processing than gain framing (e.g., Pratto & John, 1991; Skowronski & Carlston, 1987; Smith & Petty, 1996), the former is not necessarily suitable for all individuals or appropriate for promoting all behaviors (Wong & McMurray, 2002). For instance, researchers who conducted framing-related studies reported that health-preventive behaviors, such as exercise and sun-screen use, could be more effectively promoted when the message was gain-framed rather than loss-framed (e.g., Robberson & Rogers, 1988; Rothman & Salovey, 1997). Despite a great deal of research on message framing effects, health communication scholars have hardly ever discussed this issue from a cultural point of view. In a rare example of this approach, Uskul, Sherman, and Fitzgibbon (2009) recently examined the effectiveness of gain- versus lossframed messages about ossing, comparing a British group and an East Asian origin group, and found different persuasive effects for each culture. Although their study was limited by its sample quality (e.g., college students sample, small sample size), they empirically supported that the impact of message framing might depend on the recipients cultural background, thus

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allowing reasonable inferences about the dissimilar effects of gain- and lossframed messages in different cultures. Based upon such inconsistent results about message framing effects, we can assume that the persuasive effects of differently framed messages might interact with other variables. Indeed, scholars have reported that message framing effects could differ according to the type of behavior being promoted (Rothman & Salovey, 1997), issue involvement (Maheswaran & Meyers-Levy, 1990), price-perceived risk (Grewal, Gotlieb, & Marmorstein, 1994), and personal experience with the product (Rothman, Martino, Bedell, Detweiler, & Salovey, 1999). Little is known, however, about the extent to which message framing can interact with some particular cultural dimension to inuence communication effectiveness. Thus, we wondered which message frame for health-preventive messages would more effectively target members of an individualistic culture or a collectivistic culture. Integrating the need for thorough investigation and our research interests addressed above, we established the following research questions:
RQ1: How does cultural background affect womens responses to cancer prevention campaigns according to the appeal type (individualistic vs. collectivistic)? RQ2: How does cultural background affect womens responses to cancer prevention campaigns according to the message frame (gain vs. loss)? RQ3: Is there a signicant interaction effect between the appeal type by culture (individualistic vs. collectivistic) and the message frame (gain vs. loss) in terms of womens responses to cancer prevention campaigns in multiple countries?

METHOD Experimental Design and Stimuli

In light of the need for tailor-made messages to appeal to a target market, an experimental approach is appropriate for assessing message effectiveness across cultural variables. Considering the reviewed factors involved in public reaction to campaign messages, we employed a 2 (gain vs. loss frame) 2 (individualistic vs. collectivistic appeal) between-subjects factorial design. We selected a public service advertisement for our experimental message outlet because advertising has been effectively used for both commercial and noncommercial communication to inuence public perception. For this study, we sampled three countries: the United States, South Korea, and Japan. Researchers often have chosen North American and East Asian countries for their cross-national studies in order to investigate the

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impact of cultural differences (e.g., Han & Shavitt, 1994; Moon & Franke, 2000; Taylor, Miracle, & Wilson, 1997; Wu, 2006; Zandpour et al., 1994). Most of all, with the empirical support of Hofstedes (1980, 1991) studies, we identied these countries as good examples of cultural dissimilarity (especially, the United States vs. South Korea or Japan). More specically, the United States is ranked highest in the degree of individualism, whereas both South Korea and Japan are ranked in much lower positions (i.e., higher positions in the degree of collectivism than the United States). The experimental stimuli were full-color, full-page, magazine-style advertisements (hereafter ads; to view the actual ads, see Figures 13). To accommodate the ethnic and linguistic differences among our selected countries (i.e., the United States, South Korea, and Japan), we produced a total of three sets of ads. Each set contained four ads differentiated by two independent variables and their levels, and each set used a different language (i.e., English, Korean, and Japanese) and different models (Caucasian models for U.S. ads and Asian models for Korean and Japanese ads). The two independent variablesindividualistic/collectivistic appeal and gain/loss framewere manipulated by differentiating creative components (i.e., the headline copy and the main visual in each ad). We held the models image, relationship between models (a mother and her daughter), overall layout, and copy framework consistent for the different ads in order, however, to prevent the confounding effects of any uncontrolled variables.

