More on programmes using threat

An HIV-prevention video commissioned by the New York Department of Public Health (NYDPH) in November 2010 (see http://www.youtube.com/watch?v=d0ANiu3YdJg) reignited the debate about whether campaigns that aim to use the threat of HIV as a behavioural intervention work. The voice-over of the video highlighted the higher incidence of certain conditions (osteoporosis, dementia and anal cancer) in people with HIV as a reason to avoid infection. Factually, it was correct. However, it was shot in a way that seemed deliberately designed to increase viewers’ anxiety about these conditions.

A review of the psychological literature on persuasion and the use of fear in HIV-prevention messages was cited both by people in favour of ‘hardline’ HIV-prevention messages, such as the NYDPH video, and those who thought it was counter-productive.¹

This review pointed out that a health-education campaign designed to evoke a feeling of threat could have two behavioural consequences: people could react by avoiding the behaviour, or they could react by avoiding the anxiety caused by it. They could, in psychological terms, associate the activity (e.g. unprotected sex) with a feeling of anxiety or they could dissociate the anxiety and the activity. This means that public health messages using fear (which are used regularly for other behaviours such as smoking and drink-driving) need to get a balance right: too little threat and the intervention has no effect, too much and it forces people into harmful coping behaviours such as denial, dissociation or resistance.

There has been little research on whether threats work in HIV-prevention messages. What studies have been done show that people are aroused emotionally by fearful images and remember the advertisements more, but the evidence on efficacy is contradictory. In some cases there is evidence that an awareness campaign using a frightening image was followed by an increase in risk behaviour. One such was an Australian campaign featuring AIDS as the Grim Reaper.²

Devos-Combey and Salovey found that the evidence suggested that fear works best in people who already have some degree of anxiety about the behaviour being warned against, but has less effect in people who are not anxious about it. So fear-based HIV messages might work to further encourage relatively low-risk people not to take risks,   but might not serve to make high-risk people take fewer risks. Alternatively, high-risk people may feel just as much anxiety, but feel less self-efficacy in believing they can alter their behaviour. They may simply feel hopeless when confronted by threatening images.

In order for campaigns that use threat as a tool to work, the authors say, they need to meet four conditions:

1. People need to be convinced that the thing talked about really is dangerous. Thus, the New York ad was, probably successfully, correcting a perception that these days people who have HIV and take treatment are not at higher risk of illness.
2. They need to feel personally vulnerable to it. For the campaign to work, it has to use models that the targeted viewers would personally identify with. People have to feel that they belong to the same group and are subject to the same risks.
3. Campaigns need to provide a strategy people can use to avoid the threat (in the case of the New York advert, 'use a condom'). Thus fear-based adverts that provide a ‘solution’ people feel is not accessible or applicable to them, or fail to provide one at all, will not work.
4. People need personally to feel able to use that strategy (self-efficacy). People lacking self-efficacy may lack confidence that they personally will remember to use condoms, resist the temptation not to use them, or be able to persuade partners to use them. Self-efficacy is less easy than the previous three factors to predict because it is hard to define and hard to reliably induce, but an advert that leaves people feeling nothing but anxiety is not likely to increase their confidence in their ability to avoid threat.