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Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

Objectives

According to the terror management health model, conscious thoughts of death motivate productive health behaviours when the targeted behaviour is perceived as an effective route for mitigating the threat and removing death-related thought from focal awareness. The present study thus examined whether messages manipulating the efficacy of a health behaviour moderate health outcomes when participants are presented with a fear appeal that makes death thought conscious.

Design

A 3 (fear appeal: cancer vs. appearance vs. neutral) × 2 (delay vs. no delay) × 2 (effective vs. non-effective) between-subjects ANOVA was conducted.

Methods

Beach patrons were randomly assigned to a cancer, appearance, or neutral-threat fear appeal followed by a delay or no delay. Subsequently, they read messages highlighting the effectiveness or ineffectiveness of sun protection behaviours and reported their intentions to engage in those behaviours.

Results

When fear appeals primed conscious thoughts of death, framing sun protection as ineffective decreased sun protection intentions relative to framing sun protection as effective. In contrast, fear appeals that did not consciously prime death, or appeals followed by a delay that allowed thoughts of death to fade from consciousness, did not interact with efficacy messages.

Conclusions

The findings revealed that messages impacting sun protection efficacy moderated sun protection intentions only when death was conscious. The findings have implications for understanding the conditions that render certain fear appeals, and accompanying messages of efficacy, more influential than others.

Statement of contribution

What is already known on this subject? Health communications that arouse fear motivate adaptive health behaviours to the extent that people perceive that the behaviour is capable of being performed (i.e., self-efficacy) and will be effective at preventing the undesired outcome (i.e., response efficacy). According to the terror management health model (TMHM), health threats associated with mortality activate conscious thoughts of death. Moreover, the TMHM has found that when death thoughts are conscious, the belief that a health behaviour is effective predicts greater prevention intentions in an effort to remove the health threat, and conscious thoughts of death, from focal attention.

What does this study add?

  • Framing sun protection behaviours as effective increases sun protection behaviours among individuals exposed to a fear appeal that primes conscious thoughts of death (e.g., skin cancer from sun damage) relative to framing the behaviour as ineffective.

  • Framing sun protection behaviours as effective after a fear appeal that does not prime death-related thoughts (e.g., appearance damage from sun damage) does not affect sun protection behaviours.

  • Framing sun protection behaviours as effective or non-effective has no effect on sun protection intentions when death is no longer conscious.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

Health communications often combine a fear-eliciting stimulus with a message about how to avoid what has been presented as the dreaded consequence. And they do so with good reason. Research has shown that health communications that arouse fear (i.e., fear appeals) motivate adaptive health behaviours when individuals perceive that they are capable of performing the behaviour (i.e., self-efficacy) and that the behaviour is effective in preventing the undesired outcome (i.e., response efficacy); and also, that fear appeals can backfire when these conditions are not met (e.g., Rogers & Prentice-Dunn, 1997; Stephenson & Witte, 1998). While much of this research focuses on the design of the fear message (i.e., high vs. low threat; Stephenson & Witte, 1998; Morman, 2000), little research has examined the influence of the content of fear elicited (i.e., cancer vs. appearance). The recently developed terror management health model (TMHM; Goldenberg & Arndt, 2008) suggests one potentially important consideration: whether the communication activates conscious concerns with death. From this perspective, conscious thoughts of death motivate health-oriented responses that can remove the threat of death from focal attention. Thus, whether a behaviour is framed as effective or not should be especially likely to moderate outcomes in response to a fear appeal activating conscious thoughts of death. In contrast, efficacy messages may be less influential in response to fear appeals highlighting other non-death-related fears or thoughts of death that have faded from conscious attention. We tested these ideas in the context of sun protective behavioural intentions among beach goers during spring break in Florida.

