This post was originally published here.
A recent, well-publicized paper in Pediatrics cast considerable doubt on a tool public health practitioners value highly: informational messaging campaigns. The paper, based on a randomized-controlled trial, showed that neither information on the safety of vaccines nor details about the diseases being prevented by vaccination increased parental intent to vaccinate their children. In a surprising twist, graphic images of children suffering from vaccine-preventable childhood diseases, such as measles and pertussis, actually increased parental belief in an association between vaccines and autism and dramatic narratives about unvaccinated children who became ill increased parental belief in serious vaccine side effects.
The results of this study are decidedly disappointing to public health practitioners who strongly champion the utility of informational campaigns in producing better health outcomes and increasing rates of preventive behaviors. The study makes clear that much more research is needed on the particular effects of pro-vaccine messaging and that many public health campaign messages should be tested before being rolled out, not only to measure effectiveness but also to protect against any unforeseen negative effects. Testing for unintended consequences of health messaging is something that is often ignored in public health informational campaigns but may be just as important as testing for efficacy. Yet this study evokes an even wider question about public health campaign strategy: does fear-based messaging help or harm the cause? Does scaring people result in better health outcomes and increased uptake of preventive medical care or is it possible that this kind of messaging is actually associated with increased denial, psychological reactance, and increased distrust of the health and medical establishments?
Fear messaging in public health as well as in other related fields has a long history. In the past, public health authorities have tended to believe that fear messaging has the capacity to backfire. Yet recently, some health authorities such as the New York City Department of Health have begun to rely more heavily on fear appeals. For example, the city has launched a series of subway ads as well as television commercials featuring the terrifying consequences of lifetime smoking and graphic photos on the subway of amputated limbs due to diabetes from consuming too many sugary drinks. Widespread fear about an increasing tendency for parents to refrain from vaccinating their children and reports of several troubling measles and pertussis outbreaks in pockets of the country with low vaccination rates have led public health authorities to consider extending the fear appeal method to convince parents of the absolute necessity of vaccination. But is this the best way forward? If the method has a high likelihood of backfiring, as the evidence from the Pediatrics study seems to indicate, great care must be taken to vet and test all messages before they are disseminated to the public.
Several guidelines about constructing useful fear appeals do exist. In order to increase effectiveness, fear appeals must emphasize the severity of the threat as well as the intended population’s susceptibility. Without these factors, any fear-based campaign will inevitably be disregarded and fail. But these prerogatives do not justify simply flooding the public with gruesome images and messages about their inevitable susceptibility to the threat. Perhaps most importantly, fear-based messages should always be accompanied by strong efficacy messages. That is, the barriers that the intended population may face in preventing the dreaded health outcome must be carefully weighed and comprehensively addressed in any fear-based messaging campaign. Without reassuring people about their ability to prevent the feared outcome, strong fear appeals have a very high likelihood of backfiring. Public health practitioners must therefore walk the line between creating strong, efficacious messages about real, severe health threats and reassuring intended audiences that they do have the means and resources to prevent these threats. In addition, common counterproductive psychological responses, including denial and reactance, must always be taken into account when designing these types of messaging campaigns. The delicate balance between inventing efficacious fear-based messages and providing the public with hope for escaping these threatening outcomes is a large part of the reason why it is so important to test any fear-based messaging campaign before it is launched. Most importantly, if people are made aware of threatening health effects for which no practical solution seems accessible, fear-based messaging may result in precisely the reverse of the intended effect, including increased risk-taking behavior, denial, and hopelessness. It is the prerogative of public health officials to insure that messaging campaigns are not only effective but also, and perhaps even more importantly, not harmful.