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Monday, August 25, 2014

Using Fear to Change Behavior; Fear Appeals in Context

   My first love, before public health law, was health communications. A health communication in its simplest form is a PSA - think - Slip, Slap, Slop; Buckle Up Saves Lives; 1% or Less is Best.  Health communications become trickier to pull off when the goal is to change a complicated behavior, such as eating less fried food, getting more physical activity or quitting smoking.  To move people towards change in these areas some health advocates will use fear appeals embedded in a health communication.  I love a well-done fear appeal!  By well-done I mean that the fear message is constructed using a theory/model that has been tested and found effective, for example the Extended Parallel Process Model (see e.g., (Witte, 1992; Witte & Allen, 2000)
   The most important components of the Extended Parallel Process Model are the constructs that, when taken into consideration, move the target audience towards danger control (e.g., quitting smoking to prevent lung disease (the feared outcome)) instead of fear control (e.g., smoking more).  There are four constructs that, though not unique to the EPPM, are especially important because without careful attention to these four constructs, a fear appraisal can backfire.
   The important constructs are relevancy of the threat, severity of the threat, efficacy of the response, and self-efficacy in regards to the response (action to be taken by the population). Relevancy and severity work together.  Staying with the smoking example, the message that smoking causes lung disease is relevant if the person hearing the message is a smoker and believes that lung disease is a serious condition - one that will affect them negatively. The person has to believe that the condition could happen to them and that it is worse than the discomfort of quitting the old behavior or adopting a new one, here the behavior to adopt is quitting smoking. 
   The response/action is whatever the health communication encourages the person to do in order not to “get” the disease or condition they should be ‘afraid’ of getting.  Some examples include, wearing sunscreen, exercising every day, quitting smoking, using condoms.  The efficacy of response refers to whether or not a person believes: sunscreen stops aging or sunburn, quitting smoking reduces lung disease risks, exercise prolongs life or condoms prevent sexually transmitted infections.  I think you can probably guess what self-efficacy in regards to the response is and why it is vital.   If a person does not believe that they have the ability to do the action, AND they have been sufficiently frightened of the outcome if they do not, they could engage in what Witte refers to as fear control - and in the case of lung disease and smoking, that could mean smoking more. (I am scared that I will get a lung disease and die, but I do not think I can quit smoking; this is very stressful, in order to handle my stress, I need to smoke.)
   Though it is not explicit in the model, there is an association among the constructs of relevancy, severity and efficacy and the source of the message itself.  When there is time and money, health educators/advocates create the best fear appeals from formative work with the target audience.  The formative work involves asking people to rate certain sources for their veracity and impact.  A question might be - Where do you go for information about health?  * friend, *partner, *doctor, *coworker etc.
   I have a personal anecdote to offer as an example of the source concept in action.  I live in near the coast in SW Florida  and I visit the beaches as often as I can.  When I first arrived here in 2007, my running friends and I would end our runs near the water. My friends said that the cold water would reduce the inflammation caused by our long runs and help us to remain injury free.  I believed my running friends because they were a reliable source.  Who would know more about keeping the body in running condition than people who run marathons every month?!  But these same friends, and plenty of other people, told me that I should shuffle my feet in the water to avoid getting stung by a sting ray.  Really?  To me that was just asking for trouble, if the sting rays were even there.  (i.e., I did not believe in the threat itself (though I did think a sting ray was VERY scary) and I didn’t think shuffling my feet made any sense.) So…. 7 years later (yesterday)…I was walking the shore at Lido Beach and at each life guard stand there was a sign (see image below) that said “Watch out for Sting Rays, Shuffle your feet!”  That did it - to me, the source was to be trusted and now I believe 1) there are sting rays in these waters and 2) shuffling is the recommended response.  But - and here is where it falls apart.  I am very fearful of the sting rays but not very confident in the response or my ability to do the response correctly.  I am, for the most part, going to engage in fear control.  I will stay out of the water.  This response keeps me from fully enjoying my day at the beach, but it doesn’t increase my risk of the outcome (getting stung), like smoking more would increase the risk of lung disease.  My reaction to the sting ray sign may not be that uncommon.  If I were to create a health communication for sting ray awareness I would build in a component that explains what shuffling the feet accomplishes and show images (via TV) of someone successfully carrying this action out.