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© 2003 American Society for Clinical Oncology
Use of Fear-Appeal Techniques in the Design of Tailored Cancer Risk Communication Messages: Implications for Healthcare ProvidersComprehensive Cancer Center, Division of Human Genetics, College of Medicine and Public Health, Ohio State University, Columbus, OH To the Editor: Growing evidence supports the effectiveness of tailored health messages in informing members of the public of their cancer risk, with the intent of providing a framework for personal action.1–3 However, additional reinforcement measures, such as follow-up telephone calls or physician intervention, may be necessary.4 Risk also needs to be defined in the context of emotional reactions at the moment of decision-making, especially when severity of the disease is understood.5 The emotional reaction to risk can be influenced by the vividness of the imagery and the personalization of the risk message and may be more anticipation driven than outcome driven.5 There is a relationship between risk perception and the emotion of fear. "Fear appeal" is a theory of behavior modification in the design of tailored risk communication, based on the use of a persuasive message to channel fear of an adverse consequence in a positive direction and to motivate behavior change.6 The clinical cancer genetics staff at a comprehensive cancer center has used a touch-screen family history computer kiosk for self-reported family history data acquisition and cancer risk assessment since 1999.7,8 All users of the computer program have received a tailored letter with variable text paragraphs indicating high, moderate, or low cancer risk and screening measures, specific to the reported cancers, for the participant and close family members. Individuals classified as high risk (hereditary cancer syndrome or early-onset cancer) also received a recommendation to seek cancer genetic counseling. As previously reported, 8the investigators found a lack of response to the written risk assessment sent to high-risk patients. Only seven (6.9%) of 362 were seen for genetic counseling even after direct written notification of risk level. It was thought that the isolated tailored message was insufficient to produce the desired change in behavior without reinforcement from an involved clinician.8 Attention was turned to the construction and effectiveness of the tailored messages and their role in promoting the desired modification of health behavior. Focus groups were convened to gauge individual perception of severity and susceptibility of cancer risk, the understanding of the offer of genetic counseling, the format and personalization of the letter, and the timing of the response. Thirty-one individuals attended one of six focus groups. All individuals had received a mailed risk assessment and were at either high or moderate risk. One group had previous contact with the genetics staff in the form of a cancer genetics consultation. Feedback from the focus groups was combined with Kreuter’s recommendations for creating effective fear appeals9 to design a new risk communication letter template. The new message was then tested with the original focus group participants. Open-ended interview questions were developed by the investigators to guide the discussion of the focus groups. All focus group statements were transcribed, and the data were entered into ATLAS.ti qualitative analysis software (version 4.1; Technical University of Berlin, Scientific Software Development, 1997). Data were organized and coded inductively to elicit patterns and themes. The initial round of focus group participants was asked specific questions related to the content and format of the risk assessment letter, the understanding of the offer of genetic counseling, the timing of the response, and the ease of use and availability of the system. Distinctive preferences emerged, which were: The use of the term "cancer risk assessment" in lieu of "genetic counseling"; the use of motivational feedback to allow for individualization of efficacy and response; immediate receipt of risk assessment; the inclusion of graphics in addition to text to heighten the perception of the severity of threat and the understanding of the risk level; and greater personalization of the message. Fear-appeal theory appeared to be an effective method for the design of tailored health risk assessment messages. Beyond breaking down perceptions of invulnerability, people must be informed and taught what efficacy measures are most helpful to them for this process to work. When asked to describe the impact of the revised message and their immediate response, most participants expressed a feeling of empowerment. By providing a direct assessment of their cancer risk followed immediately by a variety of options to act on, the decision-making was effectively placed back in their hands, along with the tools to meet the challenge. Moreover, they wanted this information conveyed in a straightforward, understandable way; they preferred simple directives to technical explanations or medical jargon. The addition of a variety of online resources and other contact information promoted independent research and education. A variety of reasons were given for the lack of follow-through with a cancer genetic counseling appointment. Most people found it difficult to understand why the genetic counseling process might be helpful to them. This seemed to be especially true for those women who had been previously diagnosed with cancer. Genetic counseling itself was not viewed as an effective means of reducing one’s personal risk of cancer, but more as a potential tool to reduce mortality and a source of valuable decision-making information for the individual and family. Other assumptions were that genetic testing is always done as part of the counseling process and that such a service has a perceived high cost and lack of personal benefit. The use of the term "genetic counseling" was also thought to be confusing, anxiety provoking, and associated with concerns about insurance and discrimination. The term "cancer risk assessment" was better received and understood by our study population. Todora et al10 found similar misconceptions in their study of high-risk colorectal cancer families. They also wished to have more information with the assessment, such as educational pamphlets that include general information on cancer genetic services, the risk assessment process, advantages and disadvantages of testing, and additional resources and services. In summary, fear-appeal theory appears to be an effective method for the design of tailored health risk assessment messages with regard to cancer and genetic counseling. Future studies should examine and assess the mechanisms in which the use of fear appeals as an emotional tool in tailored risk communications affects the perception of cancer risk, the emotional reactions to risk, and how immediate feedback with the inclusion of efficacious measures might serve to change behavior. We propose the term "cancer risk assessment" be used instead of "genetic counseling" in the design of tailored print materials and communication of cancer risk to allay fears of an inherent association of genetic testing with the counseling process. REFERENCES
1. Holt C, Clark E, Kreuter M, et al: Does locus of control moderate the effects of tailored health education materials? Health Educ Res 15:393–403, 2000 2. Rimer B, Glassman B: Is there a use for tailored print communications in cancer risk communication? J Natl Cancer Inst Monogr 25:140–148, 1999 3. Rimer B, Halabi S, Skinner C, et al: Effects of a mammography decision-making intervention at 12 and 24 months. Am J Prev Med 22:247–257, 2002[CrossRef][Medline] 4. Champion V, Maraj M, Hui S, et al: Comparison of tailored interventions to increase mammography screening in nonadherent older women. Prev Med 36:150–158, 2003[CrossRef][Medline] 5. Loewenstein G, Weber E, Hsee C, et al: Risk as feelings. Psychol Bull 127:267–286, 2001[CrossRef][Medline] 6. Witte K, Cameron K, Lapinski M, et al: A theorectically based evaluation of HIV/AIDS prevention campaign along the trans-Africa highway in Kenya. J Health Commun 3:345–363, 1998[CrossRef][Medline]
7. Westman J, Hampel H, Bradley T: Efficacy of a touchscreen computer based family cancer history questionnaire and subsequent cancer risk assessment. J Med Genet 37:354–360, 2000
8. Sweet K, Bradley T, Westman J: Identification and referral of families at high risk for cancer susceptibility. J Clin Oncol 20:528–537, 2002 9. Kreuter M, Farrell D, Olevitch L, et al: Tailoring Health Messages—Customizing Communication With Computer Technology. Mahwah, NJ, Lawrence Erlbaum Associates, 2000, pp 145–164
10. Todora H, Skinner C, Gidday L, et al: Perceptions of genetic risk assessment and education among first-degree relatives of colorectal cancer patients and implications for physicians. Fam Pract 18:367–372, 2001
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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