1. This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation In Slide Show, click on the right mouse button Select “Meeting Minder” Select the “Action Items” tab Type in action items as they come up Click OK to dismiss this box This will automatically create an Action Item slide at the end of your presentation with your points entered. The Use of “Fear Appeals” in Public Health Campaigns and in Patient/Provider Encounters Dr. Kim Witte - Center for Communication Programs, Johns Hopkins University - Department of Communication, Michigan State University wittek@msu.edu

2. Introduction  Definitions, What is a Health Risk Message?  Theoretical Rationale for Effective Health Risk Messages  Applications to Real-Life Settings: The Risk Behavior Diagnosis Scale

3. Health Risk Messages (aka “Fear Appeals” or “Scare Tactics”)  Imply some sort of risk  Inherently fear-arousing (because of the implied risk)  Formally known as “Fear Appeals”

4. Health Risk Messages have 2 components  A Threat Component –Severity of Threat - is it serious or severe? (magnitude of threat) –Susceptibility to Threat - can it happen to me? ( possibility of experiencing threat)  A Recommended Response (address efficacy issues) –Response Efficacy - does response work? –Self-Efficacy - can I do response? –Barriers to Self-Efficacy - what blocks me from doing response?

5. Example of fear appeal focusing on threat alone, no efficacy, implicit conclusion.

6. Example of fear appeal focusing on threat alone, no efficacy. Likely to work for non-smokers and fail for smokers.

7. Balanced fear appeal, has both threat and efficacy with explicit conclusion.

8. Theoretical Rationale: The Extended Parallel Process Model (EPPM) 1. Threat motivates action, efficacy determines nature of the action. 2. When threat is low, there is NO response to the message (it’s not even processed, efficacy is not considered. 3. When threat is high, and efficacy is HIGH, then people CONTROL THE DANGER and protect themselves. 4. When threat is high, and efficacy is LOW, then people CONTROL THEIR FEAR and ignore the message. 5. Critical to measure both INTENDED and UNINTENDED campaign outcomes, to see if there’s NO response to your campaign versus a fear control response (can both look like NO response).

9. As long as perceived efficacy is stronger than perceived threat (e.g., it’s a serious problem that I’m at-risk for but I know I can do something to effectively avert it), then people will control the danger by accepting your message’s recommendations and make appropriate behavioral changes. However, the critical point is when perceived threat slips above perceived efficacy, meaning that people no longer think they can do something to effectively avert the threat. The minute that perceived threat exceeds perceived efficacy, then people begin to control their fear instead of the danger and they reject the message. Danger Control Responses Fear Control Responses

11. Studies Testing the Model  African-American Homeowners & Radon  Texas Farmers & Tractor Safety  Juvenile Delinquents & HIV/AIDS Prevention  Michigan Residents & Railway Crossing Safety  Homocysteine & Massachusetts Residents  Bulimia Prevention & College Students  Kenya Prostitutes & HIV/AIDS Prevention  Food Pantry Workers/Customers Needs Assessment  Beryllium Disease & Alabama Plant Workers  Needle Sticks & Hospital Workers  Teen Mothers & Pregnancy Prevention  Dental Hygiene & College Students  Hispanic Immigrant & African-American Jr. High Students and HIV/AIDS Prevention  College Students & Genital Warts  Skin Cancer & Texas Young Adults  Coal Miners & Hearing Loss  and so on...

12. Empirical Results  Threat and Efficacy have been shown empirically to be the two major factors of a health risk message.  Threat Determines Strength of Response, Efficacy Determines Nature of Response.  Either Fear Control OR Danger Control Processes Dominate (mutually exclusive)  Fear Appeal Campaigns may Appear to Fail, BUT Efficacy Perceptions Determine Success  Danger Control is primarily a cognitive process, Fear Control is primarily an emotional process  Target of threat varies culturally (individual, group).  Definition of threat varies with target audience.  High Threat/High Efficacy fear appeals appear to work subconsciously as well.

