Young men's perceptions of fear appeal versus neutral health messages: associations with everyday health information literacy, education, and health
Heidi Enwald, Noora Hirvonen
Information Studies, Faculty of Humanities, University of Oulu, P.O. Box 1000, FI-90014 Oulu, Finland
The Department of Sports and Exercise Medicine, University of Oulu, P.O. Box 1000, FI-90014 Oulu, Finland
Information Studies, Faculty of Humanities, University of Oulu, University of Oulu, P.O. Box 1000, FI-90014 Oulu, Finland
Introduction and background
The need to understand the users of information and their health information behaviour is increasingly attracting researchers of information disciplines (Bath 2008, Case 2012, p.37). Information is interpreted and internalized by the individual to construct knowledge, and this knowledge may result in further action (Savolainen 2008: 50, 65). The way health information is presented affects individuals' information use and the reception of information can be considered as the first stage of the information use process (Nahl and Bilal 2007: 4-8). More research is needed to understand individuals' information use and reception of health information (Enwald 2013: 43-44, 136).
It has been argued that the differences in individuals' health information behaviour should be used as a basis to tailor health information and communication (for example, Fourie 2008, Harland and Bath 2008, Ek and Heinström 2011, Johnson and Case 2012: 207, Enwald 2013: 119-133). Tailored health communication is a means to increase the effectiveness of health information by providing more user-centred information. It aims to increase the possibility that the information content is received, processed and accepted by the receiver. (Kreuter 1999: 5, Hawkins 2008.)
Health messages can be constructed on the basis of different message strategies. Fear appeal is one of these strategies (Rogers 1983, De Villiers 2008: 62-81). In this study health information behaviour is scrutinized from the perspective of information use as individuals' perception of the fear appeal message strategy. Furthermore, an investigation is carried out into the association of the perception of the fear appeal message strategy with the level of everyday health information literacy. The context of health information is considered in terms of the personal relevance of a health topic. Generally speaking, this study combines the viewpoints of health information behaviour, health communication, psychology and social marketing in an interdisciplinary manner.
Fear appeal strategy is defined as a persuasive communication that presents threatening information to arouse fear to promote safer behaviour (De Villiers 2008: 62-81). Threat based health information involves perceptions of personal susceptibility to the threat (that is, 'it can happen to me') and perceived severity (that is, 'it is a serious concern') (Witte 2001, 20). Many social cognitive theories suggest that providing threatening information is effective in promoting safer and recommended behaviour, although empirical findings have been less conclusive (Ruiter 2003). As a reaction to threat based information, individuals may be inclined to want to learn more about the threat or to take action to reduce or eliminate it. On the other hand, individuals may reject the information. Rejection may occur in the form of defensive avoidance or denial to the information. (Witte 2001, 23-26.) Rejection and avoidance of information has also been studied in Information Studies, for example by Case (2005) and Sairanen and Savolainen (2010). In addition, the perception of fear appeal message strategy has been studied by Enwald (2013). According to their study individuals who succeeded in losing weight during a three-month intervention trial were significantly more likely to perceive that threatening mental images about the onset of diabetes were able to promote their physical activity and eating behaviour. Generally speaking, individuals accept and process information in different ways.
In the research area of information behaviour, context is considered to constitute a frame of reference for information behaviour (Vakkari 1997). The conceptualisation of context has been discussed for example by Dervin (1996), (Kuhlthau 1999), (Courtright 2008) and Savolainen (2012). Context has commonly been addressed in relation to spatial and social (Savolainen 2009, Mervyn and Allen 2012) and temporal (Savolainen 2006) dimensions in which the information behaviour occurs. In this study, context is operationalised as a health topic in health communication, and it is assumed that it affects an individual's health information behaviour. Furthermore, in the research area of information processing, it has been stated that the degree of personal relevance is related to the way the individual processes health information (see for example, Liberman and Chaiken 1992, 1996). Those belonging to a risk group for some disease are considered to be 'high-relevance individuals' when it comes to health communication about that disease, whereas those not in a risk group are considered to be 'low-relevance individuals' (Liberman and Chaiken 1992). For instance, the elaboration likelihood model of persuasion by Petty and Cacioppo (1986) suggests that individuals are more likely to process information thoughtfully, and the information is more likely to have an impact on individuals' attitudes, intentions and behaviour, if they perceive it to have a moderate or high degree of personal relevance (Rimal and Adkins 2003: 504).