Terror management health model

The TMHM (Goldenberg & Arndt, 2008) was developed to elucidate how health decisions and motivations are influenced by the consciousness of death-related thought. The theory builds on terror management theory (TMT; Greenberg, Solomon & Pyszczynski, 1997), which posits that a biologically rooted fear of death, combined with the cognitive sophistication to be aware of one's mortality, renders humans defensively oriented in response to cognitions about death. TMT notes a dual defence model that distinguishes between proximal defences which are threat-focused attempts to remove conscious thoughts of death from focal attention and distal defences which are indirect attempts to manage unconscious thoughts of death by investing in symbolic indices of meaning and self-worth (Pyszczynski, Greenberg & Solomon, 1999). Thus, when thoughts of death are conscious, motivation is aimed at removing the threat from focal attention, whereas when death thoughts are active but non-conscious, motivation is aimed at investing one's self within the meaningful worldview of one's culture and living up to its prescriptions for self-significance (see Arndt, Cook & Routledge, 2004; for a review).

In applying TMT to the health domain – a logical application of a theory about death – Goldenberg and Arndt (2008) noted a parallel approach between TMT and research on health decision-making. Health-oriented health models, like TMT's proximal defences, often assume that health decisions aim to directly confront and protect one's health (Becker, 1974; Rogers, 1983) or manage the psychological implications of the threat to health with sometimes maladaptive health responses (e.g., denial, Leventhal, 1970; Witte, 1998). In contrast, another class of health models, which Goldenberg and Arndt refer to as self-oriented health models, function akin to TMT's distal defences. With respect to certain health decisions, the motivation is not health per se, but to protect valued aspects of the self (e.g., tanning to improve one's appearance, Leary, Tchividjian & Kraxberger, 1994). TMHM provides a merger of these two distinct literatures by highlighting the critical role of death thought in health or self-oriented responses to health threats. Specifically, when death is non-consciously activated, health decisions will be oriented, not primarily towards one's health, but rather by the need to protect one's sense of self-worth and important aspects of the self and identity (see Arndt & Goldenberg, 2011, for a review). It is when death thoughts are consciously activated in the context of a health decision that TMHM predicts that health behaviour will be guided more strongly by proximal, health-oriented defences.

A number of studies support these dual defence propositions. When death-related cognition is non-consciously activated (usually with explicit death-thought priming followed by a delay, or with subliminal death-thought priming), participants' health relevant decisions seem to be guided more by the relevance of the domain to a sense of self-worth. For example, under these conditions, participants report greater suntan intentions when tan skin is important to their self-esteem or has been portrayed as attractive, and they are less likely to do so when pale skin is touted as ideal (e.g., Cox et al., 2009; Routledge, Arndt & Goldenberg, 2004). Further, individuals with a higher dispositional focus on extrinsic self-esteem contingencies – bases of self-worth that come from others' approval – report a higher interest in tanning, whereas those with a lower focus on extrinsic self-esteem contingencies do not (Arndt et al., 2009). In contrast, when there is no delay following mortality priming and health decisions are assessed immediately thereafter (i.e., when death thoughts are conscious), health decisions seem to be independent of esteem relevance. For example, under these conditions, mortality reminders increase fitness intentions (Arndt, Schimel & Goldenberg, 2003) as well as interest in purchasing sunscreen products (Routledge et al., 2004), for reasons unrelated to appearance or esteem motivations.

Research has also examined TMHM's proposition that health-oriented variables moderate reactions to conscious, but not non-conscious, thoughts of death in an effort to remove death thought from consciousness. For example, the perception of adaptively coping with a health risk (e.g., Carver, Scheier & Weintraub, 1988) or maintaining optimism about health outcomes (e.g., Aspinwall & Brunhart, 1996) has been found to predict breast examination intentions and skin cancer prevention intentions when thoughts of death are conscious, but not when they are accessible but outside conscious awareness (Arndt, Routledge & Goldenberg, 2006; Cooper, Goldenberg & Arndt, 2010). Moreover, Cooper et al. (2010) showed that the effects were specific to cancer, and not dental prevention intentions, suggesting that health-oriented variables exert their greatest influence when death is conscious and engaging in a health behaviour has the potential to facilitate the removal of conscious thoughts of death.