13. Applications: Risk Behavior Diagnosis Scale  A Rapid Assessment Tool  Determines whether danger control or fear control processes are dominating (so you can give messages that yield behavior change)  A Quick 12-item template scale Rationale: 1. Sum threat score and efficacy score separately. 2. Subtract threat score from efficacy score, yielding a critical value. 3. If value is positive, indicates that efficacy is stronger than threat, and person is in danger control. Messages can focus on increasing perceptions of severity and susceptibility (with appropriate efficacy messages), to increase behavior change. 4. If value is negative, indicates that threat is stronger than efficacy, and person is in fear control. Messages must focus on efficacy only (because people are already too scared).

14. Risk Behavior Diagnosis Scale Define Threat=________________; Define Recommended Response:______________________________________ Strongly Strongly Disagree Agree RE 1. [Recommended response] is effective in preventing [health threat]: 1 2 3 4 5 RE 2. [Recommended response] work in preventing [health threat]:1 2 3 4 5 RE 3. If I [do recommended response], I am less likely to get [health threat]:1 2 3 4 5 SE 4. I am able to [do recommended response] to prevent getting [health threat]:1 2 3 4 5 SE 5. I have the [skills/time/money] to [do recommended response] to prevent [health threat]:1 2 3 4 5 SE 6. I can easily [do recommended response] to prevent [health threat]:1 2 3 4 5  Eff____ ******************************************************************************************************************* Strongly Strongly Disagree Agree SEV 7. I believe that [health threat] is severe:1 2 3 4 5 SEV 8. I believe that [health threat] has serious negative consequences:1 2 3 4 5 SEV 9. I believe that [health threat] is extremely harmful:1 2 3 4 5 SUSC 10. It is likely that I will get [health threat]:1 2 3 4 5 SUSC 11. I am at risk for getting [health threat]:1 2 3 4 5 SUSC 12. It is possible that I will get [health threat]:1 2 3 4 5  Thr_____ 15 19 Efficacy - Threat = Critical Value In this example, 15 - 19 = - 4 ( person is in fear control, needs efficacy messages, no threat).

15. Steps to Using the Scale  1. Clearly Define Threat  2. Clearly Define Recommended Response  3. Plug in threat and recommended response into the scale.  4. Administer to either client or audience.  5. Calculate and develop appropriate messages.

16. Example of Risk Behavior Diagnosis Scale. Define Threat= HIV/AIDS Define Recommended Response: Use Condoms Strongly Strongly Disagree Agree RE 1. Condoms are effective in preventing HIV/AIDS infection: 1 2 3 4 5 RE 2. Condoms work in preventing HIV/AIDS infection:1 2 3 4 5 RE 3. If I use condoms, I am less likely to get infected with HIV/AIDS:1 2 3 4 5 SE 4. I am able to use condoms to prevent getting infected with HIV/AIDS :1 2 3 4 5 SE 5. I am capable of using condoms to prevent HIV/AIDS infection:1 2 3 4 5 SE 6. I can easily use condoms to prevent HIV/AIDS infection:1 2 3 4 5  Eff___ ******************************************************************************************************************* Strongly Strongly Disagree Agree SEV 7. I believe that HIV/AIDS infection is severe:1 2 3 4 5 SEV 8. I believe that getting HIV/AIDS has serious negative consequences:1 2 3 4 5 SEV 9. I believe that getting HIV/AIDS is extremely harmful:1 2 3 4 5 SUSC 10. It is possible that I will get HIV/AIDS:1 2 3 4 5 SUSC 11. I am at risk for getting HIV/AIDS:1 2 3 4 5 SUSC 12. It is likely that I will get HIV/AIDS:1 2 3 4 5  Thr_____ Efficacy - Threat = _____ Positive score indicates danger control processes dominating (needs threat to motivate with high efficacy message). Negative score indicates fear control processes dominating (needs only efficacy messages; no threat).

17. Examples of each condition according to threat/efficacy beliefs.

18. Creating Appropriate Messages  A high threat message is: –personalistic –vivid (language and pictures)  A high efficacy message: –explains how to do the recommended response –addresses barriers to recommended response –gives evidence of recommended response’s effectiveness –may role play recommended response

19. Low Threat PictureHigh Threat Picture

20. Low Threat Moderate Threat High Threat Case study client very dissimilar Case study client a little more like Case study client identical to target to target audience, neutral language. Target audience, a bit more vivid audience, very vivid and descriptive language. language used.

21. For more information, examples of focus group protocols and survey items, or to find articles, please see: www.msu.edu/~wittek/index.htm The End...

