This research is grounded in a theoretical perspective that emphasizes the role of affective and narrative processes in digital marketing communication, particularly within institutional contexts. Rather than relying on cognitive-processing frameworks that are typically associated with quantitative approaches, this study adopts a qualitative lens to understand how meaning, emotion, and institutional structures shape digital content and audience responses.

Central to this study is the concept of narrative transportation, which explains how individuals become cognitively and emotionally immersed in story-based content. When audiences are “transported” into a narrative, they are more likely to experience emotional engagement and internalize the message, which in turn influences their attitudes and behavioral tendencies, including content sharing. This framework is particularly relevant in social media environments such as Instagram, where visual storytelling enables the integration of emotional and experiential elements in communication ( Green & Brock, 2000; Escalas, 2004).

In digital marketing contexts, audience responses are not merely the result of content exposure, but are mediated by internal processes such as emotional engagement. Prior studies have shown that emotional engagement plays a crucial role in shaping interactive behaviors, including liking, commenting, and sharing, which are central indicators of social media performance ( Dessart et al., 2015; Hollebeek et al., 2014). From this perspective, storytelling is not only a communication technique but also a mechanism that activates emotional resonance and drives engagement outcomes.

However, the production of digital content especially in organizational settings is not solely determined by communicative effectiveness. It is also shaped by broader institutional structures and norms. Therefore, this study incorporates the perspective of institutional logics, which highlights how organizational behavior is influenced by competing belief systems, rules, and values embedded within institutions. In the context of hospitals, professional, bureaucratic, and managerial logics often coexist, shaping how communication content is produced, approved, and disseminated ( Thornton et al., 2012; Friedland & Alford, 1991).

This perspective is particularly important in explaining why emotionally engaging, narrative-driven content may be underproduced despite its effectiveness. Institutional constraints such as formal procedures, risk aversion, and reputational considerations can limit the adoption of more affective and patient-centered storytelling approaches. As a result, there is often a gap between what is effective in engaging audiences and what is actually produced by organizations.

Although prior research in healthcare communication has primarily focused on cognitive dimensions such as trust, this study argues that affective and institutional dimensions must be considered simultaneously. Trust and emotion are not mutually exclusive; rather, they interact in shaping how audiences interpret and respond to health-related content ( Beldad & Hegner, 2018; Zhao et al., 2020). By integrating narrative transportation and institutional logics, this research provides a more comprehensive framework to understand the dynamics of digital communication in high-trust sectors such as healthcare.

Social media marketing (SMM) has developed into a strategic instrument in hospital management. Not only does SMM function as a means of conveying information, SMM also plays a role in building public trust in health institutions ( Ayuningtyas, 2022). In the post-pandemic context, this role has become increasingly important as people’s dependence on digital information increases.

A number of studies show that social media activities have a relationship with increasing patient visits and building brand equity and trust ( Udayana et al., 2024; Dzakiyya & Hijrah Hati, 2024; Kurniawan & Berlianto, 2022). Nevertheless, most of the studies still focus on the direct relationship between social media activity and outcomes, without explaining the underlying psychological mechanisms of the relationship.

Narrative content or storytelling is a communication approach that conveys messages through storylines that involve emotional aspects. Compared to informative content, narrative content is more effective in grabbing attention and building audience engagement.

In practice, the use of storytelling on hospital social media is still limited, although there are indications that this type of content has higher performance than informative content. This shows the potential that has not been utilized optimally, while at the same time emphasizing the need for a deeper understanding of the working mechanisms of narrative content in the context of health services.

Emotional engagement refers to an individual’s affective response to a piece of content that affects the level of attention, interaction, and connection to the message. In the context of social media, emotions play an important role in driving user engagement.

Research shows that emotional engagement can increase an individual’s likelihood of interacting and sharing content. Nevertheless, most studies still place this variable as a consequence, rather than as a mediator that explains the relationship between content characteristics and audience behavior. In addition, in the context of health services, research emphasizes more on the aspect of trust, so the role of emotional engagement is still less of a concern.

Electronic word-of-mouth (e-WOM) is one of the important indicators of the effectiveness of digital communication. e-WOM reflects the active involvement of the audience in disseminating information to other users, which in the context of healthcare has significant implications for the perception and decision to use the service. A number of studies show that social media activities contribute to the formation of trust and intention to visit patients ( Udayana et al., 2024; Dzakiyya & Hijrah Hati, 2024; Kurniawan & Berlianto, 2022). Nevertheless, the relationship between content characteristics and e-WOM is often explained directly, without examining the underlying psychological mechanisms.

