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Health Messages
Skyaid review of the literature on how to communicate health risks/possibilities to change behavioral     updated 1/11/01

Designing Health Messages 
- approaches from communications theory and public health practice
Edited by E. Maibach, R.L. Parrott 1995

Chapter 2 - Encouraging Risk Reduction 
- a decision-making approach to message design
by David R. Holtgrave, B, Tinsley, L. Kay

Authors of this chapter describe a staged model of behavior change.  Actions/events moves the target audience from precomtemplative (PC) to a contemplative (C) stage along the way to making an actual behavior change.  The subsequent stages are preparation (P), action (A), and finally maintenance (M).  This is all part of the theory of behavioral decision making (BDM).

The (apparently extensive) behavioral decision making literature has shown that target audiences have a very rich way to conceptualize risk.  Risk is associated with many dimensions/qualities.  

The literature agrees on the following dimensions:
 - voluntariness - low = indoor pollution, high = smoking
 - dread - fatal consequence
 - control - perceive low control in an airplane accident, but high control in an auto accident
 - knowledge
 - catastrophic potential - deadly to a large group of people!
 - novelty  HIV is novel - It did not exist 100 years ago.
 - equity

If risks are to be compared by the public, the risks should have similar dimensions/qualities.  The National Research Council (Improving Risk Communication, 1989) argued that people will reject comparisons of risks that possess very different dimensions of risk.  Example is given that HIV should not be compared to STD.  The two risk have different dimensions of dread, control, catastrophic potential and novelty.

There are also other difference in risk perceptions by age and developmental status. 

The behavioral decision making literature "contains empirical evidence that people have difficulty processing probability information."  

People often: 
 - overweigh small probabilities and underweigh large ones
 - have trouble revising probability judgments in the light of new information
 - overestimate the probability of easy-to-imagine events
 - underestimate cumulative risks - example risk of contracting AIDS with multiple unprotected sex encounters

• Conclusion: It would be better to communicate the 10 year risk of a health problem (say of stroke or sudden cardiac arrest) than a 1 year risk and have the audience imagine/deduce their 10 year risk.

Information presented as survival statistics is not nearly as powerful as information presented as mortality statistics.  the behavioral decision making literature refers to this as "Framing'.

• Conclusion: Much more powerful to communicate 70% mortality rate over a 30% survival rate over a 5 year time period, even though they are based on the exact same information.

Message designers need to elicit and address the decision-making perspective of the target audience, and must incorporate their time horizon.   For example, young people rarely have a 10 year time horizon. 

Message designers also need to incorporate the factors with the highest importance into the message.  They describe  extensive research to how 1278 children made decisions about recycling.  They had the students rate 41 possible factors on a scale from 0 to 10.  

The 41 factors suggested to the children included:
 - people's feelings
 - habit
 - difficulty
 - benefits to human health
 - benefits to wildlife
 - benefits to environment
 - problems from failure to recycle
 - financial benefits

The important factors  were consistent across grades and different parts of the US. 
The study by the authors of this chapter are presented in detail in an 1993 EPA report by them: Risk Communication, recycling, and young people, and in the book Applications of heuristics and biases in social issues.

The primary concerns/factors found by the study were (not in any order):
 - wildlife
 - health
 - environment
 - natural resources
 - reducing the amount of garbage in dumps
 - opinion of environmental groups.

Thus just 6 of the 41 factors were found to be important and were used the subsequent recycling effort.

• Skyaid Question: What are the important factors for stroke, sudden cardiac arrest?

Chapter 3 Moving People to behavior Change
a staged social cognitive approach to message design
by Edward W. Maibach and David Cotton

Chapter 4:  Fear Appeals in Health Promotion Campaigns
by Jerold L. Lahore and James Price Dillard

Research found that low fear message led to better dental hygiene - felt that anxiety produced by the moderate and high fear messages triggered defensive avoidance.

Organizing the Message
"An effective fear appeal must include a severe threat, vulnerability of the target to the threat, personal efficacy, and response efficacy."  "We recommend organizing the fear appeal using a problem-solution pattern."

VIVIDNESS OF THE APPEAL
Vivid information is emotionally interesting. It provokes clear images and makes content seem physically, psychologically, and temporally close to the person who experiences the information. Several researchers have con­tended that vivid information is more likely to keep a person's attention, to be recalled at a later time, and to be persuasive. Taylor and Thompson (1982) reviewed more than 50 studies of the effects of vividness, however, and concluded that support for vividness effects was equivocal at best.

Eagly and Chaiken (1993) suggest, despite research findings that are gener­ally disappointing, that there are several contexts in which vividness does appear to improve persuasiveness. Those contexts include the persuasiveness of pictorial information, health appeals, and fear appeals. Because fear appeals frequently address health issues and rely on pictorial information, vividness might be especially important for such messages. And indeed, vividness has been a staple of strong fear appeals for quite some time. An early example of vivid information would be pictures of diseased teeth and gums in Janis and Feshbach's (1953) study of dental hygiene. A recent example of a vivid high fear message comes from Witte's study of AIDS prevention behaviors, where the high fear message included color photos of an emaciated victim, tumors on a penis, and lesions on a foot. Vivid visual images on any number of health related topics should be available to producers of health promotion messages, for example, mastectomy patients, skin cancer victims, or lungs of smokers.

Appeal to loss appears to be more effective that appeal to gain. 
Example: Continue Smoking ->increase risk of heart disease
    is more effective than   Stop smoking -> decrease risk of heart disease.

Response Costs.
Response costs refer to negative outcomes that result from complying with a message recommendation. In Fruin et al.'s (1992) study of exercise to reduce risks of cardiovascular disease, response costs included lost time and physical discomfort associated with exercising. In Witte's (1992b) study of risk behaviors and AIDS, response costs of wearing condoms might have included lost spontaneity. In Hale et al.'s (1993) study of risks from ultraviolet radiation, several participants would not use a sun block every day because its application was inconvenient.

There is little doubt that perceived response costs inhibit the effectiveness of fear appeals. Response costs can, however, frequently be reduced by careful planning and communication. Witte's (1992b) messages, for example, specifically refuted the notion that condom use interfered with spontaneity. The inconvenience of applying a sun block every morning can be directly refuted by suggesting that the application takes very little time. The message producer must either anticipate the response costs or carefully pretest the messages (a strategy we wholeheartedly recommend). If response costs are not anticipated or discovered and refuted, then a certain portion of fear appeals will not reach their persuasive potential.

Chapter 5 Thinking Positively
using positive affect when designing health messages
by Jennifer L. Monahan

Excellent chapter.  summary by author follows:

1. When the intended audience is unfamiliar with an issue, use emotional benefit appeals in the form of comparison, demonstration, satisfaction, and testimonials.

2. Use heuristic or indirect affective appeals once message recipients are familiar with an issue or campaign. Humor or other positive feelings are very effective in overcoming selective attention due to boredom and overexposure.

3. Use positive affect very carefully once an issue is associated with strong negative feelings. It is difficult to use positive feelings to change strongly held negative attitudes. Moreover, using positive affect in these circumstances may backfire, making the negative attitudes even more firmly entrenched.

4. Use positive affect to change the focus of a campaign. When it is important to get the audience to view an issue in a new light, positive affect may be instrumental in shifting the mental frame that audiences use to understand an issue.

5. In order to increase compliance, stress positive outcomes rather than negative ones and emphasize control over an issue rather than helplessness.

6. Whenever the intended audience is undecided or confused (as is so often the case with health issues), positive affect is an excellent strategy. The most consistent and effective findings for positive affect changing behavior and attitudes are under these circumstances.