22. PROMOTING CHANGE/ PREVENTING DISEASE Tracy Garland Washington Dental Service Foundation May 20, 2004 Grantmakers In Health Washington, DC CITIZENS’ WATCH FOR ORAL HEALTH THROUGH POLICY

23. POLICY CAMPAIGNS: Focus shifts: From Problem defined at individual level Short term focus on programs Treating people as consumers Using mass media to change health habits To Blend of individual and societal responsibility Long term focus on policy Treating people as citizens Using mass media to influence policy

24. POLICY CAMPAIGNS You can’t have a media strategy without an overall strategy

25. POLICY CAMPAIGNS: Strategy Development  What is the problem?  What is the solution or policy?  Who has the power to make the necessary change?  Who must be mobilized to apply the necessary pressure?  What do the targets need to hear?

26. POLICY CAMPAIGNS: Problem ID “A public problem doesn’t exist until enough people with enough clout in the society say it does.”

27. POLICY CAMPAIGNS: Theory of Change  Public officials look to media as a proxy for public opinion  Media set the public agenda  Use media to frame our issue  Public officials –Feel it is safe to move the issue –Believe that people will understand why he/she is doing this

28. POLICY CAMPAIGNS: Communications Research  Media creates a framework of expectation about an issue (dominant frame)  Must understand how ordinary people think –Frame trumps facts  To change opinion, must shift the frame –Search for metaphors, messengers, images to support new frame

29. Oral Health in America: A Report of the Surgeon General EXECUTIVE SUMMARY Department of Health and Human Services June 2000

30. Q. How to give legs and longevity to the Surgeon Generals report on oral health? A. Citizens’ Watch for Kids Oral Health

31. ORAL HEALTH POLICY CAMPAIGN  Issue is unknown; no salience  Issue is undervalued; connects to toothbrushes, junk food, smiles, self-esteem  Issue is framed solely as personal responsibility (habits, discipline)  For children, likely frame is parent responsibility  No consequences, no connection to overall health  No opportunity for public/private partnerships  Dental visits an expendable luxury  Dentists seen as self-interested, not credible Research Findings

32. The Good News in the Research Findings  When prompted, adults believe that oral health is part of overall health and well- being.  When prompted, adults can understand that children’s oral health is a community responsibility. ORAL HEALTH POLICY CAMPAIGN

33. How Do We Shift the Frame?  Emphasize prevalence of problem  Explain severity of problem  Identify consequences of problem  Underscore the efficacy of prevention in solving the problem  Mainstream the issue ORAL HEALTH POLICY CAMPAIGN

34. “Tooth decay is the most common chronic childhood disease in America. It affects half of all first graders and 80% of seventeen-year-olds. In Washington State, one in seven low-income children has unmet dental needs, and many more families struggle to pay for dental care. Oral disease keeps kids out of school and later out of work…” ORAL HEALTH CAMPAIGN: Message

35. ORAL HEALTH CAMPAIGN: Solution “It doesn’t have to be this way. When communities make prevention and early treatment a priority, kids can get regular check-ups, sealants, and fluoride. So let’s watch our mouths and use them to speak up for the children of Washington State. Because if our mouths aren’t healthy, neither are our bodies.”

36. ORAL HEALTH CAMPAIGN: Tools  COALITION  MEDIA –PAID –EARNED  POLICY –Phase IPolitical advance work –Phase IIawareness solutions

37. ORAL HEALTH CAMPAIGN: Coalition Citizens’ Watch for Kids Oral Health BusinessBusiness LaborLabor MedicalMedical The Ask -Embed this in your policy agenda -Open your communication channel -Sign Op-Eds -Testify Dental Education Public Health

39. ORAL HEALTH CAMPAIGN: Results  Issue reframed, with new identity  Success broadening constituency  Policy “wins” –Defeat anti fluoridation attack –Oral health references in model nutrition legislation –WSMA policy: responsibility of md’s to identify, treat and refer oral disease  WDS Foundation seen as “moral authority” in state capital

40. ORAL HEALTH CAMPAIGN: Summary Improved health status will come about as a result of Individuals getting more knowledge about personal health behaviorsIndividuals getting more knowledge about personal health behaviors Groups getting more power to change social and economic conditionsGroups getting more power to change social and economic conditions