Healthcare organizations operate within complex institutional environments characterized by multiple, often competing, logics. According to Friedland and Alford (1991), institutional logics shape organizational behavior by embedding norms, values, and rules that guide decision-making processes. In the context of hospitals, professional logics (e.g., medical ethics, risk aversion) frequently coexist with managerial and regulatory logics, creating tensions that influence communication practices.

These institutional dynamics often manifest as bureaucratic constraints, including hierarchical approval procedures, strict compliance requirements, and limited organizational flexibility ( Scott, 2014; Reay & Hinings, 2009). In digital communication, particularly social media, such constraints can hinder the timely and creative implementation of narrative content. Hospitals tend to prioritize accuracy, risk mitigation, and reputational protection, which may result in delayed, diluted, or overly formalized messaging.

Empirical studies suggest that healthcare organizations are generally more conservative in adopting innovative communication strategies compared to other sectors, due to heightened sensitivity to public scrutiny and legal implications ( Kreps & Neuhauser, 2010). As a result, narrative-based content despite its potential effectiveness may not be routinely implemented or may be significantly altered during the approval process.

This indicates that institutional logics and bureaucratic bottlenecks play a critical role in shaping not only whether narrative content is used, but also how it is ultimately presented to audiences.

While the engagement–behavior gap explains the absence of observable public actions, it does not necessarily imply that no sharing occurs. Instead, a growing body of research highlights the role of Dark Social, a term popularized by Madrigal (2012), referring to the sharing of content through private digital channels such as messaging applications, email, and direct messages.

Dark Social represents a form of information diffusion that is largely invisible to traditional analytics tools, yet highly influential in shaping perceptions and decision-making. In contrast to public platforms, private channels offer greater control over audience, reduced social risk, and enhanced privacy, making them particularly suitable for sharing sensitive or personal information.

In healthcare contexts, where topics may involve illness, vulnerability, or stigma, individuals may prefer to share information within trusted networks rather than in public spaces. This aligns with findings in digital communication research suggesting that users strategically choose communication channels based on perceived risk and relational context ( Bansal et al., 2010; Berger, 2014).

Thus, Dark Social provides a critical explanation for the observed dissonance between high emotional engagement and low levels of public e-WOM. Rather than indicating disengagement, the absence of public sharing may reflect a shift toward private, less visible forms of communication.

Integrating the concept of Dark Social into the framework allows for a more comprehensive understanding of how digital health communication operates beyond publicly observable metrics.

Figure 1 presents a conceptual framework of institutional friction, developed to guide the qualitative analysis using a directed content analysis approach. Rather than representing a statistical or causal model, the framework serves as a process-oriented analytical map that illustrates how narrative content practices interact with institutional constraints and audience dynamics within the hospital context.

The arrows in the framework do not indicate deterministic causal relationships, but instead reflect analytical flows and points of tension between key constructs, including narrative intentions, institutional logics, implementation outcomes, affective engagement, and behavioral responses. In particular, the framework highlights the frictions between affective audience engagement and observable public e-WOM, emphasizing the role of privacy concerns, social norms, and perceived risks.

Furthermore, the inclusion of dark social captures the possibility that audience responses may shift into private communication channels, suggesting that engagement does not always translate into visible metrics. Thus, the framework is intended to map interpretive relationships and thematic patterns, rather than to test hypotheses or quantify causal effects.

This study adopts a qualitative research design grounded in an interpretivist paradigm ( Denzin, 1978; Guba & Lincoln, 1994; Patton, 2015; Saunders et al., 2019), which assumes that reality is socially constructed and context-dependent. This philosophical stance is particularly appropriate for examining complex, experience-based phenomena such as narrative content adoption in digital healthcare communication. The qualitative approach enables the researcher to capture rich, in-depth insights into how and why narrative transportation influences audience engagement, emotional responses, and meaning-making processes within the social media ecosystem. Unlike quantitative approaches that prioritize measurement and generalization, this design allows for the exploration of subjective interpretations, institutional dynamics, and contextual nuances that shape communication effectiveness in hospital settings.

Furthermore, the study is situated within the context of hospital management in Indonesia as a developing country, where digital transformation in healthcare communication is still evolving. By integrating both audience and organizational perspectives, this research provides a holistic understanding of the interaction between content production strategies and audience reception.