Participants and Procedure

We determined the sample for the experiment to be female consumers between the ages of 20 and 49. They were randomly recruited from the worlds largest online research companys global panel sample from registered U.S., Korean, and Japanese consumer lists. We designed the sample size and demographic ratio of participants to be equivalent over the three countries. An e-mail soliciting the participants to engage in the experiment was sent to a total of 4,200 consumer panelists; 955 recipients took part in the experiment (response rate: 22.7%). These participants consisted of 332 U.S. women, 321 Korean women, and 302 Japanese women. Demographic proles of the participants, which include age group, marital status, education level, and occupation, are shown in Table 1. We conrmed that the experimental groups were equivalent over the three countries in the distribution of age group using a chi-square test ( 2 = .116, df = 2, p > .05). We executed our experiment on the Internet. Participants were guided to the web page where a stimulus ad and questionnaire had been set up and were randomly assigned and exposed to one of the four experimental ads designed for their cultural background. Control over all participants in the experimental process was successfully maintained by applying technical

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FIGURE 1 Experimental advertisements: U.S. version (Color gure available online).

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FIGURE 2 Experimental advertisements: Korean version (Color gure available online).

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FIGURE 3 Experimental advertisements: Japanese version (Color gure available online).

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TABLE 1 Demographic Proles of Participants Category Age group 3039 4049 5059 Marital status Married Unmarried Other Educational level High school grad. College grad. Graduate school grad. Other Occupation Housewife Company employee Self-employed Profession Service Student Other Total U.S. 109 110 111 197 103 30 124 131 37 38 96 96 32 32 23 6 45 330 South Korea 110 105 106 269 46 6 101 190 21 9 150 78 28 35 17 1 12 321 Japan 111 111 82 224 67 13 139 109 4 52 148 72 15 15 23 0 31 304 Total 330 326 299 690 216 49 364 430 62 99 394 246 75 82 63 7 88 955 Percent 34.6 34.1 31.3 72.3 22.6 5.1 38.1 45.0 6.5 10.4 41.3 25.8 7.9 8.6 6.6 .7 9.2 100

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treatments. For instance, when participants were exposed to an experimental ad, they were not allowed to move on to the next page for 30 seconds so that they would have enough time to pay adequate attention to the ad. Owing to the advantageous functioning of this online experiment, we minimized missing data.

Dependent Measures
We used two dependent variables to measure the persuasive effects of health campaigns targeting women: attitude toward the ad (hereafter ad attitude) and behavioral intention. For the measurement of ad attitude, participants were asked to rate how much they agreed or disagreed with each of the seven evaluative items on the 5-point Likert scale. These items, which had been adapted and modied from MacKenzie and Lutzs (1989) attitude study, include this ad is appealing, truthful, reliable, useful, convincing, important, worth attention, and making me feel the need to follow the given messages. These expressions were translated to each countrys primary language. We conrmed these items to be internally consistent by conducting a reliability test (Cronbachs = .958). Behavioral intention was measured using three descriptive items with a 5-point Likert scale. They included this ad makes me want to undergo an

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early screening for womens cancer, to recommend my friends to undergo an early screening for womens cancer, and to look for more information about an early screening for womens cancer. All items were internally consistent (Cronbachs = .919).

