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RUNNING HEAD: Formative Health Communication Research

The Use of Fear Appeal Theory in Formative Health Communication Research: A Case Study

Kim Witte, Ph.D.

Johns Hopkins University (Center for Communication Programs) Michigan State University (Department of Communication)

Mailing Address: 1485 Sylvan Glen, Okemos MI 48864 517 347 3211, wittek@msu.edu

Author’s notes: Kim Witte is a Senior Program Evaluation Officer at the Center for

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Many health communication practitioners advocate using theory to develop their

campaign messages, yet when faced with a “real” project and “real” data, often practitioners are at a loss for how to translate theory into a research study, and then how to translate data collected from a research study into campaign recommendations. The purpose of this case study is to demonstrate how a fear appeal theory was used in Ethiopia to design both research and an entertainment education program. This type of research, called formative health communication research, was conducted using a well-tested fear appeal theory, called the Extended Parallel Process Model. Based on theoretical guidance from this model and the data, a 26-week radio serial drama was developed to promote family planning. This case study first describes the Ethiopian context and research project, then the fear appeal theory, and then the results of the formative research.

Family Planning in Ethiopia

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In response to the high fertility rate, as well as the low levels of contraceptive use to prevent pregnancy, the Ethiopian Reproductive Health Communication Project (RHCP/E) was launched. The RHCP/E is a four-year information, education, and communication (IEC) initiative in family planning supported by the United States Agency for International

Development. The purpose of the RHCP/E project is to improve the health status of Ethiopians and to help reduce the population growth rate. A steering committee with representatives from government agencies (e.g., the National Office of Population, the Ministry of Health), non-governmental agencies (e.g., UNICEF), and local Ethiopian-based agencies was developed. Based on a needs assessment of family planning organizations in Ethiopia, it was determined that an entertainment education radio soap opera would be developed to promote modern family planning methods.

Entertainment Education

Entertainment education is “any communication presentation that delivers a pro-social educational message in an entertainment format” (JHU/CCP, 2002, p. 1). Because radios are the most common mass medium in Ethiopia, the Ethiopian steering committee decided to develop a 26-week long radio serial. Formative health communication research was commissioned to determine the key messages for the scripts. The theoretical basis for the formative research is described next.

The Extended Parallel Process Model

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combined influence on behavioral outcomes (see Table 1 for definitions). Briefly, the EPPM suggests that when people feel at-risk for a significant threat they become scared and are motivated to act. The greater the threat perceived, the greater the motivation to act. If people believe they are able to do something to effectively avert the negative consequences of the health threat, they are motivated to control the danger and adopt the campaign’s recommended

responses in order to protect themselves. On the other hand, if people have strong threat

perceptions but doubt whether or not they are able to do something to avert the health threat and/ or believe the recommended response to be ineffective, then they will turn instead to controlling their fear about the health threat and engage in maladaptive actions like denial, reactance, or defensive avoidance.

TABLE 1 ABOUT HERE

---Study after study has proven that the EPPM’s four theoretical variables of perceived

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frightened (because they did not believe they could do anything to control the danger) and turn instead to controlling their fear through such psychological defense mechanisms as reactance, defensive avoidance, or denial. Overall, a campaign should promote strong perceptions of susceptibility, severity, response efficacy and self-efficacy to promote the greatest degree of danger control actions and always ensure that perceptions of efficacy are sufficiently strong enough to counterbalance perceptions of threat in order to prevent fear control responses. Formative Evaluation

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Methods

In EPPM parlance, the threat was defined as “having more children than desired” and the recommended response was “modern family planning methods” to prevent having more children than desired. The target population was 15-30 year olds living urban areas across five regions in Ethiopia. A statistically representative household survey was conducted with randomly selected members of the target population in the five specified regions for a total of 792 surveyed. Results of the Formative Health communication Research