Although optimistic beliefs about one's ability to overcome disease and illness are important for coping with health threats, adaptive health behaviours also rely on the belief that one can perform the behaviour (e.g., self-efficacy) and that the behaviour will, in fact, prevent the health threat (e.g., response efficacy). Health-oriented models of health decision-making have articulated the importance of expectations about response and self-efficacy in adaptively managing health threats. Protection motivation theory (PMT; Rogers, 1983) as well as Witte's extended parallel processing model (EPPM; Witte, 1992), for example, emphasizes that people engage in more adaptive health behaviours when the behaviour is perceived as effective in preventing the undesired outcome (e.g., wearing sunscreen to prevent sun damage) and they are able to perform it. Moreover, from the perspective of these models, efficacy is expected to interact with the severity of the health threat, such that people are more likely to perform a health behaviour when both severity and efficacy are high. In contrast, when the severity of a health threat is high but the effectiveness of preventing the outcome is low, people are more likely to respond by avoiding the health threat as well as the behaviours that could prevent it (Stephenson & Witte, 1998; Prentice-Dunn, Floyd & Flournoy, 2001; for a review, see Witte & Allen, 2000). Consistent with these perspectives, Cooper et al. (2010) found that when thoughts of death were conscious, but not non-conscious, individual differences in response efficacy predicted greater skin cancer prevention intentions.

The current study

While the findings of Cooper et al. (2010) introduce the relevance of efficacy perceptions to health reactions to mortality awareness, they are limited in a number of respects. First, they relied on individual differences in response efficacy to predict behavioural intentions to engage in sun protection behaviours when death is conscious. As such, it is unclear whether efficacy perceptions exerted a causal influence, or whether some other variable with which efficacy is associated was the operative agent in these effects. Further, an individual difference approach is not easily translated into developing broadly disseminated interventions. It is thus unclear but important to know whether manipulated perceptions of efficacy, which may be easier to implement in an intervention, would produce parallel effects. Second, Cooper et al. use an explicit directive to consider ones' mortality (e.g., open-ended questions about one's death), which of course is not typically the way mortality reminders are encountered in health communications. Although explicit directives provide an important initial test of the model, the utility of TMHM to inform and promote reliable health interventions requires eliciting conscious and non-conscious thoughts of death through more typical naturalistic mediums, such as might be encountered in health magazines and advertisements. Third, although the control condition in Cooper et al. and prior research prompted thought of other aversive topics, it did not arouse fear that was related to the implications of the health decision. Thus, it is not clear if it was merely the greater relevance of the fear evoked by the mortality salience manipulation (compared to the uncertainty prime, for example, in Cooper et al.) that led to the effects on sun protection intentions.

The aim of the current study was to build on Cooper et al.'s (2010) finding that the effects of conscious death thought on skin cancer prevention intentions were moderated by individual differences in efficacy beliefs, but to ask a number of more specific questions with an eye towards establishing a more solid foundation for the future development of intervention approaches. In addition, we aim to test a conceptual lens through which to understand potentially different effects based on the content of fear elicited through health communications. Specifically, this research asked the following questions: Can conscious death thought and efficacy be manipulated in the context of one-time health communications to impact health outcomes? And additionally, is priming the prospect of death distinct compared to other tanning-relevant fear-provoking outcomes, specifically concerns about appearance?

Research suggests that higher levels of fear and cancer worry can undermine cancer screening decisions and frequency (e.g., Consedine, Adjei, Ramirez & McKiernan, 2008; Consedine, Magai, Krivoshekova, Ryzewicz & Neugut, 2004). From the perspective of TMHM, it is often the specific fear of death associated with cancer that can create a barrier to adaptive health decisions, and that this will be the case specifically when individuals are not equipped with the efficacious perceptions of the behaviour that can reduce the threat. Moreover, although highlighting an appearance threat associated with a health risk behaviour, and tanning in particular, has been shown to motivate health promotion behaviour (e.g., Gibbons, Gerrard, Lane, Mahler & Kulik, 2005), we hypothesized that fear appeals highlighting the threat of death should uniquely interact with efficacy communications, and this should be the case specifically when death thought is conscious.

