Effective Health Risk Messages: A Step-by-Step Guide


Kim Witte, Gary Meyer & Dennis Martell

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    Preface for Instructors and Practitioners

    We designed this book for Instructors with the express purpose of providing students (and practitioners) with practical, theoretically based hands-on experience in designing and evaluating a health risk campaign. The book has 10 chapters to accommodate both quarter and semester systems, assuming you go through a chapter a week. It can work as a stand-alone text or as a supplemental workbook to a more traditional text. The worksheets take students step-by-step through the formative, message development, and outcome phases of a health communication campaign. Pilot tests of the worksheets indicate that students retain the material and rate classes using these worksheets as among the best they've ever taken.

    For Practitioners, we wanted to create a resource that clearly, plainly, and concretely explained how to go about conducting a theoretically based formative and outcome evaluation, as well as how to develop theoretically based messages. The worksheets and examples used in the book can be used with your clients or target audience members. This step-by-step guide was written as a resource guidebook, as well as to provide you with ready-to-use materials for your own health communication efforts. Enjoy and Good Luck!


    Thanks to Kimo Ah Yun (University of Washington), Anthony J. Roberto (Michigan State University), Dorothy Tan-Wilhelm (National Institute of Occupational Safety and Health), Susan E. Tate (University of Virginia), Mark P. Fulop (San Diego State University), Claire A. Stiles (Eckerd College), and Meagan Grant (Marquette University), for providing feedback on earlier drafts of the manuscript. Drs. Janet Lillie, Judith Berkowitz, Kenzie Cameron, Maria Lapinski, Lisa Murray-Johnson, and Wen-Ying Liu are gratefully acknowledged for their role in the research that helped form many of the ideas here. Most of all, thanks to our respective soul mates (Thom, Anne, and Colleen) for their support of this project.

  • Appendix: A Brief Analysis of Empirical Fear Appeal Studies


    This Appendix is for those interested in the academic research on fear appeals. Over the past 45 years, a large number of studies have examined how diverse variables influence reactions to fear appeals. In an effort to organize these widely disparate studies, we have adopted the traditional model of communication, source-message-channel-receiver, as an organizing framework.

    Source Factors
    Source Credibility

    In general, the degree of source credibility in a fear appeal significantly and positively influences retention of information (Williams, Ward, & Gray, 1985) and message acceptance (McCroskey & Wright, 1971; Powell & Miller, 1967). Occasionally however, credibility of the message is unrelated to message acceptance (Leventhal & Niles, 1964). No differences between expert and nonexpert sources emerged on fear appeal effectiveness in Stainback and Rogers (1983). Some studies found that credibility and strength of fear appeal interacted to influence outcomes. For example, Hewgill and Miller (1965) found the greatest attitude change occurred in the high credibility and high fear condition, but fear was most important. Furthermore, Powell and Miller (1967) found messages threatening individuals with social disapproval worked only when delivered by a highly credible source who was seen as trustworthy. With source credibility as a dependent variable, Smith (1977) found that stronger threat messages were associated with greater derogation of a source's credibility. In Leventhal and Niles (1964), those at risk for a health threat (smokers for whom the fear appeal is relevant) tended to discount the credibility of a fear appeal when compared to those not at risk (nonsmokers) (Leventhal & Niles, 1964). Overall, source credibility appears to be an important variable to consider when designing fear appeals.


    The findings for source similarity to target audiences in a fear appeal are mixed. Dabbs (1964) found that individuals were more persuaded by those more similar in coping style/esteem level to themselves. Likewise, Dembroski, Lasater, and Ramirez (1978) discovered that 6th to 8th graders were more persuaded by sources of a similar race to themselves. However, race did not have a main effect or interact with level of a fear appeal to influence persuasion for Rhodes and Wolitski (1990). Ramirez and Lasater (1977) found that Anglos were more persuasive than Chicanos regardless of fear level for 5th to 8th graders. Overall, the findings appear mixed for the effectiveness of source similarity—especially for race.

    Relevance to Topic

    No clear patterns have emerged for the influence of source relevance to topic in fear appeals. Fritzen and Mazer (1975) discovered the greatest amount of behavior change occurred when an alcoholic communicator gave a low fear message. However, they also found that retention of information was better for a high fear appeal delivered by a nonalcoholic communicator. However, none of these results was statistically significant.

    Message Factors
    Argument Quality

    Argument quality appears to be an important variable to consider when developing fear appeals. Rodriguez (1995), Gleicher and Petty (1992), and Smith (1977) all found that argument quality influenced processing of a fear appeal such that the stronger the argument, the greater the persuasiveness of a fear appeal.