Overview. A three-step process was used in the EPPM-based research. First, the

frequency distribution of each theoretical variable (i.e., susceptibility, severity, response efficacy, self-efficacy) was examined to assess if it was at high or low levels. Recall that the EPPM suggests that each of these variables should be at high levels to promote maximum behavior change. Second, the mean scores of each theoretical variable were compared to each other. The EPPM suggests that as long as perceptions of efficacy are stronger than perceptions of threat, then danger control actions would be promoted. Thus, the data were analyzed in order to

determine if efficacy perceptions had higher mean scores than threat perceptions. Third, with the information from steps 1 and 2 a chart of belief strength was created, which tells campaign designers whether or not the theoretical variables need to be strengthened or minimized in a campaign. With this information, specific, theoretically-based recommendations can be given to campaign designers about what messages should be contained in a radio serial drama.

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desired were fairly split with about 40% of respondents believing they were at risk of having more children than they wanted, but nearly 30% of the respondents failing to see themselves as at-risk. Some urban youth are motivated to act (the 40% who perceive high risk), but many are not (the 30% who do not believe themselves to be at risk). In terms of perceived severity, urban Ethiopian youth nearly universally believed that serious negative consequences come from having more children than desired. Perceived response efficacy was fairly high, as most urban Ethiopian youth believed that modern family planning methods worked and that they prevented one from having too many children. However, urban Ethiopian youth were split on their

perceptions of self-efficacy toward the pill. About 50% of urban youth strongly agreed that they were able to use the pill to prevent having more children than they wanted, but over 20% of the urban youth strongly disagreed that they were able to use the pill.

FIGURE 1 ABOUT HERE

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FIGURE 2 ABOUT HERE

---Results for Step 3. Steps 1 and 2 allow us to create a chart of belief strength and specific campaign recommendations. In Table 2, an “X” is marked in boxes indicating high, medium, or low perceptions. This table gives a snapshot of what an intervention needs to focus on. Recall that to promote danger control actions (i.e., self-protective attitude, intention, or behavior change) according to the EPPM, people must have high levels of perceived susceptibility, severity, response efficacy, and self-efficacy. Thus, according to the results of this formative evaluation, the following recommendations can be made:

Recommendation 1: Perceived susceptibility is split with a portion of the youth believing they are susceptible to having more children than they want, and another significant portion of the youth believing they are not susceptible to having more children than they want. Campaign messages should be designed to shift those with no perceived

susceptibility into the high susceptibility group.

Recommendation 2: Urban youth have strong perceptions of severity toward having more children than desired. There is no need for further messages on this issue.

Recommendation 3: In general, perceived response efficacy is high in that most urban youth believe that modern family planning methods work in preventing one from having more children than desired. It may be useful to reinforce response efficacy beliefs. Recommendation 4: Urban youth are split in their perceived self-efficacy toward using the pill to prevent having too many children. Nearly half believe they are able to use the pill but over 20% explicitly state they are unable to use the pill. A campaign explicitly needs to address perceptions of self-efficacy.

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---Summary Recommendations. The results illustrated in Figures 1 and 2 indicate that an intervention needs to increase perceptions of susceptibility and self-efficacy, and to a lesser extent, response efficacy. However, there is no need to address the issue of perceived severity of having more children than desired because it already is at a high level. Perceived susceptibility is low enough to suggest that many urban youth are in denial about their risk of having more children than they want. Interventions need to educate them about these risks. Similarly, interventions need to think of creative ways to increase urban youth’s perceived ability to use modern family planning methods like the pill. Entertainment education programs that show similar youth modeling how to use the pill, where to get it, and what its effects are is a useful strategy in increasing perceived self-efficacy. This unique health communication research demonstrates how a theory can be used to segment and analyze the audience in order to give specific guidance to campaign designers.

The Communication Campaign

The purpose of this formative research was to develop recommendations for campaign designers that were grounded in the audience’s reality and were theoretically-based. Upon completion of this formative research, a two-week long scriptwriter’s workshop was held where the characters and main storylines for the radio serial were developed. Professional scriptwriters then fleshed out the 26 episodes, actors were hired, and production began. The radio serial was first broadcast the last week in November, 2001, with the final broadcast airing June 16, 2002. Following is a brief description of the campaign.

