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.