PILOT STUDY

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

To examine these hypotheses, we first needed sun exposure communications that would elicit death-related fear, but not more general fear, than an appearance-related threat condition. Of course, it is important that both health communications arouse more fear than a comparison condition. College students (N = 200) were thus presented with one of three sun exposure communications and then rated how fearful, threatened, and how much they thought about death as well as their negative affect (PANAS; Watson, Clark & Tellegen, 1988) after viewing the message.

In the mortality-related fear appeal condition, participants viewed a woman tanning herself on the beach and surrounded by individuals that looked as if they were attending her funeral. A caption read, ‘While you like your tan today, skin cancer is a direct result of over exposure to the sun. Left alone, skin cancer can spread throughout your body and eventually kill you.’ In the appearance-related fear appeal condition, participants viewed the torso and face of a man and a woman that appeared to have been on the beach and, critically, revealed the appearance consequences of over exposure to the sun (i.e., wrinkled, prematurely aged faces in contrast to young, tanned torsos). The caption read, ‘While you like your tan today, premature wrinkling is a direct result of overexposure to the sun. Premature wrinkling contributes to a less attractive appearance that others will find less appealing.’ A third, neutral message with no accompanying image simply stated, ‘Use sunscreen to protect yourself from excessive sun exposure.’

One-way ANOVAs and post-hoc tests revealed that the appeal significantly affected feelings of fear, threat, and conscious thoughts of death, all Fs (2, 197) > 23, ps < .001, η2 = .19, but not negative affect (= .18). As can be seen in Table 1, the mortality and appearance-threat conditions elicited similar, but greater levels of fear and threat than the neutral condition. Critically, the mortality-threat condition elicited greater thoughts of death than the appearance-threat or neutral condition.

Table 1. Means and standard deviations for effects of fear appeals on fear, threat and conscious death thoughts
Fear appealFearfulThreatenedDeath thoughts
M SD M SD M SD
  1. Note. Same subscripts denote significant differences (< .01) LSD post-hoc tests.

Mortality related3.95a1.723.68a1.653.74a1.66
Appearance related3.51b1.933.36b1.722.45a1.50
Neutral1.95a,b1.491.83a,b1.342.02a1.36

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

Participants

One hundred and forty-seven participants (95 females and 52 males) were recruited at a public beach (Mage = 24.50, SD = 10.34). Ninety-five per cent were Caucasian, with the remaining 5% Asian, American Indian and more than one race. Approximately 5% reported that they were of Hispanic or Latino ethnicity. G*Power (Erdfelder, Faul & Buchner, 1996) power analysis program was used to determine the approximate sample size needed to detect an effect at a power of .80. Based on previous research demonstrating a medium effect size in mortality salience research (Burke, Martens & Faucher, 2010), a sample size of 111 would be required to detect an effect if there is one.

Materials

Pre- and post-manipulation response efficacy and self-efficacy: Efficacy was assessed prior to the fear appeal manipulation and after the sun protection intentions measure. At each time, participants responded to three items adapted from Stephenson and Witte (1998) that assessed self-efficacy (i.e., ‘I am able to effectively protect my skin from sun exposure’) and response efficacy (i.e., ‘If I use sunscreen and other sun-protective measures, I am less likely to get skin cancer’; 1, strongly disagree, to 7, strongly agree).

Fear appeal messages

Participants were told that they were randomly assigned to view and evaluate a message from a health magazine that may or may not be accompanied by a picture. The same appeals described in the Pilot Test were used.

