Challenging Dogma


...Using social sciences to improve the practice of public health

Friday, April 20, 2007

We CAN ‘Be Ready’: Why We Need to Shift Emergency Preparedness Campaigns From Emphasizing Susceptibility to Illustrating Preparedness-Jillian Koplow

Launched in February 2003, the Ready Campaign, asks individuals to do three key things to prepare for the unexpected: get an emergency supply kit, make a family emergency plan, and be informed about the different types of emergencies that could occur and their appropriate responses (1). The campaign’s initial PSAs had abbreviated messages of “Terrorism forces us to make a choice: We can be afraid or we can be ready” and “No terror that's even greater not knowing your children are safe, your family's safe”. The expanded message of the campaign was:

“As families and as a nation, we now live with a sense of unease, uncertainty that those of us who grew up after the greatest generation have rarely, rarely known. And of course this uncertainty, this sense of unease, is heightened during heightened national alerts. The sense of uncertainty steals some of the innocence and some of the security that we painstakingly try to build for our children. It's not always easy to know the right thing to say or the right thing to do. We all want to stay aware and we all want to stay informed. And at the same time, we do not want to surrender to fear. We'll never surrender to fear. Because fear is the terrorist's most effective weapon. So the threat of terrorism forces us to make a choice: We can be afraid or we can be ready (2).”

The Ready.gov campaigns for emergency preparedness thus far have focused on sending a message of individuals’ vulnerability to emergencies and current lack of preparedness, while setting forth overwhelming recommendations for preparedness. These fear-based interventions have not effectively promoted behavior change in the majority of the US population. In order to be more effective, emergency preparedness campaigns need to be framed in a positive way that demonstrates the ease and benefits of being prepared.

The campaign measures its success by the following statistics: As of September 30, 2006, the campaign's Web site has received more than 1.9 billion hits and 24.3 million unique visitors; the toll-free number has received more than 272,000 calls; and more than 9.7 million Ready materials have been requested or downloaded from the Web site (3). None of these measures are an accurate way to assess the success of the campaign. The web hits indicate a level of interest, but interest does not necessarily translate into action, and additionally an indeterminate amount of that interest was generated by all the lampooning of the campaign after it came out (on websites such as About.com Political Humor’s ‘Duct and Cover’ http://politicalhumor.about.com/library/blductandcover.htm (4), sent through mass emails, and on popular programming such as The Daily Show with Jon Stewart). Also, considering the US population size, the number of calls is relatively unremarkable. Most importantly, requests for materials is only an indication of intention to change, and do not necessarily predict actual behavior change, and since the materials (and campaign at large) are flawed in their approach to effecting change, people’s possession of them won’t necessarily lead them to be more prepared

The Failure of Fear-Based Messages
The intent of these messages were to increase people’s perceived susceptibility to a terrorist event and generate fear about the cost of not being prepared, which according to the health belief model, is an effective way to shape people’s intentions and then behavior. However, since people’s behavior is not always rational and people do not always follow through with their intentions, this method of trying to get people to be more prepared for an emergency is ineffective. As demonstrated by this statistic: 91% of Americans believe it’s important to be prepared for emergencies. However, only 55% of households report having taken any steps at all to prepare (5).

Fear-based appeals have an undeserved reputation for being an effective method of behavior change. There are multiple flaws in the research supporting fear messages as effective in motivating behavior change.

Fear research has typically been conducted in a laboratory setting. This is a setting that provides an artificial level of attention. In an ordinary setting, like your living room, or Times Square (where ready.gov posted a billboard), there are many competing stimuli. Are you going to pay attention to the boldface type of http://www.ready.gov/ or the scantily clad, larger-than-life, Calvin Klein model? This also allows you to selectively avoid stimuli that you find unpleasant. With the invention of Tivo and DVR, people now skip through television commercials entirely. People skip around on their radio dial when commercials are aired, or listen to satellite radio. People read the newspaper online, where they are completely desensitized to ads that may appear in the sidebar. All of this being the case, the effects of this kind of campaign cannot be compared to the results of research conducted in a laboratory where carefully selected respondents, who are instructed to pay attention to a specific ad or message shown in a laboratory environment. The experimental circumstances are also likely to encourage cognitive, rational processing, whereas unconstrained viewing more often produces heuristic or affective processing (6).

Often fear studies measure their effects by perceived effectiveness rather than observed effects; participants will be asked how effective they thought the particular message to be. Respondents frequently state in research that strong fear appeals are highly motivating, and state their intentions to change, even when subsequent research shows that these appeals do not change their behavior. Audiences are quite capable of recognizing and describing what they understand an advertiser to be trying to achieve, without necessarily being personally moved (6).