    Message Sidedness

    There appears to be no clear differences between one- and two-sided messages in terms of fear appeal effectiveness (Ley, Bradshaw, Kincey, Couper-Smartt, & Wilson, 1974; Skilbeck, Tulips & Ley, 1977; Smith, Kopfman, Morrison, & Ford, 1993). Furthermore, fear appeal and message sidedness do not appear to interact to influence outcomes (only fear appeals were effective) (Stainback & Rogers, 1983).

    Subliminal versus Supraliminal Messages

    Stephenson (1993) manipulated fear appeals supraliminally and subliminally and discovered that the subliminal fear appeal produced the most message acceptance and the least maladaptive outcomes.


    Vividness of a message may be defined as “the extent that it is (a) emotionally interesting, (b) concrete and imagery-provoking, and (c) proximate in a sensory, temporal, or spatial way” (Nisbett 8k Ross, 1980, p. 45). In an overall review not limited to fear appeals, Frey and Eagly (1993) found vivid messages to be “less memorable and less persuasive than pallid messages” (p. 32). However, Sherer and Rogers (1984) discovered that fear appeals with greater emotional interest, concreteness, and proximity lead to stronger intentions to perform a recommended response (Sherer & Rogers, 1984). Rook (1986) discovered that when a health threat was immediate, there was no effect resulting from vividness (defined as case history/personal story vs. abstract/generalized to all women). However, when a health threat was distal, then the vividness of a message was effective in changing beliefs. No impact on health behaviors because of vividness was found, however (Rook, 1986). Similarly, Lemieux, Hale, and Mongeau (1994) found no differences resulting from their vividness manipulation, which was a comparison of a fear appeal with color photographs to one with black and white photographs.

    Message Framing

    Framing health-related information in a fear appeal as a loss if the recommended response is not followed, as opposed to a gain if the recommended response is followed, appears to yield a more persuasive message (Meyerowitz & Chaiken, 1987; Perkins & Scott, 1986; Robberson & Rogers, 1988). Similarly, negative messages were remembered better than positive messages for Reeves, Newhagen, Maibach, Basil, and Kurz (1991). However, Lemieux, Hale, and Mongeau (1994) found no differences in persuasiveness between loss versus gain frames. Similarly, McCroskey and Wright (1971) found no differences between punishment or reward messages.

    In terms of other message framing issues, Powell and Miller (1967) discovered that social disapproval messages produced more attitude change than social approval messages (but only by a credible source). Smart and Fejer's (1974) results suggested that preventive messages produce more effect than change messages. Robberson and Rogers (1988) found that positive appeals to self-esteem (e.g., increased self-confidence) worked better than negative ones (e.g., feeling worthless). Finally, Shelton and Rogers (1981) determined that high empathy/high fear appeals worked the best for pro-environment actions.

    Severity of a Threat Depictions

    The severity of a threat can be described in terms of outcomes like symptoms, duration (length of suffering), how a threat impacts one's appearance, and how the threat interferes with one's activities (Prohaska, Keller, Leventhal, & Leventhal, 1987). Studies have shown that threats described as highly visible and disfiguring lead to stronger intentions to protect oneself (Klohn & Rogers, 1991). Bang (1993) found that negative physical consequences were more emotionally arousing and persuasive than legal consequences for an antidrunk driving fear appeal. The degree of pain described for a threat does not appear to affect intentions or behaviors (Dabbs & Leventhal, 1966).

    Imminent versus Remote/Distal Threat

    Fear appeals containing imminent and immediate threats appear to be more effective than ones emphasizing remote and distant threats (Chu, 1966; Klohn & Rogers, 1991). Additionally, threats viewed as more likely to happen now than in the distant future were seen as more serious (Kok, 1983). Neither the rate of onset for a health threat (gradual vs. sudden) nor suggestions about when to undertake a recommended behavior appear to have an impact on message effectiveness (Leventhal, Jones, and Trembly, 1966).

    Target of the Threat

    Powell (1965) discovered that messages threatening the family produced the most attitude change, closely followed by messages threatening the listener (messages threatening the nation were the weakest). Witte, Murray, Hubbell, Liu, Sampson, and Morrison (in press) found that members of collectivist cultures (Hispanics) were more frightened by fear appeals threatening the family and members of individualist cultures (African-Americans) were more frightened by messages threatening oneself than the reverse for each.

    Information about the Recommended Response

    Many, many studies have shown that information about the effectiveness of the recommended response and about one's ability to perform the recommended response leads to greater message acceptance under high threat conditions and rejection of fear appeals under low threat conditions (e.g., Rippetoe & Rogers, 1987; Rogers & Mewborn, 1976; Tanner, Day, & Crask, 1989; Witte, 1992b). Response efficacy and self-efficacy are such important message components, they have been incorporated into two fear appeal theories (PMT, EPPM). Some qualitative work is beginning to emerge that examines the degree of threat and efficacy depicted in public health campaigns. Kline (1995) found that breast self-examination pamphlets published by national organizations (National Cancer Institute, American Cancer Society) emphasized severity and susceptibility, but did not have adequate levels of response efficacy or self-efficacy. Similarly, in a study conducted along the Trans-Africa Highway in Kenya, Witte, Nzyuko, and Cameron (1995) discovered that HIV/AIDS prevention materials contained adequate levels of severity and susceptibility, but were weak on response and especially self-efficacy messages. The types of fear appeals found by Kline (1995) and Witte, Nzyuko, and Cameron (1995) would be most likely to produce fear control responses resulting in the failure of a fear appeal to influence behaviors.