Delay

As in prior research (e.g., Greenberg, Pyszczynski, Solomon, Simon & Breus, 1994), participants completed a measure of affect (PANAS-X; Watson & Clark, 1994) and a word search puzzle either subsequent to or prior to the fear appeal. This allowed death thoughts to fade from consciousness in the delay condition, but remain consciously activated in the no-delay condition.

Efficacy message

Participants were then given one of two messages adapted from Stephenson and Witte (1998). A high efficacy message highlighted that skin cancer was preventable with the use of wide-brimmed hats, protective clothing and sunscreens with a SPF of 15 or higher, and that sun protection was inexpensive, practical and easy to use. A low efficacy message highlighted that skin cancer is difficult to prevent, and sun protection is messy, expensive and not that effective. Messages highlighting both the response efficacy and self-efficacy of the health behaviour provided individuals with confidence that the behaviour is capable of being performed and is effective at preventing the health threat, and have been shown to increase overall efficacy in past research (Witte & Allen, 2000).

Sun protection intentions

Adapted from Cox et al. (2009), participants responded to five items that assessed intentions to protect one's skin from exposure to the sun (e.g., how often they would use sunscreen on future beach visits, and during future daily activities; 1, never or not at all, to 7, always or extremely; α = .93). Finally, participants completed demographic information including age, gender and race.

Procedure

Potential participants were approached either individually or in groups on Clearwater Beach, FL, during Spring Break weeks by experimenters who were blind to conditions. Participants were offered a scratch-off lottery ticket and a free gift in exchange for filling out a survey assessing personality, health and consumer attitudes. Participants who agreed to participate were randomly assigned to a health threat (cancer, appearance or no threat), efficacy message (effective or not effective) and delay (or no-delay) condition administered in sequentially numbered packets of questionnaires. Participants were given instructions to go through the packet in order and to answer the questions independently and with their first, initial response to each item. After they completed the study, participants were given the lottery ticket and a small sample of sun block.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

Efficacy manipulation check

For an overall composite of efficacy (α = .75), participants who read the high efficacy message reported feeling greater efficacy for sun protection behaviours (= 5.98, SD = 1.03) than those who read the low efficacy message (= 5.16, SD = 1.30), F(1, 144) = 17.69, < .001, η2 = .11. Additionally, the results yielded a statistical power of .99. Parallel effects were obtained for separate measures of self- and response efficacy. Individual differences in efficacy were related to efficacy subsequent to the manipulation (β = .60, SE = .10, = 6.23, < .001), but controlling for these baseline individual differences did not alter the results (< .001).

Sun protection intentions

A 3 (fear appeal) × 2 (delay) × 2 (efficacy) ANOVA on sun protection intentions revealed a marginal effect of the fear appeal F(2, 134) = 2.63, = .08, η2 = .04 (appearance = 5.03, SD = 1.58; mortality = 4.32, SD = 1.70; neutral = 4.89, SD = 1.68), and critically, the predicted 3-way interaction between fear appeal, delay and efficacy, F(2, 134) = 4.94, = .01, η2 = .07 (see Table 2 for results of ANOVA). Additionally, the results yielded a statistical power of .80.

Table 2. Summary of the 3 (threat) × 2 (delay) × 2 (efficacy) analysis of variance
Sourcedf F p η2Power
Threat22.63.08.04.52
Delay1.81.37.01.15
Efficacy11.58.21.01.24
Threat × delay2.05.96.001.06
Threat × efficacy2.40.67.01.11
Delay × efficacy11.70.20.01.25
Threat × delay × efficacy24.94.01.07.80

Separate 3 (fear appeal) × 2 (efficacy) ANOVAs within the delay and no-delay condition showed that only in the no-delay (conscious death thought) condition was there a significant interaction between the fear appeal and efficacy messages, F(2, 70) = 4.37, = .02, η2 = .11 (see Figure 1; < 1, = .30 in the delay condition). Further, within the no-delay condition, only in the mortality-related fear appeal condition was there a significant effect of efficacy message, F(1, 22) = 12.98, = .002, η2 = .37 (all other ps > .39). When sun protection behaviours were framed as having low, compared to high, efficacy, participants exposed to the mortality-related fear appeal reported lower sun protection intentions.

image

Figure 1. Sun protection intentions within no-delay condition as a function of threat and efficacy message. Note: higher numbers indicate greater sun protection intentions.