These fear messages are not only ineffective, they can also be damaging. Stamford psychologist Phillip Zimbardo (with Bruce Kluger) coined the term ‘pre-traumatic stress syndrome’, saying:
“such cursorily assembled, blithely disseminated information can wreak [psychological damage] on the public. Presumably intended as a mental health balm in this time of unprecedented global stress, these simplistic big-blast CliffsNotes… ultimately leaving the befuddled citizen to wonder--and often panic--about the real and present danger that lurks just beneath the ice. Unfortunately, the Department of Homeland Security's site is just one example of a national warning system that in the end stirs up more anxiety than it quells. Loaded with scientific terminology, yet woefully bereft of any tangible data, the U.S.' early-warning mechanism has transformed us into a nation of worriers, not warriors. Forcing citizens to ride an emotional roller coaster without providing any clear instructions on how to soothe their jitters, the current security system has had a profoundly negative impact on our individual and collective mental health (7).”

There have been multiple studies that demonstrate that people develop maladaptive responses to fear appeals, responses that are meant to cope with the unpleasant feelings evoked by the fear message. The maladaptive responses include avoiding or tuning out the message (as discussed above), blunting (failing to process the salient threat part of the message), suppression (failing to relate the threat to oneself), and counterargumentation (summoning arguments against the message’ (6).

Despite significant evidence that fear-based messages are ineffective and harmful, ready.gov relies heavily, if not exclusively, on this strategy of motivation in their campaigns. This strategy sets the Ready campaign up for failure, and creates the potential for actually doing harm to the very people it seeks to protect.

Feasibility
The concept of self-efficacy is an important one to many health behavior models- the theory of planned behavior (called ‘perceived behavioral control), the social cognitive theory, and the trans-theoretical model (referred to as self-efficacy/temptation) (8). Beliefs of personal efficacy play a central role in personal change. Unless people believe that they can produce desired effects by their actions, they have little incentive to act in the face of difficulties. Whatever other factors may serve as guides and motivators for action, they are rooted in the core belief that one has the power to produce desired changes by one’s actions. Additionally, people of low efficacy are easily convinced of the futility of effort when they run into challenges. They quickly give up trying (9). Therefore, if people come up against obstacles to getting prepared for an emergency (space for supplies, financial considerations, etc.), they are more inclined to just give up, if they never thought that it was really within their capabilities to get prepared in the first place.

Guidelines for the crucial elements of the “kits” that the campaign encourages people to prepare are either vague or overwhelming, two qualities that are detrimental to perception of self efficacy. For example: Water, one gallon of water per person per day for at least three days, for drinking and sanitation (10). For a family of four, that amounts to 12 gallons of water, which sounds like an overwhelming amount of water. When people are overwhelmed, they are inclined to give up and perhaps not do anything. Simple recommendations and illustrations of how the water goal could be accomplished could go a long way (ie- when you finish a gallon of milk in your household, rinse it out and fill it with water and store it in your closet) toward encouraging people to prepare. The food guidelines have the additional problem of vagueness, in addition to its daunting quantity. Food, at least a three-day supply of non-perishable food (10), is the main recommendation. This guideline is way too vague. What is a three-day supply of non-perishable food? Perhaps you know what you would typically consume in three days, but what would be the bare minimum for survival? For people of lower socio-economic status, storing 3 extra days of food would pose extreme financial hardship (and thus make their self-efficacy very low). Is a case of ramen adequate (then your food costs are only around $1.00) or should there be some nutritional balance? Also, most people know what is “perishable”, but it might still be worth clarifying.

Accessing this information from the internet (as opposed to a television, radio, or print ad) does provide opportunity for further instruction. On ready.gov there is a hyperlink from “food” linking to more elaborate guidelines: 1) Store at least a three-day supply of non-perishable food, 2) Select foods that require no refrigeration, preparation or cooking and little or no water, 3) Pack a manual can opener and eating utensils, 4) Avoid salty foods, as they will make you thirsty, 5) Choose foods your family will eat. There is also a list of specific food suggestions (which ironically contains ‘canned meat’ as a suggestion, which is a sodium-rich food) (11). These guidelines are somewhat helpful, but only available after a thorough exploration of the ready.gov website. People reached by other media outlets get no further elaboration upon the non-perishable recommendation. Rather than their abbreviated recommendation being ‘supply of non-perishable food’, a recommendation of a ‘supply of foods that require no refrigeration, preparation, or cooking and little or no water’ would have been a more understandable and comprehensive recommendation. And even on the website, there is no elaboration on the point of what a 3-day quantity of food might consist of.

Even if the Ready campaign motivates people for change with their fear-based messages, their recommendations are presented in a fashion that does not promote self-efficacy. Without beliefs of self-efficacy it is unlikely that people will actually take steps to prepare themselves for emergencies.

From Intention to Behavior
Even ignoring the flaws in the campaign that would present obstacles to a person reaching the stage of having the intention to prepare for an emergency, this intention will not necessarily lead to actual preparedness. As discussed before, ready.gov measured their campaign success on statistics about website hits, telephone calls, and requests for materials, which only demonstrates an intention to change.

Self-predictions of behavior are often inaccurate, and typically overly optimistic, even when the behavior is largely under the individual’s control (like shopping for emergency supplies). When people are evaluating how likely they are to carry out a future behavior they assess based on their current intention in that moment. While it is true that strong current intentions correlate with an increased likelihood that the behavior will be carried out in the future, research has shown that current intention typically accounts for an average of 20-40% of variance in later behavior. Therefore more than half of the variance in behavior in unaccounted for by current intentions (12).