Journey of Life. JOURNEY OF LIFE (JOL) was a weekly radio drama that focused on promoting family planning and preventing HIV and AIDS.1 Based on the theoretically-based formative evaluation, the scriptwriters focused on increasing perceived susceptibility with regard

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to over-population and perceived self-efficacy toward using family planning, by discussing the benefits, myths and rumors about family planning and by motivating the audience to realize that family planning is the most important way they can improve their own lives, the lives of their families and the quality of the life throughout Ethiopia.

The main message in JOL was "YICHALAL" (It is possible), meaning that it is possible for people in Ethiopia to improve their quality of life by planning their families and it is possible to control the epidemic of HIV/AIDS by taking appropriate measures to control the spread of the disease. The emotional focus of the series was to generate feelings of hope and confidencethat determining one's own family size and protecting oneself from HIV/AIDS are things that can be achievedby all. Table 3 shows that the majority of episodes focused on family planning issues (Episodes 2, 3, 6, 7, 10, 14-18, 22-25). The synopsis is as follows.

Askale, a female police investigator, Bahiru, her husband, were an affectionate

married couple that actively educated and taught others about health topics like family

planning. They constantly tried (and eventually succeeded) in persuading their mother,

the interfering and vocal Amelwork, that child -spacing was the best way to raise a

healthy and economically stable family. Saba was Askale`s carefree sister who went out

drinking and socializing with many men. She did not heed her sister's warnings to either

abstain from sex or use protection and Saba wound up discovering that she was HIV

positive after she had infected others. Tedjie, their servant, frequently asked questions on

health-related issues and adopted the use of condoms for himself as well as developed

healthy beliefs regarding the benefits of child spacing and the birth control pill.

Elias, a judge, and his wife, Azeb, lived next door to Askale and Bahiru. Elias and

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destroying the marriage. Azeb had a son that she had to give up for adoption because she

had been raped by an employer and needed to be childless to get a new job. She shared

her concern with Askale and they plotted to investigate, leaving Elias in the dark.

Meanwhile, another couple, Zeleke and Fikirte, agreed to take in Azeb`s son and

find him a family to live with. Zeleke planned to give Azeb`s son to the shady character,

Alemu, who cripples children and forces them to beg on the streets, extracting some of

their money for profit. Fikirte caught wind of the plan and kept the boy from this fate. In

order to do so she eventually turned her husband into Askale and Zeleke and Alemu were

sent to jail. Unfortunately, the marriage of Azeb and Elias suffered, since he was

suspicious and she would not reveal what was going on. Elias succumbed to Saba`s

advances, contracted HIV, and infected his wife (Azeb). They both died. Saba decided to

better her life and teach others to avoid her path. Intermingled in these various plots

were discussions of different health-related topics like the problems of overpopulation,

unwanted pregnancy, different family planning methods, ways of HIV transmission,

prevention of HIV/AIDS, crimes committed against children, etc, where the character of

Doctor Hailu was frequently consulted for an expert opinion.

Throughout the radio drama, self-efficacy issues were addressed by frequent

role-modeling of a variety of family planning decisions and options. In addition, barriers, myths, and rumors regarding family planning were specifically countered in order to increase perceived efficacy. Finally, everyone’s personal susceptibility (both males and females) to having more children than desired was emphasized in order to motivate the use of family planning. These are the variables that the formative evaluation suggested focusing upon.

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The evaluation of JOL impact revealed that the targeted theoretical variables – especially perceived self-efficacy and susceptibility – were successfully influenced by the theoretically-base radio drama . Specifically, almost all of the respondents (97.6%) said that JOL made them believe that they were able to use family planning methods (i.e., perceived self-efficacy). Perceived susceptibility to threat was moderately influenced, with an increase of 6-percentage points of respondents strongly agreeing that they might have more children than desired (from 40% to 46.6%). Overall, the impact evaluation found that about 91% of the respondents agreed or strongly agreed that JOL influenced them to use family planning.

