Fear Appeals in Health Promotions: An Analysis of Empirical Evidence - Essay Example

?Fear Appeals in Health Promotions: An Analysis of Empirical Evidence This paper will look at empirical research, across a range of health promotion issues, about the use of fear appeals by health promoters, and will try to identify conditions where fear appeals are least and most effective. This paper will consider alternative behavior-change approaches. We will consider gender, age, culture, type of change anticipated, severity of fear tactic used, communication structural support, and the ethical logic of inducing fear in health promotion. We will consider studies with a watchful eye on five basic theoretical frameworks: Parallel Process Model (PPM), Planned Behavior, Protection Motivation Theory (PMT), Health Belief and Extended Parallel Process Model (EPPM). The paper will be guided by the following two questions: Does the empirical evidence support the widespread use of fear appeals by health promoters? Might alternative approaches to encouraging behavior change be more effective? Health promotion falls into three categories: primary prevention (lowering risk factors before illness occurs), secondary prevention (treating an illness in the early stages, attempting to cure it), and tertiary prevention (slowing down the damage of serious disease and trying to rehabilitate the patient). Health promotion falls under the category of primary prevention (Standen, 2003). One example would be: trying to persuade smokers to stop smoking, so that their lungs and heart have a better chance, with reduced risk of disease, or trying to persuade young people not to start smoking. Other examples are: educating sexually active people to use condoms, thus reducing the risk of sexually transmitted disease; raising awareness about HIV, so that people will get tested before they become ill, and keep AIDS from materializing right away; persuading pregnant women to not drink alcohol, so that their children will not suffer from Fetal Alcohol Syndrome; reminding people to wash their hands to prevent the spread of germs; raising awareness of diabetes and its management, so that people at risk or with symptoms will get tested right away, and so they can use diet and exercise instead of insulin. There are endless important areas for health promotion campaigns, but there is not a lot of agreement on how to go about it. One approach is using a fear appeal approach. A fear appeal, in health promotion, is when health promoters, trying to inspire change in behavior from high risk to lowered risk, place emphasis of a health message on the use of gruesome fear content or try to arouse fear responses in the audience (Witte, 1992). It is hoped, through one or both of these fear appeal methods, that the audience of the message will be shocked and frightened into paying attention and will be convinced to change behavior. Implied in that hope is the expectation that audience intention will result in action implementation. There are three audience responses to health promotion fear appeal messages. A person can accept the message. A person might use defensive avoidance (be inattentive, ignore, stay in denial). The person might choose reactance (rebels and does the opposite of what is expected) (Witte, 1992). Health promoters want to be able to predict what audience members will choose. It is assumed that the appeal will not cause so much shock and fear as to seriously damage message recipients. After all, one of the main objectives of health promotion is to increase wellbeing. Since it is not possible to know each individual member of a health promotion audience, there is an underlying assumption that they are pretty much the same as each other. This is not necessarily so. In order to decide whether widespread use of fear appeals in health promotion is supported, we will need to consider these assumptions: 1. That fear appeals persuade people to change behavior 2. That being persuaded leads to actually changing behavior 3. That the use of fear appeals is ethical, in health promotions, in that causing fear is a safe practice, and agrees with the goal of increasing wellbeing 4. That the people who hear these appeals are similar to each other in their vulnerability and response to fear appeals The use and efficacy of fear appeals in health promotions is not a new topic in the field, yet it is one of ongoing controversy and apparently incompatible research findings. Some studies show that the use of fear appeals is highly effective and recommended. Some studies show that the use of fear appeals is entirely counterproductive. Some studies show that the use of fear appeals is good for inspiration but not followed through on, with action. Some studies show that the use of fear appeals is only effective for certain groups and not for others. Some researchers argue that while it may be effective, it is not ethical. Reading only a few research reports is interesting but can lead to confusion. A more systematic examination and analysis of the empirical literature is called for. A significant theory that has emerged from the literature is the Parallel Process Model. As opposed to reacting at an emotional level, the person reacts at an intellectual level, trying to control the danger or threat by using protective behaviors to adapt to it (Witte, 1992). So, in the case of health promotion, the idea is that a person will think about the danger specified or implied in the fear message, and will devise a rational strategy to escape danger, by adjusting attitude, intention or behavior change (danger control processes), hopefully, instead of engaging in fear control processes, dominated by emotional responses. Danger control processes are adaptive, while fear control processes are maladaptive (Witte, 1992). Although there is a lack of empirical research supporting Leventhal’s theory, the model is important because of contributing the distinction between cognitive and emotional reactions