    Order of Recommendations

    The optimal position for message recommendations appears to be immediately after the fear-arousing message. Skilbeck, Tulips, and Ley (1977) found that fear-arousing messages immediately followed by recommendations were much more persuasive than recommendations given first or recommendations given much later. Similarly, the highest level of acceptance (though nonsignificant) toward a message emerged in Leventhal and Singer (1966), when the recommendations were given after the fear appeal, as compared to before or during the fear appeal. Finally, Harris and Jellison's (1971) study suggested that fear arousal followed by recommendations produced more persuasiveness than fear arousal alone.

    Duration of Exposure to a Fear Appeal

    Leventhal and Niles (1965) showed the longer the exposure, the more positive were the attitudes toward the message's recommendations and the greater were the perceived seriousness of a threat. Fear arousal was not affected by duration of exposure.


    The findings for repetitions of a message are mixed. Horowitz (1969) found that number of exposures (1 vs. 5) to a fear appeal had no effect on attitude changes. Kirscht and Haefner (1973) discovered that number of repetitions (1, 2, or 3) had no effect on intentions but did have an effect on behavior with more repetitions resulting in more behavior changes. Skilbeck, Tulips, and Ley (1977) determined that a single exposure to a fear appeal resulted in more persuasiveness than did multiple exposures (daily reminders).

    Channel Factors

    Frandsen (1963) compared high and low fear appeals presented live, by television, and by audiotape. He found that media type did not significantly influence message acceptance. However, his results indicated that the high threat/live presentation was the most persuasive and the low threat/audiotaped fear appeal was the least persuasive. Janis and Mann (1965) found that those who role-played a fear-arousing message (a lung cancer victim receiving bad news) changed their smoking habits more than those who listened to the role-play session on audiocassette.

    In terms of channel features, Leventhal and Trembly (1968) found that the larger the screen and the louder the sound was, the lower were perceived invulnerability, coping, and concentration, and the greater were the strength of emotions (disgust, impotence, egotism, depression, avoidance). There was no effect on intentions resulting from screen size or sound volume.

    Receiver Factors

    There appears to be no effect due to gender on acceptance of fear appeal recommendations (Insko, Arkoff & Insko, 1965; Leventhal, Jones, & Trembly, 1966; Rhodes & Wolitski, 1990). However, Struckman-Johnson, Gilliland, Struckman-Johnson, and North's (1990) study suggested that males were more persuaded by condom ads than females.


    Those people with high self-esteem appear to accept fear appeal recommendations and take protective action compared to those with low self-esteem (Leventhal & Trembly, 1968; Ramirez & Lasater, 1977). In addition, those individuals with low self-esteem appear to adopt more maladaptive coping strategies (e.g., fatalism, denial) than individuals with high self-esteem (Leventhal & Trembly, 1968; Rosen, Terry, & Leventhal, 1982). Dabbs and Leventhal (1966) found that those with high self-esteem complied only in the high fear condition (although compliance was low overall). Leventhal and Perloe (1962) found that high self-esteem individuals were more persuaded by a positive message while low self-esteem persons were more persuaded by a negative message.

    Locus of Control

    Beck and Lund (1981) found that those with an external health locus of control with high susceptibility perceptions reported flossing their teeth the most. Health locus of control did not interact with fear appeal level to influence behaviors. Burnett (1981) also found that those individuals with an external locus of control were more persuaded by any fear appeal message when compared with those with an internal locus of control (no interactions with strength of fear appeal).

    Trait Anxiety

    In a replication of Boster and Mongeau (1984), the effects of trait anxiety on fear appeal persuasiveness were assessed in Witte and Allen (in press). Eleven investigations measured either trait anxiety or similar concepts (e.g., repression-sensitization, coper/avoider).1 The results indicated that low anxiety individuals are slightly more persuaded by fear appeals than high anxiety individuals (r = −.049, p < .05, N = 1,641, X2 = 15.07). There appeared to be no interaction between level of fear appeal and trait anxiety. Recent research has shown that trait anxiety also appears to influence the degree of defensive avoidance produced by a fear appeal (Witte & Morrison, 2000).