The competencies that are needed to find and use health-related information, that is to say health information literacy (see for example, Eriksson-Backa 2012; Niemelä 2012; Shipman 2009) can influence the way individuals perceive health messages. The Medical Library Association (2003) defines the concept of health information literacy as
the set of abilities needed to: recognize a health information need; identify likely information sources and use these to retrieve relevant information; assess the quality of the information and its applicability to a specific situation; and analyse, understand, and use the information to make good health decisions.
Niemelä et al. (2012) use the concept of everyday health information literacy to study individuals' general and non-professional abilities related to health information. They have designed a screening tool aimed to detecting individuals with problems related to their interest and motivation, finding, understanding, evaluating and using of health information. This screening tool is used in this study to evaluate the everyday health information literacy of young Finnish men.
Surprisingly little research has been conducted on differences in individuals' perception of fear appeal as a message strategy in health communication. In a study of prediabetic individuals, those who succeeded in losing weight during a three-month intervention trial were more likely to perceive that threatening mental images about the onset of diabetes were able to promote their health behaviours (Enwald et al. 2013). In a study by McKay et al. (2004) lower education level, as well as some existing chronic disease were factors associated with attenuated effectiveness of fear appeal messages. On the contrary, in a study by Szklo and Coutinho (2009), smoking-related fear appeal messages raised awareness especially among heavy smokers with fair or poor self-estimated health status. In this current study, differences are investigated by focusing on individuals' education, level of everyday health information literacy, as well as self-estimated and objectively measured physical health status. These factors are seen as important in relation to the perception of health messages. For instance, in a study by Hirvonen et al. (2013, in press) the stage of change in exercise behaviour and level of education were associated with a preference for ipsative and normative feedback message tactics in an exercise context among young men. Furthermore, we are not aware of any studies focusing on an association between individuals' everyday health information literacy and the perception of fear appeal message strategy.
The study population and the effect of personal relevance
The study population consists of young men. Despite the known benefits of physical activity for health, recent evidence consistently demonstrates that a majority of adolescents, also in Finland, do not meet current physical activity and public health recommendations of at least 60 minutes per day of moderate or vigorous intensity activity on at least five days per week (Tammelin et al. 2007, Whitt-Glover et al. 2009). Sedentary lifestyle, adiposity and an unhealthy diet are risk factors of prediabetes and type 2 diabetes mellitus. Nowadays, as more children and adolescents become overweight or obese and are physically inactive, type 2 diabetes is also occurring more often in young people (Kaufman 2011). At least 200-300 young Finnish adults are diagnosed with type 2 diabetes every year (Lammi 2009). It is also worth noticing that the slow initial phase of the disease is usually asymptomatic and may last for many years.
Accordingly, the majority of young Finnish men can be considered as high relevance individuals when it comes to health communication on physical inactivity, but low relevance individuals when it comes to communication on type 2 diabetes. In this study, message pairs focusing on inactivity and on type 2 diabetes are investigated. One alternative in each message pair is based on fear appeal, and the other is a positively framed neutral message. On the basis of the scientific literature concerning the effect of personal relevance, we can assume that those men who choose the message alternative based on fear appeal related to inactivity are at least partly different from those who choose it in the context of type 2 diabetes. The main elements of the study are illustrated in Figure 1.
The aim of the study
This study aims at increasing knowledge on perceptions of fear appeal message strategy as a factor affecting information use. The objective is to investigate whether young men with different characteristics perceive health-related fear appeal messages differently in different contexts. If differences are found they could be utilised as a basis to tailor health communication.
The research questions of the study were set as follows:
- Did the young men perceive fear or neutral messages as motivational in a) inactivity and b) type 2 diabetes contexts?
- Did the same men perceive fear appeal messages as motivational in both contexts?
- How was the perception of fear appeal message strategy associated with
- self-estimated physical health status,
- objectively measured physical health status, and
- everyday health information literacy, of the men?
The study was conducted in the setting of a MOPO study, which aims to promote well-being among young men and prevent their social marginalisation (MOPO study 2014, Ahola et al. 2013). The MOPO study (2009-2015) combines traditional health promotion, modern technology and measurement of physical activity. The information obtained in the study can be used to promote the wellness of young men in the education, study and decision-making of the professionals of social and health services.