Download figure to PowerPoint

Analyses within each efficacy condition suggested that the effect was largely due to decreased intentions in the mortality/no-delay/low efficacy condition, F(2, 37) = 4.76, = .01, η2 = .21. Post-hoc LSD tests revealed that when the message highlighted that sun protection behaviours were not effective, participants in the mortality condition reported less sun protection intentions than participants in the appearance (= .004) or control condition (= .05). There was no difference in intentions between participants in the appearance and control conditions (= .30). In contrast, there was no difference between fear appeals when sun protection behaviours were described as effective (= .65).

In an effort to better understand why effects emerged in the low, but not high, efficacy condition, additional analyses were conducted examining post-manipulation efficacy relative to pre-manipulation efficacy. A 2 (efficacy message) × 2 (pre-manipulation vs. post-manipulation) mixed repeated-measures ANOVA revealed that there was a significant change from pre- to post-manipulation efficacy, F(1, 142) = 6.50, = .01, η2 = .04. Critically, however, this effect was qualified by a 2-way interaction between efficacy message and time of efficacy measurement, F(1, 142) = 20.92, < .001, η2 = .13, such that only in the ineffective condition was there a significant difference between pre- and post-manipulation efficacy, F(1, 73) = 29.43, < .001, η2 = .29 (= .19 in the effective condition). Participants who read that sun protection behaviours were not effective reported less post-manipulation (= 5.15, SD = 1.31) than pre-manipulation efficacy (= 5.81, SD = .88). In other words, highlighting the effectiveness of sun protective behaviours had little effect on efficacy, whereas highlighting that they were ineffective decreased feelings of efficacy.

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

According to TMHM, when health threats activate conscious thoughts of death, responses are engaged to the extent that they can effectively alleviate the fear of death. Consistent with these predictions, when sun protection behaviours were framed as effective and participants were exposed to a fear appeal that primed death (e.g., skin cancer from sun damage), they reported higher sun protection relative to when sun protection was framed as ineffective. In contrast, there was no effect of priming the effectiveness of sun protection behaviours after an equally fear-provoking fear appeal that did not prime death (e.g., appearance), or when participants were given a delay exercise that allowed death thoughts to fade from consciousness.

Although the findings supported the prediction that efficacy would moderate responses to conscious thoughts of death, the results suggested that low efficacy decreased (rather than high efficacy increasing) sun protection intentions when death thoughts were conscious (relative to other fear appeals). Analyses of the effects of the efficacy manipulation relative to baseline suggest that this may be due to the low efficacy manipulation being more impactful than the high efficacy manipulation. In hindsight, considering that individuals are routinely exposed to messages that sun protection is effective, it is perhaps not surprising that individuals did not show a significant increase in pre-existing levels of efficacy, but that challenging the effectiveness of sun protection behaviours seemed to undermine existing levels of efficacy. Of course, additional approaches to manipulating efficacy are needed to further examine whether enhancing efficacy and conscious death thought can increase sun protection more than efficacy in conjunction with other fear appeals. At the very least, the findings highlight the potential for maladaptive reactions to health promotions that underscore the mortal consequences of tanning when individuals are not equipped with the efficacy to cope with the threat.

Implications of the TMHM for efficacy and fear appeals

The present study has implications for understanding the conditions under which certain fear appeals may be more or less effective than others. These implications are potentially important given the extensive research examining fear appeals, but the comparative paucity of work examining the effects of different sources of fear. Witte and Allen (2000) note that as the severity of a health threat increases, so too does people's defensive responses to that health threat. The present study suggests that the difference between the high and low severity health threats may not just be fear of the threat. Indeed, we found that the cancer and appearance threat induced similar levels of fear, but it was only when death was presumably conscious that the efficacy messages moderated health promotion intentions.