    Relevance of Study Topic to Receiver

    Four studies have shown that greater resistances to fear appeals emerge for those most in need of self-protective behavior change (Berkowitz & Cottingham, 1960; Leventhal & Niles, 1964; Leventhal & Watts, 1966; Liberman & Chaiken, 1992). For example, Leventhal and Niles (1964) found that smokers exhibited greater resistances to an antismoking communication when compared with nonsmokers. Similarly, Leventhal and Watts (1966) found that light smokers who felt vulnerable to harm were most persuaded by fear appeals but heavy smokers who felt invulnerable to harm were least persuaded. Liberman and Chaiken (1992) also found greater fear and less message acceptance for those to whom the message was relevant when compared with those to whom the message was irrelevant. Additionally, they discovered biased message processing (discounting, more defensive reading, more critical) for high relevance persons, but no defensive inattention to the message. In contrast, Beck and Davis (1978) found that relevance of topic and interest level of subject did not influence persuasiveness; only fear level did.

    Defensive Processing

    One relatively new way to look at fear appeals is through the message processing models of Chaiken (systematic-heuristic model, 1980, 1987) and Petty and Cacioppo (elaboration likelihood model, 1986). Though there are differences between the models, each model suggests two general routes to persuasion. When persons are motivated and able to process a message, they centrally or systematically process the message by carefully evaluating the message's arguments and then make their decisions. Messages that are processed via a central or systematic route can be processed in either a biased or unbiased manner (e.g., accurate vs. inaccurate). In contrast, when persons are not motivated and/or are unable to process a message, they process it peripherally or heuristically and evaluate messages on the basis of cues (e.g., number of arguments in a message) or heuristics (i.e., mental models; e.g., my neighbor uses aspirin, so I will, too) when making decisions. Typically, researchers look at the degree of message-relevant thoughts to determine whether systematic/central processing or heuristic/peripheral processing occurred. Greater message-relevant thoughts indicate systematic/central processing and fewer message-relevant thoughts indicate heuristic/peripheral processing.

    Thus far, the research testing these dual process models has had mixed results. Some scholars have found that strong fear appeals promote systematic/central processing (Liberman & Chaiken, 1992), although others have found that strong fear appeals promote heuristic/peripheral processing (Hale & Mongeau, 1995; Jepson & Chaiken, 1990). A possible explanation for these results is that strong fear appeals promote biased defensive systematic/central processing and not the “normal” kind of systematic/central processing tested for in the two studies finding support for heuristic/peripheral processing (i.e., Jepson & Chaiken, 1990). For example, Liberman and Chaiken (1992) found that fear appeals were processed in a defensively biased manner such that threatening information was critically evaluated but reassuring information was not (Liberman & Chaiken, 1992). For high relevance subjects (those at risk for harm by the health threat), the defensive systematic processing was even more pronounced. Other researchers also have found selective and biased processing of fear appeals (Alvaro & Burgoon, 1995).

    It may be that this biased defensive systematic/central processing masquerades as heuristic/peripheral processing because of the types of message processing measures used in the two studies finding evidence for heuristic/peripheral processing. For example, Hale and Mongeau (1995) defined degree of message processing as the proportion of positive thoughts to total thoughts about the fear appeals. However, if individuals were engaging in defensive systematic/central processing, then a potentially more accurate measure of systematic processing (defined as message-relevant thoughts) might be the proportion of negative thoughts to total thoughts. If this type of measure had been used, then it appears that Hale and Mongeau's (1995) results would have flipped with the strong fear appeal promoting more defensive systematic/central processing than the low fear appeal, as indicated by the number of negative thoughts toward the fear appeal. In Jepson and Chaiken (1990), degree of message processing was determined by assessing the total number of message-related thoughts listed as well as the number of planted errors alluded to by the subject. This latter measure is likely to indicate the degree of unbiased message processing, in that it tests whether a subject detects errors, but it does not give the degree to which biased message processing occurs. Their results indicated that there was no relationship between the strength of the fear appeal and number of message-related thoughts. Interestingly, there was a significant negative relationship between strength of the fear appeal and detection of errors. This finding would indicate that strong fear appeals result in less unbiased message processing, but it does not indicate whether biased defensive systematic processing occurred. It is plausible that subjects detected errors only for threatening information, but not for reassuring information. This type of pattern would indicate biased systematic processing.

    Finally, Gleicher and Petty (1992) found a marginal interaction (p < .07) between fear appeal (moderate vs. low), argument quality (strong vs. weak), and response efficacy (whether a crime prevention program was successful).2 Specifically, they found that, regardless of response efficacy level under low fear conditions, strong arguments were more persuasive than weak arguments. Under moderate fear conditions, a similar pattern emerged for low efficacy individuals where strong arguments were more persuasive than weak. However, for high response efficacy people under moderate fear conditions, strong and weak arguments were both very persuasive. Gleicher and Petty (1992) concluded that because the high response efficacy/moderate fear group did not differentiate between strong and weak arguments, the message must have been peripherally processed. However, another plausible interpretation of these results is that the high response efficacy/moderate fear group engaged in defensive systematic/central processing where reassuring arguments (even if they were weak) were bolstered, and threatening arguments were criticized. Overall, it is unknown whether the lack of differentiation between strong and weak arguments was the result of peripheral processing of the fear appeal or biased systematic processing. Further research is needed on this point.