The empirical data of this study were collected using a questionnaire survey and anthropometric, aerobic fitness and muscle strength measurements administered at the Finnish Defence Forces' call-ups in the city of Oulu, Finland, in September 2012. All 1242 men present at the call-ups were invited to participate in the study. Of these 824 (66.3%) returned the questionnaire and 778 (62.6%) participated in the physiological measurements. In addition, the results of the Finnish Defence Force's health questionnaire were available for research. In Finland military or civilian (non-military) service is mandatory for all male citizens, and annually all 18-year old men are called for service in call-ups. Hence, the entire age cohort attends the call ups except for those whose physical or mental health or psychological capacities do not allow independent living. Thus, at the call-ups a large, population-wide, representative sample of young men was reached.
All men attending the call-ups were invited to participate in the study. The participants were given both oral and written information about the study prior to their consent being sought. The information for participants described the study and its benefits and their drawbacks, and their right to refuse to take part or withdraw from the study without it affecting their future care or military service. Notice of the statement in favour of the MOPO study has been received from the Ethics Committee of the Northern Ostrobothnia Hospital District. The study protocol's registration number is NCT01376986 (clinicaltrials.gov).
The questionnaire included themes with items on socio-demographic information, health behaviour and everyday health information literacy. The following measures were incorporated into the analysis of this study:
The respondents were given two pairs of messages from two health contexts, namely, inactivity and type 2 diabetes, and they were asked which message they would consider as to be motivational. In both cases one alternative was based on fear appeal and the other was neutral. The message pairs were designed in such a way that a clear difference could be recognised between those who perceive the fear appeal -based message to be motivational and those who do not.
The first message pair related to physical inactivity. It is henceforh called the 'inactivity message pair'. Its first message alternative contained threatening health information and was based on the fear appeal message strategy: 'Due to an increase in obesity and inactivity today's children will die younger than their parents'. The other message was a positively written neutral message ran as follows: 'Increased physical activity reduces visceral fat even when body weight does not change'.
The second message pair related to type 2 diabetes (henceforh called the 'diabetes message pair'). Its first message alternative was a positively written neutral message stated as follows: 'The onset of diabetes (type 2) can be prevented through a change of lifestyle. A five percent weight loss will cut the risk of type 2 diabetes by half and a 10 percent weight loss corresponds to an 80 percent risk reduction. Prevent diabetes now!'. The other message contained threatening health information and was based on the fear appeal message strategy: 'Every 30 second someone in the world loses his/her feet because of diabetes. In Finland around thousand lower limb amputation surgeries are performed every year on diabetic individuals. Prevent diabetes now!'.
The health information literacy level of the participants was assessed using a tool by Niemelä et al. (2012). This tool consists of ten statements assessing the everyday health information literacy of the participants and was designed by elaborating the Medical Library Association's (2003) definition of the concept.
The statements were:
1) It is important to be informed about health issues.
2) I know where to seek health information.
3) I like to get health information from a variety of sources.
4) It is difficult to find health information from printed sources (magazines and books).
5) It is difficult to find health information from the Internet.
6) It is easy to assess the reliability of health information in printed sources (magazines and books).
7) It is easy to assess the reliability of health information on the Internet.
8) Terms and sentences of health information are often difficult to understand.
9) I apply health related information to my own life and/or that of people close to me.
10) It is difficult to know who to believe in health issues.
The participants were instructed to respond to each of the ten tasks on a scale from 1 (strongly disagree) to 5 (strongly agree). The individual health information literacy statements were then summed to form a sum variable for everyday health information literacy (with a minimum of 10 and a maximum of 50 points). Variables 4, 5, 8 and 10 were reversed. Self-estimated health status was assessed by asking the individual to estimate their health status. The choices were good, rather good, average, rather poor and poor. For analysis, good and rather good and poor and rather poor were combined. The information on the men's education level was assessed in a survey by the Finnish Defence Forces. The categories for educational level were: compulsory school only, upper secondary school's vocational track, and general upper secondary school or higher education.