Qualitative data from another evaluation found similarly profound effects on family planning attitudes and behaviors. For example, “Seble’s” self-efficacy beliefs were influenced by modeling from Askale, “I admire her (Askale) resolve to stick to family planning in spite of her mother-in-law’s constant nagging to have more children.” “Belay” reported a strong desire to space his children by using family planning, “To see one’s child get somewhere in life because of the care and guidance the parents gave makes one very happy. If one does not apply child spacing, achieving this will be hard. I have learnt much about family planning. Now I am better off. I feel I have to apply family planning when I get married.” And, a married couple (“Tigist” and “Asfaw”) reconsidered their notions of an optimal family size based on JOL exposure, “I do not think that just because one has a lot of children one can consider children as wealth. Children are wealth when you have one or two and they turn out well. Having a lot of children is not advantageous.”

Conclusion

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practitioners, creative talent, and researchers can work together to create effective behavior change communication interventions.

This theory-research-practice model is being used around the world across a variety of theories, health topics and populations at Johns Hopkins University’s Center for Communication Programs (www.jhuccp.org). At the Center for Communication Programs, researchers work hand-in-hand with program development staff to help people and organizations in developing countries create interventions that work. A new initiative, the global “Health Communication Partnership” (funded by the United States Agency for International Development), plans to expand this work by focusing on different levels of analysis such as the community and

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REFERENCES

Belete, S., Girgre, A., Witte, K. (2003). Summative evaluation of “Journey of Life”: The Ethiopia reproductive health communication project. Addis Ababa, Ethiopia: JHU/CCP and Ethiopia National Office of Population.

Central Statistical Authority (Ethiopia) and ORC Macro (2001). Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: Central Statistical Authority and ORC Macro.

Ferrara, M., Jerato, K., & Witte, K. (2002). A case study of “Journey of Life”: A process evaluation of a radio serial drama. Addis Ababa, Ethiopia: JHU/CCP and Ethiopia National Office of Population.

JHU/CCP (2002). Entertainment education: What is it? Baltimore, MD: Johns Hopkins University Center for Communication Programs. (www.jhuccp.org/centerpubs/sp_9/pg4.stm)

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RELEVANT CONCEPTS

Perceived Susceptibility Perceived Severity

Perceived Response Efficacy Perceived Self-Efficacy Entertainment Education Formative Research

RESOURCES

1. www.jhuccp.org (full of materials, videos, survey drafts, etc.)

2. http://www.comminit.com/ (full of lectures, discussions, and a list serve for international health communicators)

3. “Scared Straight.” (Written, Produced and Directed by Arnold Shapiro. VHS video cassettes of this program may be purchased for private home use. Please call 1-800-367-2467 ext. 306 for pricing information.)

DISCUSSION QUESTIONS

1. Define perceived susceptibility, perceived severity, perceived response efficacy, and perceived self-efficacy.

2. What combination of the above variables leads to behavior change? What inhibits behavior change?

3. How might you use the fear appeal theory discussed here (the Extended Parallel Process Model) in other topic areas like skin cancer prevention? Occupational safety?

4. How would you counsel an HIV-negative woman in an HIV-testing clinic based on the EPPM? How about an HIV-positive woman?

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TABLE 1. KEY VARIABLES IN THE EXTENDED PARALLEL PROCESS MODEL.

VARIABLE DEFINITION EXAMPLE

PERCEIVED

SUSCEPTIBILITY The degree to which one feels at risk for experiencing a health threat. “Is it likely that I’ll have more children than I really want?” PERCEIVED

SEVERITY

The magnitude of harm or negative consequences expected from the health threat

“Does having more children than I want negatively impact my life? How?”

PERCEIVED RESPONSE EFFICACY

The degree to which one believes that the recommended response works in averting the health threat

“I am able to use modern

contraceptive methods to prevent my getting pregnant.”