This begs the question of whether previous research finding an interaction between severity of a health risk and response efficacy and/or self-efficacy (e.g., Rippetoe & Rogers, 1987; Self & Rogers, 1990; Stephenson & Witte, 1998; Sturges & Rogers, 1996) may be at least partially attributable to severity manipulations raising conscious death concerns. Although the present study does not offer a definitive answer to this question, it is interesting to note that many of such prior studies use a cancer prime to instigate a severe threat (e.g., Stephenson & Witte, 1998) or explicitly highlight death in the manipulation of severity (e.g., ‘You are susceptible to the deadly disease meningitis, and if contracted, you may suffer a horrible death!’, Gore & Bracken, 2005). Future research should more directly examine this question of whether conscious death-related thought serves as a critical variable for promoting health behaviour in the context of high efficacy.

Moreover, the current research may shed light on previous findings where severe threats and low efficacy were found to backfire (e.g., Rippetoe & Rogers, 1987; Stephenson & Witte, 1998; Sturges & Rogers, 1996). According to Witte and Allen (2000) when severe threats are coupled with low efficacy, individuals enter a state of defensive rather than protection motivation. TMHM adds to this understanding by suggesting a particular type of defence that is instigated (i.e., death denial), and a theoretically grounded model for understanding the nature of the threat and, by virtue of this, tools for optimally managing it.

Implications for the application of the TMHM

The current study takes an important step in the application of TMHM from theory to practice. Most past TMHM research, including Cooper et al. (2010), has used conventional mortality salience treatments that manipulate conscious and non-conscious thoughts of death by having participants write about the thoughts and emotions that arise when they think about their own death and what will happen to them when they die (e.g., Greenberg et al., 1994). More recent research, however, has begun to examine the effects of presenting the death-related health threat in the context of a more traditional health communication. Hansen, Winzeler and Topolinski (2010), for example, found that messages on cigarette packages reminding participants that smoking could lead to lung cancer and death actually increased positive smoking attitudes among participants who based their self-esteem on smoking. Thus, as predicted by TMHM, non-conscious thoughts of death led to a backfire in attitudes towards smoking when smoking was important to their self-worth. The present work thus adds to growing documentation of how naturalistically encountered health warnings can activate thoughts of death and elicit theoretically predicted reactions.

Notably, however, the present work offers a unique contribution by examining a different class of psychological responses than those studied by Hansen et al. (2010). Whereas the present study was focused on what TMHM construes as proximal reactions to conscious death thoughts of death, Hansen et al. were focused on distal responses to non-conscious thoughts of death. That is, Hansen et al. did not assess attitudes towards smoking immediately after the mortality threat, when thoughts of death may have been conscious. In this case, TMHM would likely predict more negative attitudes towards smoking regardless of the extent to which smoking is based on self-esteem (see Arndt & Goldenberg, 2011) – at least to the extent that people perceive an efficacious relationship between quitting smoking and avoiding lung cancer. Thus, the present study is the first we know of to examine how naturalistically elicited conscious concerns about mortality impact health intentions.

In addition, although there are a handful of TMHM studies in field settings (e.g., a mammography clinic, on a public beach), in this prior work, as in Hansen et al. (2010), health outcomes were again examined as a function of non-conscious death thought. Thus, these studies could only assess, and indeed only have found, self-oriented motivations produced by non-conscious death. The present study was the first to examine health outcomes in response to conscious awareness of death outside of a laboratory. To the extent that people are exposed to health threats messages in magazines, television commercials and on the side of cigarette boxes, and that such messages can at least momentarily increase conscious concerns with death, it is critical to understand the variables that can interact with conscious death thought to promote, or present risks, to health.