Anthropometric, aerobic fitness and muscle strength measurements were selected to provide information about the participant's physical health status, adiposity and fitness. Body composition (fat mass, fat free mass, percentage body fat, muscle mass) and weight were assessed by bioelectrical impedance assessments (DSMBIA; direct segmental multi-frequency bioelectrical impedance analysis). For this purpose, InBody 720 Body composition analysis (Biospace Co., Ltd., Seoul, Korea) was used, since it has been shown to be practical in large epidemiological studies with limited time for examining each subject (Mikkola et al. 2009). Total body fat percentage and muscle mass were utilized in this study. The Body Mass Index (BMI) of the participants was calculated as body weight (kg) divided by height (m) squared and waist circumference was measured with a tape measure. Measurements of body mass index, body fat percentage and waist circumference all relate to an individual's body composition and especially to their visceral adiposity. A linear relationship exists between adiposity (obesity) and most health conditions (Ortega 2008). Aerobic fitness was measured using a fitness test (Polar Fitness Test®, Polar Electro, Finland) conducted while resting comfortably during approximately 5 minutes. This test predicts maximal oxygen uptake (ml/min/kg) indirectly from the resting heart rate, heart rate variability, sex, age, height, body weight, and self-assessed physical activity. The result of the test is an OwnIndex, which is comparable to the maximal oxygen uptake (VO2max, ml/kg/min). Muscle strength was assessed with a bilateral grip strength test using a dynamometer (Saehan, SAEHAN Corporation, Korea). During the examination, the participants stood with their legs apart, with an elbow at a 90° angle, and were asked to grip the instrument with maximum strength. The result was the better of two attempts per hand. The mean grip strengths for the right and left hands were used in the analysis.
Statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 19.0 (IBM Corp, 2010). No criteria for rejecting incomplete questionnaires were set. In the analysis all non-responses were excluded, and the percentages reported were calculated from the number of responses per question. Descriptive analyses were performed using mean and standard deviation for continuous variables and percentage for categorical variables. Association between the categorical response and explanatory variables were analysed using cross-tabulation with Pearson's chi square test or the two-sided Fisher's exact test. The non-parametric test was used when the expected cell counts were low because of unequally distributed data among the cells of the table. The measurement values of health information literacy, anthropometric, aerobic fitness and muscle strength were treated as continues variables. For these variables, the t-test was used to investigate whether the groups differed significantly from each other. Non-normally distributed data (BMI, body fat percentage, waist measurement) were analysed following logarithmic transformation. Level of significance for all tests (α) was set at p<0.05.
The participants were all men and homogeneous in terms of their age. Of them 26.5% were 17 years old and 67.9% were 18 years old. Only 5.6% were older than 18. Only a few of the men were married or had children. Most of them currently studied on either the general or vocational track of upper secondary school, and lived with one or both parents. The majority did not have any medical conditions or symptoms and in this study the men are considered to represent healthy individuals. However, some of the men might already be at risk of lifestyle-related diseases, such as type 2 diabetes.
The inactivity message pair was answered by 714, and the diabetes message pair by 700 men. In the inactivity message pair 58.4% (416) and in the diabetes message pair 45.7% (320) of men chose the message alternative constructed based on the fear appeal strategy. In other words, in the context of physical inactivity, the message based on fear appeal was generally seen to be more motivational than the neutral alternative. In the context of type 2 diabetes, in turn, the neutral message was considered somewhat more motivational. Furthermore, in these two cases the men who chose the fear appeal message were not entirely the same as the men who choose the neutral message (Fisher's exact test p = not significant).
Education and self-estimated physical health status
The educational level of over half of the men was upper secondary school or higher. Most estimated their health status to be good (or rather good). (See Table 1.)
|Variable||Inactivity message pair||Diabetes message pair|
|Neutral (n=416)||Fear (n=296)||Neutral (n=380)||Fear (n=320)|
Upper secondary school or higher
|Self-estimated health status
No statistically significant associations were observed between educational level or self-estimated health status and perceptions of fear appeal in the contexts of physical inactivity or type 2 diabetes. However, the association between educational level and perception of fear appeal in the context of physical inactivity was nearly significant (Pearson chi-square p=0.061).