to fear appeals (Witte, 1992). The Theory of Planned Behavior says that intention best predicts deliberate behavior. The Theory of Planned Behavior says that we can predict someone’s intention, based upon knowing their beliefs (subjective norm) about how the behavior in question will be viewed by valued others. Knowing these beliefs is of equal importance to knowing their attitudes, and a third aspect of equal importance is a person’s perception of how well they can perform a specific behavior. The rule, then, is, “The more favorable the attitude and the subjective norm, and the greater the perceived control, the stronger should be the person’s intention to perform the behavior” (University of Twente, 2010). But intention is only one piece of the puzzle. Sutton emphasized cognition over fear arousal by arguing that people decide whether to accept a fear appeal call to action based on the assessment of the utility of the threat, the likelihood it will occur without any behavior change, and the likelihood it will occur even if they make behavior change. Each probability is multiplied by the utility (Witte, 1992). Highest score wins their decision, meaning that they choose the lowest probability risk. However interesting this quantitative approach was, empirical research did not support it. Rogers developed Protection Motivation Theory, a main theory in the field of fear appeal research for three decades (Witte, 1992). This theory focuses completely on Leventhal’s danger control process and says that cognitive mediation processes occur as a result of how the fear appeal message’s presentation of the likelihood of the danger actually happening leads to the person accepting that they are themselves vulnerable to the danger; the extent to which the repulsive delivery of the message causes the person to recognize that the problem is quite severe; the recommendations made in the fear appeal cause the person to believe that making changes can really save them; and the person confidently accepts that they can actually do what needs to be done (self-efficacy) (Witte, 1992). Maladaptive responses occur if the rewards of the high risk behavior are greater than the person’s perceived vulnerability to danger and perceived severity. Adaptive responses occur when the person’s perception of response efficacy and self efficacy are high and perceived response cost is low (Witte, 1992). Fear has only an indirect role, in this theory. There is some empirical support for this theory, however there are some inconsistencies in empirical results (theory predictions do not necessarily agree with empirical results) and some holes in its logic (for example, the failure to show how coping processes interact with susceptibility/severity processes) (Witte, 1992). The Health Belief Model agrees that a person has to feel some amount of threat, in order to change behavior. The person needs to feel that there is a way to avoid the threat, by taking some recommended action, and that they can successfully take that action. Four factors lead a person to action readiness: seeing themselves as being susceptible, seeing severity, seeing benefits for an avoidance strategy, and seeing their way past the barriers. Another factor, cues for action, activates readiness to act, and self-efficacy refers to the confidence a person needs in order to make a change (University of Twente, 2010). Fear appeals may or may not address all parts of this model. Most identify the threat and target the population under threat, and they specify, in some way, the severity of consequences for high risk behavior, Some clarify the benefits of changing behavior, but not all, or even most, necessarily identify and reduce barriers to change, specify a reformed strategy to take, and give training to increase confidence. Witte, inspired by the view that fear appeal research was lagging because of an over-emphasis on cognition and the nearly total theoretical neglect of emotions, used Leventhal’s model as a framework and introduced the Extended Parallel Process Model. PMT explained the cognitive side of how messages come to be accepted (danger control), but the parallel side, of how messages come to be rejected (fear control), has been unduly ignored. Witte focused on showing both sides (Witte, 1992). Witte argues that a fear appeal inspires the person to assess the perceived threat and, if the assessment is high enough, fear happens and the person assesses response and self efficacy. When the assessment of threat is low, the person is not motivated to consider efficacy at all. When perceived threat and perceived efficacy are high, danger control is implemented. When danger control is the main focus of a person’s attention, fear takes a backseat to protection motivation strategies. On the other hand, when the assessment of threat is high, and the assessment of efficacy is low, fear processes begin to dominate. People cope with fear then through defensive, maladaptive responses (Witte, 1992). EPPM is considered to be a predominant message design theory in the fear appeal literature. It is a very thorough, holistic theory that leads us to effective communication of health-related information. EPPM continues to generate questions for research (Maloney, Lapinski, & Witte, 2011). We now have a theoretical container for considering whether the empirical literature supports widespread use of fear appeals. Now we will turn to specific research studies to consider our questions. The EPPM was tested in a Hong Kong research study that integrated the use of forewarning cues with EPPM, to promote low-risk behaviors in response to the H5N1 influenza virus. Two kinds of forewarning cues were used: alerting people that they are about to hear a persuasive message and telling them the topic and stance. It was found that forewarning enhanced coping, self-efficacy and the intention to act on the message (W., 2008). Age is a variable that should be considered in fear appeal health promotion. A very early