    Volunteer and Choice Status

    Overall, volunteers are more persuaded by fear appeals than nonvolunteers (Horowitz, 1969; Horowitz & Gumenik, 1970). Furthermore, as strength of the fear appeal increases, so does message acceptance by volunteers and nonvolunteers allowed choice (they were allowed to choose among multiple experiments) (Horowitz & Gumenik, 1970).

    Miscellaneous Individual Differences

    A variety of personality factors appear to influence whether a fear appeal is persuasive. Highly misanthropic people (cynically hostile, distrustful) (Alvaro & Burgoon, 1995), conservative white middleclass consumers (Burnett & Oliver, 1979), children of high social status (Haefner, 1965), students with high aptitude scores (Insko, Arkoff, & Insko, 1965), and depressed and antisocial people (Self & Rogers, 1990) are not persuaded by fear appeals. In contrast, fear appeals tend to be more effective for older liberals and older blue-collar blacks (Burnett & Oliver, 1979), children of low social status (Haefner, 1965), and students with low aptitude scores (Insko, Arkoff, & Insko, 1965).

    An individual's need for cognition appears to interact with level of threat and recommendations to influence intentions (Stout & Sego, 1994). Similarly, uncertainty orientation (the degree of motivation one has to resolve uncertainty) appears to interact with threat and efficacy such that those with a high uncertainty orientation are more likely to seek health information as the level of threat and efficacy in a fear appeal increases (Brouwers & Sorrentino, 1993). Some studies showed that regardless of age, gender, ethnicity, or group membership, the stronger the fear appeal, the more persuasive it was (Kirscht, Becker, Haefner, & Maiman, 1978; Rhodes & Wolitski, 1990).

    Miscellaneous Fear Appeal Factors
    Irrelevant Situational Fear

    Mixed findings have emerged for the type of fear aroused—be it relevant or irrelevant to the fear appeal. Fear arousal unrelated to the fear appeal increased persuasiveness for Lundy, Simonson, and Landers (1967). However, Gleicher and Petty (1992) found no differences between relevant versus irrelevant fear conditions for message processing, and Simonson and Lundy (1966) discovered that any type of fear led to more positive attitudes.

    False Physiological Feedback

    Any type of arousal, actual or false (subjects were told they were aroused), appears to improve persuasiveness—regardless of the affective label it is given (Beck, 1979; Giesen & Hendrick, 1974; Hendrick, Giesen, & Borden, 1975; Schwarz, Servay, & Kumpf, 1985).

    Subjective Expected Utilities

    Using a rational decision-making perspective, Sutton and colleagues have obtained mixed results in tests of a Subjective Expected Utility model. Sutton and Hallett (1988) found the (a) utility of experiencing a health threat (e.g., the degree to which one cares about being harmed) and (b) the probability difference (the difference between experiencing the health threat minus the decrease in the perceived probability of experiencing the health threat if the recommended response is adopted) led to stronger intentions to quit smoking, but that (c) confidence (whether one thinks s/he can succeed in performing the recommended response) and (d) fear arousal were unrelated to intentions. In a three-study report, Sutton and Hallett (1989a) obtained mixed findings where utility never influenced intentions, confidence always positively influenced intentions, and fear arousal and the probability difference positively influenced intentions in two out of three studies. Similarly, the probability difference and fear significantly and positive influenced intentions to wear seatbelts in Sutton and Hallett (1989b). In contrast, confidence and fear positively influenced intentions to quit smoking in Sutton and Eiser (1984). Overall, the model has not fared well. Sutton and Eiser (1984) concluded in one study that there appeared to be “no evidence for the multiplicative combination of utilities and subjective probabilities” suggested by the SEU (p. 14). Furthermore, it appears that fear offers the most reliable influence on intentions, even though it is unrelated to the SEU model.

    Multiple Affective Responses

    Several studies have found that fear appeals produce multiple affective responses beyond fear (Dillard, Plotnick, Godbold, Freimuth, & Edgar, in press; Kirscht & Haefner, 1973; Kohn, Goodstadt, Cook, Sheppard, & Chan, 1982; LaTour & Pitts, 1989; Leventhal & Trembly, 1968). For example, Dillard, Plotnick, Godbold, Freimuth, and Edgar (in press) found that although the strongest emotion produced by fear appeals was fear, fear appeals also produced significant levels of surprise, puzzlement, anger, and sadness. Other outcomes of fear appeals include irritation (Kirscht & Haefner, 1973), disgust and feelings of impotence (Leventhal & Trembly, 1968), tension and energy (LaTour & Pitts, 1989), and varying degrees of emotional upset including anxiety, loss of pleasure, and depression (Kohn, Goodstadt, Cook, Sheppard, & Chan, 1982).