Everyday health information literacy and objectively measured physical health status
The analysis revealed that there was a statistically significant association between men's choice of a message alternative in the inactivity message pair and their everyday health information literacy levels (t-test p=0.020). The mean value for everyday health information literacy was significantly higher with men who chose the fear appeal alternative. The measurements of anthropometric, aerobic fitness and muscle strength were not statistically significant in relation to the inactivity message pair. (See Table 2.)
|Variable||Neutral (n=231)||Fear (n=299)|
|Mean (SD)||Mean (SD)||p*|
|Everyday health information literacy||33.96 (4.52)||34.85 (4.80)||0.020|
|Body mass index(kg/m2)||23.08 (4.33)||22.87 (4.25)||Ns.|
|Body fat (kg %)/td>||16.58 (8.37)||15.54 (8.08)||Ns.|
|Muscle mass (kg)||34.08 (4.65)||34.06 (4.84)||Ns.|
|Aerobic fitness(OwnIndex)||52.85 (7.77)||53.30 (7.12)||Ns.|
|Grip strength (kg)||46.58 (7.79)||46.89 (8.33)||Ns.|
|Waist circumference (cm)||82.42 (11.22)||81.30 (9.78)||Ns.|
The mean body mass index (p=0.011), body fat percentage (p=0.004) and waist circumference (p=0.007) were significantly lower in men who chose the fear appeal message alternative from the diabetes message pair. No statistically significant association was noted between the diabetes message pair and the level of everyday health information literacy. (See Table 3.)
|Variable||Neutral (n=231)||Fear (n=299)||p*|
|Mean (SD)||Mean (SD)|
|Everyday health information literacy||34.70 (4.55)||34.44 (4.78)||Ns|
|Body mass index (kg/m²)||23.42 (4.40)||22.46 (4.14)||0.011|
|Body fat (kg %)||16.98 (8.63)||14.90 (7,67)||0.004|
|Muscle mass (kg)||34.25 (4.80)||33.88 (4,74)||Ns.|
|Aerobic fitness (OwnIndex)||53.39 (7.92)||52.76 (6.87)||Ns.|
|Grip strength (kg)||46.57 (8.32)||47.09 (7.84)||Ns.|
|Waist circumference (cm)||82.92 (11.13)||80.44 (9.62)||0.007|
Limitations and strengths
The strengths of this study include the population-based, representative sample of young Finnish men. However, sociocultural factors influence health information behaviour, and thus the results could be best transferable to other Western countries. A limitation of the study is that the main topics were assessed using only a few questions and statements. In addition, the results can be affected by the wording of the questions and message alternatives, the length of the questionnaire and the situation in which self-reporting was conducted.
Discussion and conclusions
The study answers the call for a further study of health information users by investigating young men's perceptions of the fear appeal message strategy. Furthermore, the associations between perceptions and individual characteristics (education, everyday health information literacy, self-estimated and objectively measured physical health status) were studied in the context of physical activity and type 2 diabetes.
Summary of the results
In the context of physical inactivity, the message based on fear appeal was generally seen as more motivational than the neutral alternative. In the context of type 2 diabetes, the neutral message alternative was somewhat more popular (see research question 1). Furthermore, in these two cases the men who chose the fear appeal message were partly different from the men who chose the neural message (Fisher's exact test p = ns) (see the research question 2).
In Information Studies context is seen to be an important factor affecting individuals' information behaviour. In this study, the context is elaborated as a topical area in health communication. The results of this study highlight the context, as it seems to matter whether the topic is of high relevance or of low relevance to young men. Because the majority of young Finnish men are physically inactive (Tammelin 2007) but only few are diagnosed with type 2 diabetes, they can be considered as high relevance individuals when it comes to health communication on physical inactivity, but as low relevance individuals when it comes to communication on type 2 diabetes.
According to the results, the men who found the fear appeal message strategy motivational in the two contexts were partly different from the men who preferred the neutral message, which confirms our assumption presented in the Introduction. Our assumption was based on the scientific literature on the effect of personal relevance to the perception of fear appeal. The personal relevance is crucial in determining whether fear appeal will motivate an individual to change their attitude and behaviour
Interesting differences were observed in the perceptions of fear appeal according to everyday health information literacy and objectively measured physical health status of the men (see the research question 3). The analysis revealed that there was a statistically significant connection between the men's choice of a message alternative from the inactivity message pair and their everyday health information literacy levels (t-test p=0.020). Higher everyday health information literacy was associated with finding fear appeal as motivational in the context of physical inactivity. However, in the context of type 2 diabetes, lower adiposity (according to body mass index, body fat percentage and waist circumference) was associated with cosidering the fear appeal message to be motivational. (See Figure 2.)