RESULTS Manipulation Check

To verify whether we successfully performed our experimental manipulations, participants were requested to evaluate the multiple semantic differential items based upon a 5-point scale in terms of how each participant perceives the ad. As we intended, the participants perceived the two ads with individualistic appeals as focusing on an individual who is looking after herself more so than the other two ads with collectivistic appeals (individualistic ad M = 4.52, collectivistic ad M = 3.87, t = 19.53, p < .001). They also perceived in the two ads with gain framing the suggestion that a positive result could be achieved by undergoing an early screening, while perceiving in the other two ads with loss framing the suggestion that not undergoing an early screening could have negative consequences (gain frame M = 4.28, loss frame M = 3.13, t = 48.90, p < .001). Thus, we conrmed that the participants perceived the stimuli material as originally intended.

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Effects of Appeal Type (Individualistic vs. Collectivistic)

With the collected data set, we rst examined the effects of the two types of appeal according to the individualismcollectivism dimension on the persuasiveness of cancer communication targeting women. Considering the ndings of Hofstede and other scholars on the individualismcollectivism index for the three countries selected in our study, we assumed that U.S. women are likely to respond more favorably to an individualistic appeal than to a collectivistic appeal, whereas Korean and Japanese women are likely to respond more favorably to a collectivistic appeal than to an individualistic appeal. As presented in Table 2, we found signicant differences between the two types of appeals for ad attitude in the U.S. sample (t = 1.665, p < .10) and the Japanese sample (t = 2.016, p < .05); specically, U.S. participants responded more favorably to individualistic appeals than collectivistic appeals, whereas the opposite was the case for Japanese participants, as predicted above. On the other hand, for the Korean sample, no signicant difference was found in the persuasive effects on either ad attitude (t = .367, p > .05) or behavioral intention (t = 1.421, p > .05). Also, neither the U.S. nor the Japanese samples showed a signicant difference for behavioral intention (t = 1.371, p > .05; t = -1.209, p > .05).

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TABLE 2 Persuasive Effects by Individualistic vs. Collectivistic Appeal Dependent variable: Ad attitude Country U.S. South Korea Japan Appeal type Individualistic Collectivistic Individualistic Collectivistic Individualistic Collectivistic N 165 165 153 151 160 161 M 3.911 3.792 3.901 3.879 3.639 3.771 SD .657 .637 .544 .508 .565 .580 t 1.665 .367 2.016 p value .097 .714 .045

Dependent variable: Behavioral intention Country U.S. Appeal type Individualistic Collectivistic Individualistic Collectivistic Individualistic Collectivistic N 165 165 153 151 160 161 M 3.687 3.560 3.775 3.661 3.414 3.519 SD .854 .831 .711 .733 .731 .781 t 1.371 1.421 1.209 p value .171 .156 .228

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South Korea Japan

p

< .05.

Effects of Message Frame (Gain vs. Loss)

For each respective country, as shown in Table 3, our independent samples t-tests revealed no signicant differences in the impact of gain framing and loss framing on ad attitude or behavioral intention.

TABLE 3 Persuasive Effect by Gain- vs. Loss-Framed Messages Dependent variable: Ad attitude Country U.S. South Korea Japan Message frame Gain frame Loss frame Gain frame Loss frame Gain frame Loss frame N 164 166 153 151 160 161 M 3.830 3.873 3.894 3.886 3.692 3.717 SD .640 .659 .530 .522 .564 .588 t .594 .125 .382 p value .553 .901 .703

Dependent variable: Behavioral intention Country U.S. South Korea Japan Message frame Gain frame Loss frame Gain frame Loss frame Gain frame Loss frame N 164 166 153 151 160 161 M 3.565 3.680 3.742 3.694 3.425 3.508 SD .852 .835 .722 .726 .786 .726 t 1.246 .595 .955 p value .214 .552 .340

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Interaction Effects of the Two Independent Variables

We used a two-way ANCOVA to examine whether interaction effects between the appeal type (individualistic vs. collectivistic) and message frame (gain vs. loss) existed. To control against the potential intervening effects of other factors, we dealt with the following demographic and experiential variables as covariates in our statistical analyses: age, education level, occupation, marital status, and prior experience with early cancer screening. As shown in Table 4, there were signicant interaction effects only in ad attitude for the U.S. sample (F = 5.307, p < .05) and behavioral intention for the Korean sample (F = 2.598, p < .05); for the remainder, no signicant interaction effects were found. As illustrated in Figure 4, both interaction effects indicate that a loss frame would be more effective when used with an individualistic appeal, rather than a collectivistic appeal, in both the United States and South Korea. On the other hand, gain-framed messages in cancer screening promotions targeting women are more likely to be persuasive than loss-framed messages when combined with a collectivistic appeal in these two countries.