study into fear appeal usefulness in health promotion was done in 1953 (Janis & Feshbach, 1953). It was investigating oral hygiene promotion among young people (first year high school). They found that using strong fear appeal caused the most anxiety and was perceived as the most interesting. However, it reduced the effectiveness of the message (as indicated by the least behavior change) (Janis & Feshbach, 1953). The effectiveness of using threats of death with young people was investigated, based on the popular assumption that young people believe in their own immortality and would probably be immune to death threats. Actually, the data indicated that young people respond to death threat appeals and also to non-death-threat appeals in stop smoking health promotion campaigns, and also that young smokers (16-25) respond better than older smokers (40-50). Older females respond better to non-death threat appeals than do older males, and do not respond much at all to death threat appeals (Henley & Donovan, 2003). Another study dealt exclusively with the impact of fear appeals and humor on fifth grade children. An online education program, to inform children about Avian Influenza and to help them develop low risk behaviors, was subjected to a quasi-experimental research design. The researchers were interested in identifying any differences between humor and fear appeals, in terms of effectiveness on risk perception, learning, retention and behavior. Results indicated that the fear appeal program was far more effective than the humor appeal program. Results also indicated, however, post-tests did not indicate significant behavior change or health practice improvement a month later, with either the fear appeal or the humor based program (Kim, Sorcar, Um, Chung, & Lee, 2009). Another variable that has been investigated, in the effort to make fear appeals optimally effective, is the size and type of warning. A study was done comparing two sizes of fear appeal text messages on Chinese cigarette packs with each other (one small on the side and the other covering 30% of the front of the pack) and with fear appeal text and fear appeal text plus graphic (graphic covering 50% of the front of the pack) messages on cigarette packs from Canada, Singapore, Hong Kong and the European Union (Fong, et al., 2010). Participants (adults and young people) rated how effective they thought the warnings were in their likelihood to persuade adults to stop smoking and young people to not start. The researchers found that, across all demographic variables, the picture-based appeals were rated highest, text only were rated in the middle, and the two Chinese warnings were least effective of all, although the larger text warning was a little bit more effective (Fong, et al., 2010). Of course, this study examined intention only, and not follow-through. This study is not alone in its findings. Another recent study analyzed 72 quantitative and 16 qualitative research studies, 5 studies that were both quantitative and qualitative, and a review paper. The studies were from various countries: Canada, USA, Australia, UK, The Netherlands, France, New Zealand, Mexico, Brazil, Belgium, other European countries, Norway, Malaysia, and China (Hammond, 2011). All studies had investigated the impact of warning messages on cigarette packs. The findings overwhelmingly indicate that the impact of the warnings depends upon design and size. Small text messages have little impact. Picture warnings that elicit strong emotion, placed on the front of the pack, have the most impact. Prominent warnings increase health knowledge and perception of risk, and lead people to quit smoking, and help young people to not start smoking. Not only the size of the message but also other communication variables are significant in persuading people to lower their risk and promote their health by changes in behavior. One of these variables is transportation by narrative (Dunlop, Wakefield, & Kashima, 2010). Apparently smokers who are transported (caught up in and carried away by) the narrative delivery of a health promotion message, to encourage them to quit smoking, report a greater commitment to their intention to quit. This is mediated by emotion and intellect (Dunlop, Wakefield, & Kashima, 2010). This was a cognitive study, but was complemented by an experiential study as well. In this experiential study of people’s responses to magazine messages promoting skin protection, they expressed the intention of self-protection, and it was mediated by perception of risk (Dunlop, Wakefield, & Kashima, 2010). It is important to deliver text messages in such a way that people experience being transported by them and not so boring or silly that they do not move the audience. Another communication tip for delivery of effective persuasive messages is to position the message in the causality location of the narrative. Apparently this is much more effective, in terms of information acceptance, than positioning the message at a non-causal location in the narrative (Dahlstrom, 2010). Causality influences the in-narrative impact of persuasion. Another communication variable to consider is how fear-arousing communications are processed by a health-risk vulnerable audience; protective action recommendation argument quality; and attributed source for processing and acceptance of recommendations made. It was found that the quality of arguments influenced attitude but not intention to act. Vulnerability influenced intention to act but not attitudes. Apparently, although vulnerability to health risk leads to biased processing of the suggestions made, the bias is limited to intention only and does not predict the way the message is evaluated ultimately (Hoog, Stroebe, & Wit, 2005). Bourne examined the research on fear appeals, specifically with a population of gay men who are at risk for HIV. He wanted to know whether fear appeals are an effective approach with this population. He concluded that (Bourne, 2010): Fear