    Overall, under all cases, the stronger the fear appeal, the greater the fear and perception of risk and the more persuasive a fear appeal is (Boster & Mongeau, 1984; Witte & Allen, 1996). Furthermore, several studies suggest that recommendation messages alone are less effective than recommendations with fear appeals (Harris & Jellison, 1971). Thus, it appears the combination of high threat and high efficacy messages produce stable and strong levels of attitude, intention, and behavior change. Fear appeals without efficacy messages or efficacy messages without fear appeals appear to be less persuasive.

    When conducting a fear appeal study, it is critical to carefully define and make constructs operational. Furthermore, it is important to not only assess attitudes, intentions, and behaviors (i.e., danger control responses) but fear control responses, too (such as defensive avoidance, denial, and reactance). Throughout this book you are given clear definitions and questionnaire items useful in research studies.


    1. Given Witte and Morrison's (2000) finding that previous fear appeal reviews examining the influence of trait anxiety on outcomes had inadvertently switched the high and low ends of scales measuring related constructs, great care was made to ensure the directionality of scales and labeling of anchors was accurate in Witte and Allen (in press). For example, sensitizers, high anxiety in-dividuals, and copers all score high on trait anxiety scales; repressors, low anxiety individuals, and avoiders all score low on trait anxiety scales. See Witte and Morrison (2000) for complete review of the literature.

    2. This interaction should be viewed cautiously as the manipulation check failed for response efficacy, indicating no differences between high and low response efficacy messages.


    The following are definitions and examples of the important variables found in most health behavior change models in the health risk message literature. See chapters 2, 3, 4, and 5 for descriptions of how these variables work together theoretically.

    Attitudes An evaluation of an object, recommended response, or a belief. For example, “computers are good; too much information is bad; anything that takes time is undesirable, are all attitudes.

    Barriers Anything that inhibits one from carrying out a recommended response, such as cost, time constraints, language difficulties, cultural differences, and so on. Some researchers see barriers as the inverse of self-efficacy, because barriers inhibit one's perceived ability to carry out a recommended response. Therefore, one can think of barriers as “barriers to self-efficacy.” Examples of barriers for the NN/LM might be a lack of computer skills, cost, embarrassment, language issues, cultural issues, and so on.

    Behaviors The actual action carried out. For example, did you or did you not use the Internet daily last week?

    Benefits The rewards or positive consequences occurring as a result of performing a recommended response. Do people see any benefit to performing a certain behavior? Benefits are somewhat similar to response efficacy.

    Cues to Action, External and Internal Examples of external cues include public service announcements and informational flyers. Some internal cues are symptoms of an illness, such as an itchy or bleeding mole. Cues are pieces of information that trigger decision-making actions.

    Danger Control A process individuals engage in when they believe they are at risk for a serious or significant threat (i.e., high perceived threat), they believe they are able to effectively avert it from occurring (i.e., high perceived efficacy) and are motivated to control the danger or threat. When people are motivated to control the danger, they change their attitudes, intentions, and behaviors. These changes result in the individual's adoption of behavioral recommendations in the message and subsequent enactment of the behavioral recommendations.

    Defensive Avoidance A motivated resistance to a recommended response, usually occurring at the subconscious level. Characterized by a lack of attention or remembrance of a particular concept, threat, or recommended responses. For example, the following are typical defensive avoidant responses: “It's too overwhelming, I'm just going to not think about it”; “I don't want to know anything about X, I'm just going to block out any-thing I hear about it.” Defensive avoidance occurs when one perceives a significant and relevant threat, but believes nothing he or she can do will effectively avert the threat.

    Efficacy The effectiveness, feasibility, and ease with which a recommended response impedes or averts a threat. For example, can your audience easily and effectively find the in-formation needed to avert a threat? Efficacy is comprised of two dimensions, re-sponse efficacy and self-efficacy. See these definitions below.

    Fear A high level of emotional arousal caused by perceiving a significant and personally relevant threat. Fear motivates both protective and maladaptive action, depending on the circumstances. For example, sometimes fear motivates one to seek out infor-mation. However, sometimes fear causes people to deny they are at risk for experi-encing a threat or to defensively avoid a threat and thereby ignore recommended responses. Fear can be one of the most powerful influences on behavior if it is channeled in the right direction.