The present results also have implications for the application of TMHM's proximal defences specifically. In previous TMHM research (e.g., Cooper et al., 2010), proximal defences have been observed by examining intentions or behaviour immediately after conscious death thought activation (e.g., sun protection intentions). No prior studies have attempted to frame a proximal defence option immediately following mortality reminders, and thus, it has not been known whether peoples' reaction to already elicited conscious thoughts of death could be influenced. The present study offers the first insights into this issue. In the present study, the intervention (i.e., the efficacy manipulation) was presented immediately after the health threat but before the measurement of sun protection intentions. This seems to imply that TMHM's proximal defences have the potential to be both more durable and more flexible than perhaps previously thought. This has a number of implications. It suggests, for example, that interventions might be productively introduced after people have already confronted, but are still dealing with, conscious reminders of death. Further, it suggests that it is not necessarily the behaviour, or behaviour intentions that need to be expressed when death is conscious for these mortality reminders to have a measurable impact. Rather, interventions can be designed in such a way as to maximize the impact of conscious death thought (by pairing it with efficacy) on health promotion. Of course, the outcome in this study, although not immediately after a conscious death prime, was still expressed within 10 min or so. Future research should be designed to better test the durability of the proximal, as well as distal, TMHM responses in the longer term.

Limitations

It is, however, important to be cautious extrapolating intentions to actual behaviour. Indeed, although the present study revealed that framing sun protective behaviours as effective (compared to ineffective) revealed more protective intentions among individuals primed with death, we cannot be certain that those intentions would predict an actual decrease in protective behaviours. However, a number of health models rely on intentions to engage in a behaviour to test the model, and indeed, research suggests that intentions predict health behaviour (e.g., Aspinwall, Kemeny, Taylor, Schneider & Dudley, 1991). In the context of efficacy studies, for example, Wurtele and Maddux (1987) found that intentions to exercise, which were increased by higher levels of self-efficacy, predicted subsequent exercise behaviour. Additionally, meta-analysis reveals that health interventions that lead to medium to large changes in intentions result in small to medium changes in behaviour (Webb & Sheeran, 2006).

Recent TMHM studies have provided evidence that reminders of death can promote not only intentions, but also behaviour. In exploring peoples' propensity to avoid the physicality (or creatureliness) of the body in the context of existential threat, Goldenberg, Arndt, Hart and Routledge (2008) found that reminders of mortality decreased breast self-examination intentions among women primed with the similarity between humans and animals, as well as behavioural examination duration on a breast model. In exploring the effects of non-conscious thoughts of death on appearance-related tanning intentions, Cox et al. (2009) found that tanning intentions increased when women were exposed to a mortality prime and an article highlighting tanned skin as attractive but decreased when the article highlighted the attractiveness of pale skin. In a second study, they found that the mortality prime and article highlighting pale skin led public beach patrons to choose a more protective sunscreen product in addition to increased intention to use sunscreen. However, these prior studies have found an increase in intentions and behaviour only after a delay between the mortality salience prime and outcome variable (i.e., when death is non-conscious). The present study potentially adds to this literature by showing an increase in intentions when death is conscious as well. While these studies suggest that the present findings might also correspond to behaviour, future research is needed to test this directly, as well as to examine the durability of this change.

Conclusion

Health communications that elicit fear have been found to be a strong predictor of health behaviours when the behaviours are seen as an effective route for reducing the health threat and preventing the undesired outcome. The present study elucidates conditions under which these messages may be especially likely to increase health-oriented motivations. In sum, all fear appeals may not be created equal. It was found that only when death thought was conscious and a health behaviour was framed as effective at reducing the health risk did people show greater intentions to engage in the health behaviour relative to framing the behaviour as ineffective. Moreover, low efficacy was associated with health risk especially when death thoughts were salient. Equipped with this information, health educators may be better able to design the types of health communications that will most effectively motivate adaptive health outcomes and minimize messages that backfire and increase risk.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References

Preparation for this article was partially supported by National Cancer Institute Grant R01CA09658.

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  3. Background
  4. PILOT STUDY
  5. BEACH STUDY
  6. Methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. References
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