This study employs purposive sampling, combining criterion sampling and maximum variation sampling to ensure both relevance and diversity of perspectives. The inclusion criteria required informants to have direct exposure to and engagement with hospital social media content, particularly those who actively interact with the hospital’s official Instagram account.

Maximum variation sampling was applied to capture heterogeneity across demographic and professional backgrounds, enabling a more nuanced understanding of audience responses across generational and occupational segments. A total of ten informants participated in the study, consisting of eight audience members and two internal management representatives ( Hennink et al., 2017; Hennink & Kaiser, 2022). This composition was intentionally designed to facilitate data triangulation, integrating: Outside-in perspectives (audience experiences and expectations), and Inside-out perspectives (organizational strategies and constraints). This dual perspective is critical for identifying gaps between narrative intention and audience reception, as well as uncovering institutional barriers in digital health communication. The detailed characteristics of the research informants are presented in Table 2.

Data collection was conducted between January and March 2026 using in-depth Stimulated Recall Interviews (SRI) ( Griffioen et al., 2020; Lyle, 2003). This technique is particularly effective in uncovering tacit knowledge and capturing participants’ real-time cognitive and emotional responses, especially in media consumption contexts where reactions are often subconscious and difficult to articulate retrospectively.

The interview protocol was deliberately designed to include a maximum of five open-ended core questions. This structure ensured depth of inquiry while minimizing respondent fatigue and maintaining focus on the research objectives. Each interview session incorporated visual and narrative stimuli to enhance recall accuracy and ecological validity. Informants were exposed to two contrasting types of content from the hospital’s official Instagram account: 1)

A high-performing narrative-driven video, portraying a clinician’s post-retirement story, designed to evoke emotional engagement and narrative immersion.

This comparative design allowed participants to reflect on differences in emotional resonance, perceived authenticity, and engagement mechanisms. It also enabled the identification of key drivers of narrative transportation and barriers to effective communication. All interviews were conducted in Indonesian to preserve linguistic and cultural authenticity. Data were audio-recorded with participant consent and transcribed verbatim to ensure accuracy and analytical rigor.

Data were analyzed using a Directed Qualitative Content Analysis (DQCA) approach ( Assarroudi et al., 2018; Hsieh & Shannon, 2005). This method is particularly suitable when existing theory or prior research can guide the initial coding framework, while still allowing for the emergence of new insights from empirical data. In this study, DQCA was used to validate and extend a predefined theoretical framework consisting of Narrative Transportation, Dark Social, and Institutional Logics. A deductive category matrix was developed as the primary analytical structure, enabling systematic organisation and comparison of data across informants.

At the same time, the analysis remained open to inductive sub-category development, allowing unexpected themes such as specific emotional triggers or organizational bottlenecks to emerge organically from the data. All interview transcripts were imported into ATLAS.ti 9 ( Friese, 2019; Paulus & Lester, 2022) to support: systematic coding, relationship mapping between categories, and transparent documentation of analytical decisions (audit trail). The analytical process followed a structured sequence: 1)

Data familiarisation: Repeated reading of transcripts and listening to recordings to understand context and nuance.

This process led to the identification of a central phenomenon, institutional friction which reflects the tension between audience expectations for emotionally engaging content and organizational constraints in content production.

To ensure methodological rigor, this study applies the trustworthiness criteria of credibility, transferability, dependability, and confirmability ( Lincoln & Guba, 1985; Tobin & Begley, 2004). 1)

Credibility was achieved through triangulation of data sources, member checking, and prolonged engagement with the research context.

Reflexivity was an integral part of the research process. The researcher continuously reflected on their positionality and potential biases through regular peer debriefing sessions with an academic supervisor. This process enhanced analytical transparency and reduced subjectivity. Ethical considerations were strictly adhered to throughout the study. Ethical approval was obtained prior to data collection. All participants provided verbal informed consent, and confidentiality was ensured through anonymisation using alphanumeric codes. The study complies with internationally recognised ethical standards for research involving human participants, including the principles outlined in the Declaration of Helsinki.

This category demonstrates that audience engagement is fundamentally governed by affective expectations rather than content characteristics alone.

As illustrated in Figure 3, engagement emerges from an integrated affective system consisting of five interrelated mechanisms: sensory stimulation, dramaturgical structuring, character humanization, visual authenticity, and personal projection. Rather than reflecting abstract preferences, emotional engagement is constructed through concrete viewing experiences. Sensory stimulation particularly through audio-visual synchronization creates an immediate emotional atmosphere that precedes cognitive processing. At the same time, dramaturgical structuring determines whether audiences remain engaged within the critical first seconds of exposure. These findings reinforce the dominance of affective processing in fast-paced digital environments.

