Lentis/Public Health: Fear Appeals vs Self-Efficacy and Social Norms Campaigns
Public Health Campaigns
Public Health is the science of protecting the safety and improving the health and well-being of people and communities.  While public health shares many of its core principles with medicine and health care, it differs in three key ways.
While a doctor treats people who are sick, public health systems aim to prevent sickness by targeting the sources of illness and injury. Thus, public health solutions are necessarily larger in scope than strictly medical solutions. These solutions often deal with entire communities and populations involving research, behavioral and informative advertising campaigns, and law and public policy. Public health concerns go beyond those of the body and also focus on mental and social health, on an individual and a communal scale.
The World Health Organization elaborates on the core functions of public health as providing leadership on critical health matters, stimulating research and promoting the generation and dissemination of valuable knowledge, setting standards and advocating their implementation, and monitoring health trends.
Even with all of this emphasis on systems and communities, individuals affect the trends of public health. Influencing good habits and behaviors in these individuals through campaigns and advertising is crucial for good public health trends going forward.
Fear appeals are persuasive messages that emphasize the danger to individuals related to either some circumstance or some choice of their own that can be ameliorated or avoided. Despite their popularity, fear appeals have not always proven more effective than their less viscerally captivating counterparts. One of several competing theories used to explain this phenomenon is protection motivation theory (PMT).
PMT postulates that any fear appeal has three primary components: the severity of the threat, the probability of that threat occurring, and the perceived efficacy of the recommended behavior. Severity and probability are analyzed by the threat appraisal process which determines whether the threat is bad enough and likely enough to merit concern. If either one of these is not significant, the threat is ignored; otherwise, the coping appraisal process dominates. The coping appraisal analyzes the efficacy of the suggested response, as well as perceived self-efficacy (see below) to determine what course of action should be taken to mitigate the threat. If either response efficacy or self-efficacy are deemed insufficient, the responder tends to panic and revert to fear mitigation tactics or defense responses. For example, a smoker who sees a daunting fear appeal message on effects of tobacco might become overly scared and pull out a cigarette to calm himself down. This is where many fear appeals fail to motivate a proactive behavioral response and instead affect negative change or reinforce old habits. However, if response efficacy and self-efficacy are deemed adequate, then a positive change of behavior is much more likely.
Self-efficacy refers to one’s belief that he or she is capable of performing the necessary steps to achieve a specific goal. Higher levels of self-efficacy lead to higher rates of behavior change; thus, it is recommended that public health campaigns aim to enhance self-efficacy in their programs.
According to Bandura, there are four main sources of self-efficacy. These are past experiences (either success or failure in a certain area contributing to high or low self-efficacy respectively), seeing others succeed at the same task, encouragement from others, and one's own physiological state. Ben-Ami et al. conducted research and found that this sense of self-efficacy can also be influenced through marketing actions. 
According to the National Social Norms Center, the social norms approach directs people towards a specific behavior by “letting them know it’s the normal thing to do.”  This approach is based on two psychological phenomenon: pluralistic ignorance and the false consensus effect. Pluralistic ignorance is when every member of a group privately rejects a specific belief or behavior, but believes that everyone else privately accepts it. The false consensus effect is when one overestimates how much other people agree with their beliefs and behaviors. Believing that everyone else accepts a belief or behavior influences one’s own attitudes and behaviors. For example, most college students grossly overestimate the alcohol intake of other students. The false perceptions causes students to drink more by overestimating how much their peers drink. In response, social norms campaigns often target misperceptions with statistical facts to change the social norms. Issues that are commonly combated with social norms approaches are drinking, drinking and driving, smoking, and other unhealthy behaviors.
In the area of college binge drinking specifically, the social norms approach has seen some success. A five year study at a large public university used both a traditional campaign against binge drinking and a social norms campaign. While the traditional method was unsuccessful, the social norms approach resulted in an 18.5% drop in the number of students with misperceptions about binge drinking and an 8.8% drop in the number of students that binge drink. 
Drunk-driving is a public health concern that costs lives and causes monetary damage. In 2016, there were over 10,000 deaths from drunk-driving related crashes. In 2010, these accidents resulted in damages worth $44 billion. 
Campaigns against drunk driving most often employ fear appeals and social norms.
- The “Faces of Drunk Driving” campaign is a prime example of a fear appeal. One of the most famous anti-drunk-driving advertisements contains a graphic image of Jacqueline Saburido before and after a drunk-driver crashed into her. The ad appeals to people’s fear of ending up like or causing someone else to end up like Jacqueline in hopes of reducing drunk-driving.  The advertisement is on the internet, television, college newspapers, and sent to high schools throughout Texas. 
- In almost every bathroom at the University of Virginia (UVA) there is an issue of the Stall Seat Journal. The journal uses the social norms approach to change the culture surrounding several issues at UVA by fighting misperceptions with statistical facts. One installment says 86.6% of UVA students plan to get home safely or use a designated driver. The journal doesn't target any specific group at UVA. Instead, it aims to garner the largest audience possible to have the biggest effect. 