arousing imagery can be good at attracting attention and is often memorable. Fear-based campaigns are more persuasive for individuals who are already engaging in the desired, health-protective, behaviour. Arousing fear in individuals can have many unintended consequences, such as denial or othering. Most homosexually active men are already fearful of HIV. Arousing fear is not an effective means of facilitating sexual behaviour change. Bourne is not the only researcher who questions the effectiveness of facilitating behavior change through fear appeals. In this paper, we have looked at a lot of research in the fear appeal health promotion field that draws positive conclusions about the inspiration of intention to act, but not too many supporting that intention translates into action. In fact, it seems that translating intention into action is fairly complicated and much of the research simply accepts intention as a sufficient measure of effectiveness, when it is not. This means that a lot of the empirical research which presents apparent evidence of effectiveness, is measuring intention as synonymous with effectiveness, the results are not really as encouraging as the researchers imagine them to be. Witte’s Expanded Parallel Process Model, I must conclude, is the most complete and thoughtful theory among the ones I found to consider. Yet I think there is still cause to claim that widespread use of fear appeals is not supported by the literature. On the one hand, much of the literature defends it. On the other hand, there are too many supplemental variables that have not been combined into and accounted for by a particular theoretical system. For example, Witte spells out a really elegant theory, but this theory does not include any examination of cultural influence, gender distinction, how age changes the application of the theory, message text size and picture-based vs textual message display, the influence of quality or lack of quality in health promotion arguments, the importance of causality in the health promotion narrative, and surely there are other variables that have not yet been identified. Prediction of human behavior is not as straightforward as some researchers apparently fantasize it to be. Nor has there been, it seems, sufficient research documentation of alternatives to fear persuasion. Various of these were woven throughout this paper: Humor, for example, was tested and found to be less effective, with children, than fear appeals. Giving people cues that they are about to experience a persuasive technique, the topic and the stance, has been found to be effective. However, it was attached still to the fear appeal approach. Hypnosis is a candidate for alternative persuasive techniques. However, not all health promotion is done in person, and hypnosis by audiotape is still of indeterminate effectiveness. Subliminal suggestion is an alternative technique, perhaps, but its use is limited by law. It is not so easy to put suggestive hidden pictures into the magazine ad or to sneakily induce moviegoers to buy more coke and popcorn or put antisocial musical messages backwards onto rock and roll DVDs. Force is another persuasive technique, but not practical for health promotion. It is a pleasant thought to believe that people can respond directly to rational argument and the imparting of information. Unfortunately, as we have seen from this review of the empirical research, the intellect requires emotional partnership in order to turn intention into action. That is perhaps why there is so much emphasis placed on fear appeals. There is also the matter of fear appeal ethics. Health promotion is a field committed to the promotion of well-being. The use of fear appeals, according to the research reviewed here, increases anxiety, and anxiety, of course, is a mental health issue. Anxiety induces stress and stress releases adrenalin and cortisol, hormones which do long term damage to the human body. How can this be an ethical practice of a field committed to promoting well-being. It is obviously a violation of health promotion identity. On the other hand, if we can save thousands or millions or billions of lives from suffering and death, does the end justify the means? If we can save the economies of the world from staggering health-related costs, doesn’t the end justify the means? Doubtless, many more people will die from lack of high risk behavior change than will die from health promotion message- induced anxiety and stress. Still, does addressing one sin justify committing another? Does the empirical evidence support the widespread use of fear appeals by health promoters? Not absolutely and conclusively, no, not beyond the shadow of a doubt and not in adequate detail and understanding, but we are moving steadily in that direction. Might alternative approaches to encouraging behavior change be more effective? That question cannot be fairly and accurately answered until the first question has a deeper understanding. The conclusion of this paper cannot be precise, with respect to a specific answer or solution, because the state of research is not yet sophisticated enough for me to draw sufficient wisdom. I must feel satisfied with having reviewed the research, raising issues and questions. It is a valuable thing to do, even if the answers are not readily apparent, and if they seemed readily apparent, it could not be trusted at this point. References Bourne, A. (2010). The role of fear in HIV prevention. Sigma Research. Dahlstrom, M. (2010). The role of causality in information acceptance in narratives: An example from science communication. Communication Research, vol. 37 , 857-875. Dunlop, S., Wakefield, M., & Kashima, Y. (2010). Pathways to persuasion: Cognitive and experiential responses to health-promoting mass media messages. Communication Research, vol. 37:1 , 133-164. Fong, G. T., Hammond, D., Jiang, Y., Li, Q., Quah, A., Driezen, P., et al. (2010). 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