Engagement is further intensified through human-centric storytelling. Audiences respond more strongly to personalized portrayals of healthcare professionals, where empathy, dedication, and sacrifice serve as indirect signals of service quality. This is reinforced by visual authenticity, as real-life representations enhance both credibility and emotional resonance. Moreover, emotional responses are amplified through personal projection, allowing audiences to interpret content based on their own experiences and social contexts. These mechanisms converge into empathic resonance, where viewers develop emotional proximity even toward unfamiliar individuals. Overall, this category establishes affective expectations as a central driver of engagement, extending existing literature beyond predominantly cognitive explanations of audience behavior.

The findings reveal that audience engagement in healthcare social media is predominantly driven by affective mechanisms rather than rational-cognitive evaluations. Audiences consistently reject rigid, institution-centric documentation in favor of human-centric storytelling that highlights the dedication and empathy of healthcare professionals. This aligns with Narrative Transportation Theory ( Green & Brock, 2000), suggesting that well-constructed narratives reduce cognitive resistance and foster deep emotional immersion.

In the context of healthcare, which is fundamentally a credence service, clinical quality is notoriously difficult for lay audiences to evaluate objectively ( Ostrom et al., 2015). This study provides empirical qualitative evidence supporting the concept of surrogate evidence ( Andraus Quintero et al., 2025). Audiences use the visual authenticity of dedicated healthcare workers as a heuristic proxy to evaluate the overall credibility and warmth of the institution. Furthermore, the capacity to trigger high-arousal emotions such as awe and inspiration through audio-visual synchronization proves to be a critical catalyst. As Berger and Milkman (2012) and Moriuchi and Gonzalez (2026) posit, emotional arousal, rather than mere positive valence, is the primary engine of digital engagement. This study demonstrates that without intense sensory stimulation, hospital content fails to disrupt the audience’s habitual scrolling behavior.

This category addresses the discrepancy between high affective engagement and low observable public e-WOM. Contrary to linear assumptions that emotional engagement directly leads to sharing behavior, the findings reveal a mediated and selective process.

As illustrated in Figure 4, audience sharing behavior is regulated by three primary filters: personal exclusivity, promotional sensitivity, and situational relevance. The exclusivity filter reflects impression management dynamics, where individuals selectively share content that aligns with their desired online identity. Health-related content, despite its emotional impact, is often perceived as lacking the symbolic value required for public display.

Secondly, audiences demonstrate strong resistance toward overtly promotional content, as such messages may undermine perceived authenticity. Thirdly, sharing decisions are shaped by situational relevance, where content is evaluated based on immediate personal or relational needs rather than habitual engagement patterns. As a consequence, a significant shift occurs from public sharing to private communication channels referred to as Dark Social. Audiences prefer disseminating healthcare information through trusted interpersonal networks (e.g., WhatsApp or direct messaging) due to concerns related to privacy and psychological safety. Importantly, sharing in these spaces is driven by relational motives, such as providing support or recommending services to close contacts, rather than performative self-presentation. These findings demonstrate that the effectiveness of healthcare communication cannot be fully captured through visible engagement metrics, as its impact is often embedded within unobservable private interactions.

A major contribution of this study is the untangling of the engagement-behavior gap. Despite experiencing profound emotional resonance, audiences exhibit a severe reluctance to amplify hospital content through public e-WOM. This behavioral dissonance can be explained through the lens of Impression Management and Social Currency ( Mishra & Singh, 2021). Audiences meticulously curate their public digital personas and often perceive health-related content as lacking the “wow factor” necessary for public broadcast.

Moreover, the episodic nature of health needs and the stigma associated with medical conditions activate a robust psychological defense mechanism ( Jordá et al., 2021; Börsting, 2022). Consequently, audiences strategically migrate their sharing behaviors to Dark Social private, encrypted interpersonal channels such as WhatsApp or Direct Messages ( RadiumOne, 2016). In these safe spaces, sharing transforms from a performative public act into a genuine gesture of moral support and interpersonal recommendation ( Zomorodpoush et al., 2025; Sharma & Sharma, 2025). This finding challenges the traditional paradigm of digital marketing metrics, arguing that the true virality and effectiveness of healthcare communication are often invisible to public social media analytics.