    Fear Control When people believe they are at risk for a serious or significant threat (i.e., high perceived threat), but they believe they are unable to perform the recommended response or they believe the recommended response to be ineffective (i.e., low perceived efficacy), then they focus on controlling their fear about the threat. When people control their fear they do not control the actual danger. Instead, they control their fear by denying they are at risk for the threat, defensively avoiding the threat, or reacting angrily toward those trying to help them.

    Intentions Your plans to carry out a recommended response or do a certain thing. For example, “I intend to use the Internet daily.” Intentions are often used as proxies for actual behavior.

    Reactance Another form of motivated resistance where one becomes angry at an issue or source and reacts against a recommended response. Typically characterized by perceptions of manipulation (e.g., “they're just trying to manipulate us into using this stuff; it doesn't really make a difference”) or message/issue derogation (e.g., “this stuff is stupid; I know all I need to know”). Reactance occurs when one feels threatened but feels unable to do anything to effectively avert a threat (e.g., “I guess it's important to have up-to-date information, but there's no time and no money for me to get what I need.”).

    Response Efficacy The degree to which the recommended response effectively averts the threat. Sometimes response efficacy is called “outcome expectations,” and answers the question, if you perform a certain behavior, what do you expect the outcome to be?. For example, do people believe condoms prevent HIV transmission? Do people believe that having current medical information prevents harm to patients?

    Self-Efficacy The degree to which the audience perceives they are able to perform the recommended response to avert the threat. Sometimes self-efficacy is called “efficacy expectations,” and answers the question, what do you expect will happen if you attempt to perform a certain behavior? For example, do people believe they can use condoms to prevent HIV transmission? Do people believe they are really competent and able to access the information needed to make good medical decisions?

    Severity The magnitude of harm expected from a threat. The significance or seriousness of a threat. The degree of physical, psychological, or economic harm that can occur. For example, is AIDS severe and serious? Is there a danger in not having up-to-date information?

    Social Marketing The use of marketing principles and ideas to “sell” a pro-social idea or belief. This approach promotes the use of market research to discover important demographic and psychographic characteristics of one's target audience. Then it uses the Four Ps of marketing to sell the concept: product (the behavior or the product you want the target audience to adopt), price, promotion, and place (or positioning). This is a popular approach used in many outreach campaigns, but it is important to note that social marketing is an approach, and not a theory. Thus, it is best used in conjunction with a theory that offers guidance on the variables to study and how these variables work together to produce desired outcomes.

    Stages of Change A classification scheme that suggests five stages to the performance of a behavior, namely, Precontemplation, Contemplation, Preparation, Action, and Maintenance. For example, people are in different stages of readiness with regard to given behaviors. Different persuasive strategies are needed in the different stages of change. It is important to determine your client's or audience's stage of change before developing a campaign. For example, if your audience is completely unaware of certain technological innovations, they have not begun to even consider using such innovations and are in the precontemplation stage. An awareness and knowledge campaign is most appropriate for this target group to move them from the precontemplation stage to the contemplation and preparation stages. A motivational campaign is used to move people from the contemplation and preparation stages to the action and maintenance stages.

    Subjective Norm One's motivation to comply with what one believes his or her important referents believe. Notice this definition has two parts. First, your subjective norm is based on what you believe your significant others believe (note that the focus is on what you believe they believe, not what they actually believe). The more you are motivated to comply with a certain significant other or referent, the stronger the subjective norm. For example, if you are motivated to comply with your boss and your boss thinks it's a good idea that you utilize up-to-date information sources, then your subjective norm is strong for you to utilize up-to-date information sources.

    Susceptibility The likelihood that a specific person or audience will experience a threat. The degree of vulnerability, personal relevance, or risk of experiencing a threat. For example, am I susceptible to AIDS? Are you at risk for falling behind in current medical knowledge?

    Threat A danger or harmful event existing in the environment of which people may or may not be aware. For instance, a lack of pertinent information may be a threat, because this lack may cause harm to a patient. A threat is comprised of two dimensions: severity and susceptibility. See the definitions of these terms in this Glossary.


    Figure 1.5 Hepatitis Public Service Announcement

    Worksheet 1: Analyzing Health Risk Messages

    Figure 1.6 “If what happened on your inside happened on your outside”

    Worksheet 2: Analyzing Health Risk Messages

    Figure 1.7 “No way, a giant data eating virus”

    Worksheet 3: Analyzing Health Risk Messages

    Figure 2.4 “It's not just dust.”