- The Texas Department of Transportation (TDOT) uses the fear appeals approach. TDOT is the sponsor of “Faces of Drunk Driving” with the mission of reducing crashes and fatalities on Texas roads via “increased targeted awareness and education” among other things. 
- The Department of Student Health at the University of Virginia sponsors the Stall Seat Journal and is a proponent of the social norms approach. They believe students underestimate healthy behaviors in their peers. The health center aims to showcase healthy choices to allow students the freedom to “make decisions that align with their values.”
Almost 500,000 Americans die annually from smoking cigarettes.  The economic cost of smoking is tremendous with $160 billion spent annually treating smoking related illness. The death toll and economic cost of smoking have made it an epicenter for modern public health campaigns. Despite the dangers of smoking, it is deeply ingrained in American society.  The participants in this crisis are the populace which has been plagued with smoking related illness, the tobacco industry motivated by profit, medical professionals trying to improve patient care, the CDC which is in charge of public health in America, and various grassroots anti-smoking groups.
- Fear appeals are the most memorable anti-smoking campaigns.  These campaigns are often graphic showing a severe threat, cigarettes will kill you, with high probability.  Where they often lack is promoting the capability to quit smoking. 
- The efficacy of fear appeals is controversial. They are poor at creating a behavioral change.  Smokers often use nicotine to relieve anxiety and stress. Showing a smoker a fear appeals anti-smoking ad creates anxiousness, and can make them likely to reach for a cigarette.  However some fear appeal campaigns have been effective at reducing cigarettes sales such as the graphic images seen on cigarette packages in England.  The effectiveness of this is questionable because it could be caused by the removal of cigarette brand labeling not the fear appeal ads alone.
- Self-efficacy campaigns appeal to a smoker's ability to quit. They are often used in advertisements for nicotine replacements aids that show smokers that these aids make it possible to quit smoking.  The purpose of this technique is to tell smokers that they can quit and appeals to their personal resolve and tenacity. However, using self-efficacy alone may not be effective because it does not provide smokers with a motivation to quit smoking. 
- Social norms campaigns seek to correct misperceptions. In smoking this can be done by showing that the majority of people do not smoke and find the smell of smoke unpleasant.  The rationale for the misperceptions is smokers often surrounded themselves with other smokers or show tolerance to smoking; thus, their perceptions on the percentage of people who smoke is inflated.  Ad campaigns will often focus on emphasizing how few people smoke by making statements like ‘9 out of 10 high school seniors don’t smoke’. This type of campaign has been effective in getting people to quit by targeting false perceptions, and is often targeted at teenagers. 
- When smoking was at its height in 1964, nearly half of Americans smoked.  Smoking was marketed to be cool and fashionable and this belief was reflected in the populace.  A social norms campaign is designed to show not everyone is smoking, and that actually most people do not think smoking is cool. Therefore, the efficacy of a social norms campaign would likely be reduced in 1964 due to the prevalence of smoking; however, a social norms campaign may be more effective than a fear appeals campaign now.
Targeting those Most Effected
- Targeting a specific sub-population with higher incidents of a public health problem can increase efficacy, but risks reinforcing stereotypes. For example, in America HIV has a higher occurrence in the African-American and homosexual populations. Targeting gay, black men would be more effective than the population as a whole. However, if an advertisement targeted this population at the height of the HIV epidemic, it would increase stereotyping and discriminatory activity in an era when HIV was heralded as God’s punishment to homosexuals. By targeting this sub-population, members could be less likely to get tested out of fear, and have a higher chance of being a target of a hate crime. In this instance, the opposite of the intended effect could occur.
- Properly portraying statistics is the primary ethical concern of social norms campaigns. The validity of statistics lies in impartiality. Take for example a social norms campaign in a college to reduce drinking. To encourage students to drink less, freshmen could be shown statistics on how much their peers are drinking. For this to be the most effective, women could be informed of how much other women in college are drinking. However, since men drink more than women, college men could be informed of how much ‘other college students’ are drinking. In this way both groups will likely perceive their peers as drinking less, but will be compared to different groups. None of the above statistics are false, but they can be geared to a specific audience. Social norms campaigns are meant to correct societal misconceptions, but the ways statistics are presented can create misconceptions for a non-critical reader. Under a utilitarian paradigm, this may be ethically sound if it increases public health, but raises concerns with factual integrity.
Public health covers such a wide array of issues that there is no optimal strategy for all campaigns. In general, the effectiveness of a campaign relies on more than just the strategy, but also the social and political climate. Moreover, the most effective strategy is not always ethical, further reinforcing the role of societal values in public health campaigns. However, this may change with further research on campaigns that require people to start versus stop exhibiting a specific behavior. Examining the differences between persuading people to make a one-time change versus a lifestyle change may also yield results.
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