This category shifts the focus to internal organizational dynamics, highlighting structural constraints that impede digital agility. The findings reveal that the implementation of narrative-driven content is not merely a creative challenge but is significantly constrained by institutional processes.

As illustrated in Figure 5, the primary barrier is the approval bottleneck, where content must pass through multiple layers of medical and administrative review. While this process ensures clinical accuracy and risk mitigation, it introduces substantial delays that undermine the timeliness required for effective social media communication.

In addition, the analysis identifies significant limitations in technical infrastructure and human resources. As noted by one informant, content production often relies on personal equipment due to the absence of dedicated budgets (Informant R-010). Furthermore, the presence of dual workloads where digital content creation is treated as a secondary responsibility indicates that social media management is not yet institutionalized as a strategic function. These constraints create a structural misalignment between dynamic audience expectations and rigid organizational capabilities. While audiences demand authentic and responsive content, the institution remains anchored in bureaucratic processes that prioritize caution over agility.

These constraints create a structural misalignment between dynamic audience expectations and rigid organizational capabilities. The institution remains anchored in bureaucratic processes that prioritize caution over agility, creating an internal reality that presents a starkly contrasting picture to the fluid demands of digital media. This qualitative synthesis exposes the ‘Institutional Black Box,’ characterized by chronic resource constraints, dual workloads, and a debilitating approval bottleneck. From a Resource-Based View (RBV) perspective, the lack of dedicated infrastructure and budget for digital content creation paralyzes the creative capabilities of the marketing team. ( Naeem & Ozuem, 2021; Walsh et al., 2022).

More fundamentally, this operational friction is rooted in competing Institutional Logics ( Friedland & Alford, 1991; Thornton et al., 2012). Hospitals operate under a dominant professional logic that prioritizes risk mitigation, patient privacy, and clinical dignity. The findings demonstrate an intense ethical tension: while algorithms reward sensationalism and trend-jacking, hospital management actively resists these tactics to preserve institutional prestige ( Alhafez et al., 2023; de Oliveira Araújo et al., 2020). The mandatory pursuit of written informed consent, while legally and ethically imperative, inadvertently strips content of its natural authenticity, creating highly choreographed and sanitized narratives. This structural rigidity explains why hospitals inherently struggle to achieve digital agility, as the imperative to comply with medical regulations constantly throttles creative momentum ( Hügle & Grek, 2023; Udayana et al., 2024).

The final category elaborates on the overarching influence of institutional logics, particularly the tension between digital adaptability and the preservation of professional dignity. The findings indicate that content production is governed not only by creativity but also by strict medico-legal and ethical considerations, including patient privacy, clinical accuracy, and advertising regulations.

As illustrated in Figure 6, these constraints necessitate a “safe framing” of communication, often limiting the use of emotionally provocative or attention-grabbing elements. Beyond formal regulations, there is a strong emphasis on maintaining institutional prestige. Management demonstrates a cautious stance toward adopting popular social media trends due to concerns that such approaches may compromise credibility among key stakeholders.

This reflects the dominance of professional logic, where institutional identity and trust are prioritized over virality or algorithmic visibility. Consequently, emotionally engaging content is often moderated or avoided when it is perceived as potentially undermining clinical authority. This category reveals a fundamental paradox: although narrative and emotional content are empirically effective in engaging audiences, their implementation is constrained by institutional norms that prioritize dignity, trust, and compliance. As a result, storytelling strategies are frequently diluted within the hospital’s digital ecosystem despite their recognized value.

To reconcile the fundamental asymmetry between fluid audience expectations and rigid organizational capabilities, this study conceptualized and validated a specialized Quality Control (QC) Checklist. In healthcare management, the absence of standardized creative workflows results in a high Cost of Poor Quality (COPQ), characterized by wasted man-hours on rejected or ineffective content ( Choi et al., 2025).

The QC Checklist acts as an institutional nexus, translating tacit ethical boundaries and aesthetic preferences into explicit, pre-approved guidelines ( Nothacker et al., 2025). By instituting “filtering gates” based on narrative structure, affective stimulation, social currency, and regulatory compliance, hospitals can bypass repetitive bureaucratic reviews. This mechanism effectively reduces the approval turnaround time and alleviates operational burnout ( Hassmann et al., 2025), enabling hospitals to execute narrative strategies with digital agility without compromising their medico-legal integrity.