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DISCUSSION Research Summary and Interpretations

Our primary purposes for this study were twofold: a) to examine crosscultural differences in the persuasive effects of various message approaches in the context of health promotion and b) to provide health marketers with useful insights to enhance the effectiveness of their public communication strategies, particularly for cancer prevention campaigns targeting women. We thus conducted a series of experiments that manipulated the appeal type (individualistic vs. collectivistic) and frame type (gain vs. loss) of advertising messages for 955 female participants from three countries (the United States, South Korea, and Japan). Although many studies have focused on the communication effects of cancer prevention campaigns, our examination of this issue over such a wide cultural scope offers a new perspective.
TABLE 4 Interaction Effects Between Appeal Type and Message Frame Country U.S. South Korea Japan
p

Dependent variable Ad attitude Behavioral intention Ad attitude Behavioral intention Ad attitude Behavioral intention

SS 2.198 1.716 .366 1.296 .081 .017

df 1 1 1 1 1 1

MS 2.198 1.716 .366 1.296 .081 .017

F 5.307 2.444 1.354 2.598 .258 .032

p value .022 .119 .245 .048 .612 .859

< .05.

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FIGURE 4 Test Results of Interaction Effects. (Presented only signicant results)

We predicted that appeal type (i.e., Hofstedes individualismcollectivism dimension) would inuence womens responses to cancer prevention campaigns and that there would be cross-cultural differences in this causal relationship. Our experimental study revealed that U.S. women tended to have a favorable attitude toward individualistic appeals, in contrast to Japanese womens favorable attitude toward collectivistic appeals. This result is consistent with our initial presumption based on Hofstedes original individualismcollectivism index by country. Among Korean participants, however, there was no signicant difference between the two types of appeal. We could nd some clues of these inconsistent results between South Korea and Japan, the neighboring countries considered to have similar cultural traits, from several recent studies about cultural changes of

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the two nations. According to them, although South Koreas culture has been quite collectivistic by tradition, some segments of Korean society have been inclined to more individualistic cultural values since the 1980s as the society has become increasingly Westernized and individualized in the social, economic, and political spheres, with growing emphasis on individual freedom and rights (Cho, Mallinckrodt, & Yune, 2010; Han & Shin, 1999; Park & Kim, 2006). On the other hand, Hamamura (2011) recently observed continuing emphasis on some collectivistic values such as the perceived importance of family and friends, social obligation, and contribution to society among Japanese young adults, despite a rise of individualism in Japan over the past several decades. In another analysis, the impact of message framing (gain vs. loss) was not signicant for any of the countries investigated; differences between the two types of framing in persuasive effects for both ad attitude and behavioral intention were found to be insignicant. This result is inconsistent with Uskul, Sherman, and Fitzgibbons (2009) study, which found cultural differences in the effectiveness of different message frames. From our result, we learned that one message frame does not always induce the expected effect. We might also conclude that campaign effectiveness according to message framing in the communication context for cancer prevention tends to be universal rather than divergent across different cultures. In the examination of interaction effects between individualistic/ collectivistic appeals and gain/loss message frames, statistically signicant effects were found in some of the responses from U.S. and Korean participants. After an in-depth investigation of these interaction effects, we found that a gain message frame is likely to be more persuasive when it is combined with a collectivistic appeal rather than an individualistic appeal, whereas a loss message frame tends to be more effective when combined with an individualistic appeal rather than a collectivistic appeal. Although this tendency was not the case for Japanese participants, our results indicate that the effectiveness of a particular message frame can be inuenced by an appeal that reects a certain cultural value, particularly the individualismcollectivism index inspected in this study. On the other hand, a similar pattern in such interaction effects between the United States and South Korea suggests that, in certain circumstances, some countries might have similar tendencies in communication effectiveness although they are culturally different.