PERCEIVED SELF-EFFICACY

The degree to which one believes s/he is able to do the recommended

response

“Modern contraception will prevent me from getting pregnant.”

DANGER CONTROL RESPONSES

Responses that control the danger such as adoption of the campaign’s

recommendations; typically attitude, intention, or behavior changes

“Modern contraceptive methods are good.” (attitudes)

“I intend to use modern contraceptives.” (intentions) “I use the pill.” (behaviors) FEAR CONTROL

RESPONSES

Responses that control one’s fear (and not the danger); typically

psychological defense mechanisms such as reactance, defensive avoidance, or denial of a threat

“Modern contraceptives are just a way to destroy our people. They’re a UN plot.” (reactance)

“I don’t even want to think about my risks; it’s safer to just block out scary thoughts.” (defensive

avoidance)

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TABLE 2. CHART OF BELIEF STRENGTH TO GUIDE CAMPAIGN MESSAGE DEVELOPMENT.

Theoretical Variables

Weak or Low Belief Strength

Moderate Belief Strength

Strong or High Belief Strength

Susceptibility

X

Severity

X

Response Efficacy

X

Self-Efficacy

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TABLE 3. CONTENT OF “JOURNEY OF LIFE” EPISODES. Episode 1: General Introduction of Story and Characters Episode 2:* Overpopulation and its Consequences

Episode 3:* What is Family Planning (FP) and why is it important? Episode 4 Transmission of HIV/AIDS

Episode 5. Who is Vulnerable to HIV/AIDS? Episode 6:* Consequence of not Using FP Episode 7:* Cultural Barriers to Using FP

Episode 8: Technical Explanation of HIV/AIDS Episode 9: Need for Expert Advice

Episode 10:* Contraceptives: Condom (also for HIV) Episode 11: General Story Development.

Episode 12: Fear and Shame with HIV/AIDS Episode 13: Preventing HIV/AIDS

Episode 14:* Contraceptives: Oral Contraceptive Pills Episode 15:* Contraceptives: Injections

Episode 16:* Need for Counseling and Informed Choice Episode 17:* Contraceptives: IUCD

Episode 18:* Contraceptives: Norplant

Episode 19: HIV/AIDS and Marriage / Polygamy Episode 20: Care and Support of people with AIDS Episode 21: Socio-economic Problems of HIV/AIDS Episode 22:* Myths and rumors with FP

Episode 23:* Contraceptives: Vasectomy Episode 24:* Contraceptives: Tubal Ligation Episode 25:* Benefits of Family Planning Episode 26: Story Conclusion

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FIGURE 1. PERCEIVED SUSCEPTIBILITY, SEVERITY, RESPONSE EFFICACY, AND SELF-EFFICACY DISTRIBUTIONS.

Figure 1a Responses to the statement, “I AM AT-RISK FOR HAVING MORE CHILDREN THAN I WANT.”

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Figure 1c. Overall responses to perceived response efficacy statements, e.g., “USING MODERN FAMILY PLANNING METHODS WORK IN PREVENTING MY HAVING MORE CHILDREN THAN I WANT.”

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Figure

TABLE 1.  KEY VARIABLES IN THE EXTENDED PARALLEL PROCESS MODEL.
TABLE 2.  CHART OF BELIEF STRENGTH TO GUIDE CAMPAIGN MESSAGE  DEVELOPMENT. Theoretical  Variables Weak or Low  Belief Strength Moderate Belief Strength Strong or High Belief Strength Susceptibility X Severity X Response Efficacy X Self-Efficacy X
FIGURE 1.  PERCEIVED SUSCEPTIBILITY, SEVERITY, RESPONSE EFFICACY, AND  SELF-EFFICACY DISTRIBUTIONS.
Figure 1d  Responses to perceived self-efficacy statements, e.g., “I AM ABLE TO USE THE  PILL TO PREVENT MY HAVING MORE CHILDREN THAN I WANT.”
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