    Worksheet 4: Understanding Health Risk Message concepts

    Figure 2.5 “Jill got reinfected …”

    Worksheet 5: Understanding Health Risk Message concepts

    Worksheet 6: Understanding the Extended Parallel Process Model

    Worksheet 7: Understanding The Extended Parallel Process Model

    Worksheet 8: Applying Health Behavior Change Theories

    Worksheet 9: Applying Health Behavior Change Theories

    Worksheet 10: Questions for The Health Risk Message Developer

    Worksheet 11: Open-Ended Questions To Determine Salient Beliefs About the Threat, Appropriate Recommended Responses, and Salient Referents

    Worksheet 12: Open-Ended Questions To Determine Salient Beliefs About Threat, Efficacy, and Benefits/Barriers

    Worksheet 13: Closed-Ended Questions To Determine Perceptions of the Threat and Recommended Response

    Worksheet 14: Determining More Audience Variables

    Worksheet 15: Conducting Formative Research

    Worksheet 16: The Risk Behavior Diagnosis Scale

    Worksheet 17: Case Five—Risk Behavior Diagnosis Scale (1of 2)

    Worksheet 18: Case Six—Risk Behavior Diagnosis Scale

    Worksheet 19: Case Seven—Risk Behavior Diagnosis Scale

    Worksheet 20: The Risk Behavior Diagnosis Scale

    Worksheet 21: Program Evaluation

    Worksheet 22: Focus Groups

    Worksheet 23: Measures of Central Tendency

    Worksheet 24: Measures of Dispersion

    Worksheet 25: Computation of the T Test

    Table 9.6t Distribution

    Worksheet 26: Getting the Message Out

    Worksheet 27: Field Application


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    Witte, K., & Allen, M. (in press). A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Education & Behavior.
    Witte, K., Berkowitz, J., Lillie, J., Cameron, K., Lapinski, M. K., & Liu, W. Y. (1998). Radon awareness and reduction campaigns for African-Americans: A theoretically-based formative and summative evaluation. Health Education and Behavior, 25, 284–303.
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    Witte, K., Murray, L., Hubbell, A. P., Liu, W. Y., Sampson, J., Morrison, K. (in press). Addressing cultural orientation in fear appeals: Promoting AIDS-protective behaviors among Hispanic immigrants and African-American adolescents, and American and Taiwanese college students. Journal of Health Communication.
    Witte, K., Nzyuko, S., & Cameron, K. (1995). HIV/AIDS along the Trans-Africa Highway in Kenya: Examining risk perceptions, recommended responses, and campaign materials. Preliminary report for the AURIG, Michigan State University.
    Witte, K., Stokols, D., Ituarte, P., & Schneider, M. (1993). A test of the perceived threat and cues to action constructs in the health belief model: A field study to promote bicycle safety helmets. Communication Research, 20, 564–586.
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    About the Authors

    KIM WITTE (PhD, University of California) is professor in the Department of Communication at Michigan State University. Her current research focuses on the development of effective health risk messages for members of diverse cultures. Dr. Witte is the chair of the Health Communication Division of the International Communication Division and a past chair of the Health Communication Division of the National Communication Association. She sits on 10 editorial boards and has served as expert consultant to the National Libraries of Medicine, the Centers for Disease Control and Prevention (CDC), the National Institute of Occupational Safety and Health (NIOSH), and other agencies. Her work has appeared in Social Science and Medicine, International Quarterly of Communication Health Education, Communication Yearbook, Health Education & Behavior, Communication Monographs, and Journal of Community Health, among other publications. Dr. Witte has received funding from the CDC, NIOSH, the American Cancer Society, and others. Her work has been recognized by more than a dozen “Top Paper” awards at both national and international conferences, as well as by the “Distinguished Article Award” from the Applied Communication Division of the National Communication Association, in recognition of the applied and practical value of her research. In 1997, Dr. Witte was awarded the “Teacher-Scholar Award” from Michigan State University, in recognition of excellence in research and undergraduate education. Recently, Dr. Witte was named the Lewis Donohew Outstanding Scholar in Health Communication, in recognition of her outstanding research contributions to the health communication field during the preceding biennium.

    GARY MEYER (PhD, Michigan State University) is assistant professor in the Department of Communication Studies at Marquette University in Milwaukee, Wisconsin. His primary research focuses on health communication in the areas of health promotion and disease prevention. Dr. Meyer has been an investigator for the Agency for Health Care Policy and Research as well as the U.S. Environmental Protection Agency, and has been published in the Journal of Health Communication, Journal of Communication, Communication Research, Science Communication, and Social Marketing Quarterly. He has received a Telly Award (1998) for his work in the area of violence prevention and has been named Outstanding New Teacher (1999) by the Central States Communication Association.

    DENNIS MARTELL (PhD) is a health educator and Director of the Center for Sexual Health Promotion at Michigan State University, where he supervises the HIV/AIDS Counseling and Testing Center. He has a B.S. in biology, M.A. in health education, M.A. in family therapy, and Ph.D. in family dynamics and human sexuality. Dr. Martell also teaches human sexuality in the Department of Psychology at Lansing Community College. He is a well-respected educator and researcher in the area of health promotion and has been involved nationally in numerous conferences, presentations, television productions, and publications.

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