Blood donation is an example of behavior that is very poorly predicted by intentions. In a survey conducted in Canada, 75% of Canadians surveyed said they “have plans to donate or might donate in the future”, but only 3.5% of eligible Canadians actually donate blood. This was with the understanding that there was a blood shortage in Canada at the time and it might be in their personal best interest to boost the blood supply should they need blood someday. But a further examination of the research reveals a breakdown in the logic of the thought process. Eighty-two percent of Canadians believed there to be a shortage of blood in the country, but 73% of Canadians believed that if they needed a blood transfusion they would be confident that Canada had a safe and adequate supply (13). Those two beliefs almost directly contradict each other. In a smaller study using college students, predicted donation was 43% and actual donation was 20% (27 out of 136 respondants) (12).

Even when considering a behavioral change with a greater direct impact upon personal health, intention does not always lead up to action. Ninety percent of coronary heart disease patients have at least one behaviorally-based cardiovascular risk factor such as smoking, poor diet, or sedentary lifestyle. In a study of 723 patients diagnosed with an MI or angina, intention was not a reliable predictor of health behavior (regular exercise, smoking cessation, or change in distance walked in a 6 minute interval). Again, people were generally overly optimistic at the time of survey (percentages of intentions to change hovered around 80%), but 12 months later no overall significant behavior change had occurred. Increases in rates of exercise and smoking cessation were predicted solely by perceived behavioral control (essentially self-efficacy) (14).

The threat of a terrorist attack is a far less personally threatening than the threat of worsening heart disease in a cardiovascular high risk population. If even in the case of an extremely personal threat intention does not lead to behavior change, it is likely that there would be an even lower correlation between intention and behavior with regard to emergency preparedness. Particularly as the gap between present day and September 11th, 2001 grows wider, which further diminishes feelings of personal threat from terrorism. The Ready campaign judges its success on people’s intention to change, which is clearly an inappropriate barometer by which to assess actual effectiveness in causing behavior change.

Conclusions
The Ad Council has declared ready.gov to be one of the most successful campaigns in its more than 60-year history, based on the high attention the campaign has received (3). If the goal was solely attention, that goal was successfully accomplished. However, the success of the campaign in getting more people to actually prepare for an emergency is highly questionable. Its fear-based approach to motivation for change is one that has been shown to be largely unsubstantiated as a successful technique in real world settings, and has the potential to evoke a maladaptive response. Its instructions do not provide clear and feasible guidelines that encourage the self efficacy typically required to provoke behavior change. And there is substantial evidence that even if the campaign manages to create an intention to change behavior, which is really all it can possibly claim with its statistics about requests for materials and web hits, there can easily be a breakdown between intention and behavior. The campaign is flawed in its approach to changing people’s emergency preparedness habits and flawed in its reliance on intention to change as a measure of success.

REFERENCES
1. Ready America. About Ready. http://www.ready.gov/america/about/index.html.
2. CNN Live Event/Special. Ridge on Preparations for Possible Terror Attack. Aired February 19, 2003. Cable News Network LP, LLLP. http://transcripts.cnn.com/TRANSCRIPTS/0302/19/se.01.html.
3. US Department of Homeland Security. Homeland Security Launches New Ads to Demonstrate Importance of Family Emergency Planning. Release Date: November 14, 2006. US Department of Homeland Security. http://www.dhs.gov/xnews/releases/pr_1163518483290.shtm.
4. About.com Political Humor. Duct and Cover: Terrorism Preparedness Guide. http://politicalhumor.about.com/library/blductandcover.htm
5. Ad Council. Emergency Preparedness. US Dept of Homeland Security. http://www.adcouncil.org/default.aspx?id=50.
6. Hastings G., Stead M., Webb J. Fear Appeals in Social Marketing: Strategic and Ethical Reasons for Concern. Psychology & Marketing 2004; 21(11):961-986.
7. Zimbardo P. Kluger B. Phantom Menace: Is Washington Terrorizing Us More Than Al Qaeda? Psychology Today 2003. http://psychologytoday.com/articles/pto-20030724-000001.html
8. Noar S.M., Zimmerman R.S. Health Behavior Theory and Cumulative Knowledge Regarding Health Behaviors: Are We Moving in the Right Direction? Health Education Research 2005; 20(3):275-290.
9. Bandura A. Health Promotion by Social Cognitive Means. Health Education and Behavior 2004; 31(2):143-164.
10. Ready America. Get A Kit. http://www.ready.gov/america/getakit/index.html.
11. Ready America. Food. http://www.ready.gov/america/getakit/food.html.
12. Koehler D.J., Poon C.S.K. Self-predictions overweight strength of current intentions. Journal of Experimental Social Psychology 2006; 42:517-524.
13. Canadian Blood Services. Not Enough Canadians Rolling Up Their Sleeves. Canadian Blood Services Press Release 2002.
14. Johnston D.W., Johnston M., Pollard B., Kinmonth A., Mant D. Motivation is Not Enough: Prediction of Risk Behavior Following Diagnosis of Coronary Heart Disease From the Theory of Planned Behavior. Health Psychology 2004; 23(5):533-538.

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