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Managerial Implications
From the ndings of this study, we might provide health marketing practitioners with several managerial insights. First, an insignicant difference between gain and loss frames in their impact on persuasion indicates that there is no particular message frame that can yield better effectiveness in

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every situation, and this proposition appears to be universal across different culture. Prior research has suggested that loss-framed messages might induce a better persuasive effect than gain-framed messages for campaigns against smoking or drunk driving. In an ad encouraging early screening for cancers found in women, however, neither frame appeared to cause signicantly higher effectiveness than the other. Thus, for successful implementation of health campaigns, message frames in advertising should be carefully selected according to attributes of the particular health issue. Also, health marketers need to consider the demographic and sociopsychological characteristics of their target audience before they select an appropriate message frame to increase the effectiveness of their campaign. We obtained somewhat complicated results for the comparative effects of individualistic appeals versus collectivistic appeals by country. Although the individualistic and collectivistic message effects were revealed to be mixed among the different countries, this result does not mean that a persuasive approach reecting particular cultural values will be inadequate. On the contrary, as implied by the culturally different aspects of the interaction effects between appeal types and message frames, we suggest that practitioners carefully consider the diversity and variability of cultural attributes that their target audience might have and thereby reect these cultural characteristics in persuasive messages based on consumer research. Owing to rapid developments in communication technology, people can share information and trends with others all around the world faster than they could in the past. Also, because similarities and dissimilarities coexist in cultural values and public attitudes, health marketers are likely to have difculty in nding consistent rules for communicative success. Therefore, campaign strategies for cancer prevention need to be established by monitoring and considering generic consumer attitudes and changing public trends in the country where the campaign will be implemented. In addition, because Hofstedes cultural dimensions are becoming outdated, we highly recommend that researchers attempt cross-national studies that will complement and update this cultural data.

Study Limitations and Directions for Future Research

There were several limitations in administering the present study, and the attempt to overcome those limitations could furnish opportunities for further research. First, the use of health promotions for cancer prevention in women limited potential determinants for persuasive effects to message factors only. Other than the expressional elements, however, an individuals health beliefs, medical interest, past experience with early screening, marital status, family type, education level, economic status, and so on could also be factors inuencing campaign effectiveness. Therefore, future studies need to expand

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beyond the independent variables evaluated by this study in order to assess further the effects of other potential elements. Second, we used only print ads as a channel for campaign messages due to limitations in creating experimental stimuli and conducting crossnational research. In reality, however, a number of health campaigns are transmitted to the public not only through print media but also through television, radio, and the Internet, often in combination. Consequently, in order for future researchers to generalize study results across other media, they will need to set up more communication channels for the experiment, thus examining the comparative effects of various media. In particular, health marketers and scholars need to consider how to utilize social media channels, which recently have received wide attention as a new marketing platform, for distribution of health information or public campaigns. Finally, although we selected only three countries for the experiment, the potential value and signicance of this research persists because little effort has been made so far in exploring cross-national differences in the persuasive effects of health promotions. Nevertheless, since the domain of public campaigns for cancer prevention investigated in this research is just a small part of the wide range of health communications, we propose that future researchers examine more diverse health campaign issues from the cultural perspective, thus extending and elaborating on this studys results. Marketers have increasing difculty in persuading contemporary audiences as they intend due to rapid changes in lifestyle, media environment, and information distribution. Predicting such struggles in conducting their communication plan, health marketers need to incorporate careful preanalyses and strategic approaches for effective and successful public marketing.

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