Discussion of the results
In the context of inactivity those men with low everyday health information literacy may have different kinds of attitudes towards health and health information than the men with high literacy. They may have problems in interpreting and evaluating the credibility of the fear appeal alternatives and thus they might find it less motivating than the positively written neutral message.
The men with higher adiposity might acknowledge that they are at risk of lifestyle-related diseases such as type 2 diabetes. Therefore, they can be considered as high relevance individuals when it comes to health communication on this topic. Furthermore, the strength of their belief in their ability to avoid issues related to type 2 diabetes, that is to say their self-efficacy relating to the topic, may be low.
According to the scientific literature, high relevance individuals may perceive that a message based on fear appeal might be more likely to have an impact on their attitudes, intentions and behaviours (in other words be more motivational) (Rimal and Adkins 2003: 504). However, if the high relevance individuals' self-efficacy is low, the threat might be too high, and individuals may end up avoiding information related to the health topic (Bandura 1994: 261-267). This could explain why in this study the men with higher adiposity did not perceive type 2 diabetes related threat as motivational. They may have found information on lower limb amputation surgeries too scary or too repellent. Correspondingly, in a previous study focusing on prediabetic women and men, those who had improved their physical health status (and hence maybe also their self-efficacy) during an intervention trial did not perceive fear appeal to be so threatening, but responded in a more flexible manner to it (Enwald 2013).
Implications and recommendations for future research
This study is among the first to investigate the association between individuals' everyday health information literacy and their reception of health information from the perspective of the perception of fear appeal message strategy. A cluster analysis on the data could provide deeper understanding on the associations of the studied factors.
Niemelä et al. (2012) have stated that it would be worthwhile adding an everyday health information literacy component to health interventions aiming at behaviour change. Furthermore, the differences in individuals' health information literacy should be taken into account in designing tailored health information, and especially the presentation of information, for example, by using different kind of message strategies for different individuals. Fear appeal could be used for certain individuals and in situations in which it has been shown to be effective based on scientific findings. According to this study, fear appeal should be used for young men with higher health information literacy levels, especially in the context of a health topic that can be considered to be of high relevance for this target group.
The results provide knowledge related to health information behaviour that could be taken into consideration when presenting health information to different kind of individuals. However, there is a dearth of theoretically-driven empirical studies investigating individual characteristics of the information user in the context of health communication and promotion. The discipline of information studies has the potential to fill in gap in the existing knowledge and contribute to theory building within this multidisciplinary research area, as pointed out also by MacDonald et al. (2010). Additionally, the relationship between individuals' health information behaviour, particularly information use and information reception and physical health status, should be further studied. Fear appeal, in particular, also relates to information avoidance, something that has been examined in Information Studies. Thus, research on perception of fear appeal message strategy could even benefit further from the perspectives of our discipline.
The study was supported by the Finnish Cultural Foundation, Juho Vainio Foundation, the Ministry of Education and Culture, the European Social Fund, the European Regional Development Fund, and the Finnish Funding Agency for Technology and Innovation. We thank the MOPO research group for organizing the data collection.
About the authors
Heidi Enwald is a University Lecturer in Information Studies, Faculty of Humanities, at University of Oulu, Finland. She holds a M.Sc. in biochemistry and an M.A. in information studies from University of Oulu. She received her doctorate degree from information studies in 2013. She can be contacted at: email@example.com.
Noora Hirvonen is a doctoral student in Information Studies at the University of Oulu, Finland and holds an M.A. in information studies from the same university. She can be contacted at: firstname.lastname@example.org
Raija Korpelainen is Professor of Health Exercise in the Institute of Health Sciences, University of Oulu, Finland and the Department of Sports and Exercise Medicine, Oulu Deaconess Institute, Finland. She can be contacted at: email@example.com
Maija-Leena Huotari is Professor of Information Studies, Faculty of Humanities, University of Oulu, Finland. She holds a B.A. in economics from Vaasa University, Finland, an M.Sc. in social sciences from the University of Tampere, Finland, and a Ph.D. in social sciences from the University of Sheffield, UK. She can be contacted at: firstname.lastname@example.org