Motivation and emotion/Book/2013/Protection motivation and health

Protection motivation and health: What is protection motivation and how does it affect health?

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What it is?

There are a variety of health related behaviours that increase our risk of illness, disability and death. It has become and will continue to be, a national priority to reduce these behaviours and encourage healthier behaviours which result in longevity and general well-being (Keller, 1999). These attempts to reduce those behaviours range from print on tobacco packaging depicting the negative consequences of smoking, adverts in daily papers of the consequences of excessive drinking to stories relayed on the news containing the latest developments of STD’s. Unfortunately seeing these health messages is not as entirely effective as receiving advice over the telephone, face to face therapy and seeking medical advice in person (Keller, 1999). This is a major problem health communication faces, and to overcome this the media and health experts tend to focus on fear arousal and how this can effectively affect persuasion (Keller, 1999). A fear appeal usually contains three parts, first it will focus on a particular health risk, it will then focus on consequences and vulnerabilities to that health risk, and thirdly it outlines a protective action that can be taken up to prevent this health risk (Keller, 1999). The persuasion to take up this protective action stems from the feeling and arousal of fear, the unpleasant emotional state brought upon by being exposed to the fear appeals presented to those who would be at risk of negative health behaviours (Keller, 1999). There are a variety of fear-persuasion theories and models which examine and explain fear appeals, and these are:

Extended Parallel Process Model
Health Belief Model
Theory of Reasoned Action
Transtheoretical Model
Protection Motivation Theory

This chapter will be focusing on specifically Protection Motivation Theory (PMT), a theory put forth by R.W Rogers in 1975 in an attempt to better understand fear appeals, and how it affects a person's health. According to PMT, an individual exposed to a fear appeal results in that person assessing the severity and importance of a behaviour, the probability of the behaviour's occurrence, and the belief in the effectiveness of the recommendations provided in the fear appeal. Perceptions about these three factors arouse protection motivation and adaptive or maladaptive changes in behaviour, which in turn provides the incentive to seek a healthier behavior and to reduce the probability of that health risk (Keller, 1999). Two cognitive process upon exposure to a health threat message or a fear appeal are initiated, and these are threat appraisal and coping appraisal (Sturges & Rogers, 1996). Essentially PMT show the difference and distinguishes between adaptive and maladaptive coping behaviours when faced with a health threat (Ireland, 2011). PMT suggests that a risk to health is appraised by considering the following factors:

How severe the threatened health behaviour is considered to be, which is the threat appraisal of it's severity
How susceptible or how vulnerable a person believes themselves to be, which is the threat appraisal towards vulnerability
How successful a preventative behavior actually is, which is the coping appraisal of success
How confident the person feels in preventing and reducing the health risk, which is the coping appraisal of that person's self-efficacy (Ireland, 2011)

Fear arousal is expected to enhance protection motivation by heightening threat appraisal and creating an adaptive response (Ireland, 2011). If coping appraisal is unsuccessful a maladaptive response may occur, for example a person who smokes feels that smoking is just too addictive, and that if they make the decision to quit by themselves they are unlikely to complete this adaptive change of behaviour (Ireland, 2011). The threat-appraisal process takes into account the factors associated with the response that creates the danger, such as the severity of the danger and a person's susceptibility towards it (Sturges & Rogers, 1996). The coping-appraisal process evaluates a persons' ability to cope with and avoid the health risk (Sturges & Rogers, 1996). Previous research has discovered that usually these threat and coping processes interact with each other (Sturges & Rogers, 1996). For example if response efficacy or self-efficacy was high, higher levels of the severity of the threat and one's vulnerability to it culminated in stronger intentions to adopt the recommended behavioural change (Sturges & Rogers, 1996). On the other hand if response efficacy or self-efficacy was lower, increases in severity and vulnerability weakened behavioural intentions (Sturges & Rogers, 1996). This has been discovered in studies exploring people's intentions towards moderate drinking, intentions to stop smoking, intentions to protect oneself against sexually transmitted diseases, and self-reported condom use (Sturges & Rogers, 1996). Two of the core variables in this theory are the effectiveness of the response and a persons' ability to act upon it successfully (Sturges & Rogers, 1996).

Other theories with fear appeals

Extended Parallel Process Model - All health risk messages are essentially fear appeals because they usually outline certain health consequences that would occur if the recommended plans of action were not followed by that individual (McQueen, Vernon, & Swank, 2013). The Expanded Parallel Process Model focuses on to two parallel processes or responses to fear appeals, and these are danger and fear control (McQueen et al., 2013). For danger control, people cope with perceived danger by changing their intentions, rationalising their actions, attitudes and behaviours to reduce or prevent that health threat (McQueen et al., 2013). This is similar to the cognitive adaption people go through when they experience cognitive dissonance, when a person becomes faced with the negative consequences of a decision, they will rationalise and change their behaviours to rid themselves of that discomfort felt (McQueen et al., 2013). Fear control processes on the other hand represent how a person emotionally deals with their fear of the health threat by denying and avoiding the health threat (McQueen et al., 2013). When a health risk or a health behaviour which would increase a person's chance of risk is seen as trivial or not relevant personally, then no further action is taken by that individual (McQueen et al., 2013). However, even when a risk is perceived to be important and relevant to that person, when an individual's drive for reducing the risk is low, further action is of course delayed (McQueen et al., 2013). So for an EPPM example, an effective health message is one that evokes high levels of perceived risk, with high levels of response and self-efficacy (Hatchell, Bassett-Gunter, Clarke, Kimura, & Latimer-Cheung, 2013).

The Health Belief Model - The Health Belief Model (HBM) has been used frequently throughout research in health psychology in changing health behaviours (Montanaro & Bryan, 2013), and it consists of five dimensions:

Perceived susceptibility which is how vulnerable a person feels towards health threats
Perceived severity which is an individuals assessment on how serious a health threat may be
Perceived benefits are a person's belief about whether a certain action would reduce the risk of that health threat
Perceived barriers which are beliefs about if an individual can overcome the difficulties taking action, or overcome the negative consequences of failing at taking that action
Self-efficacy (Montanaro & Bryan, 2013)

Fear appeals created from the HBM usually focus on the susceptibility and severity of the negative consequences of health risks as a core reason to make a change in health behaviour (Montanaro & Bryan, 2013). For example Montanaro and Bryan, (2013) recently looked at university students' intentions to use condoms and further preparatory behaviours of safe sex, and if the HBM was a successful model for triggering positive health behaviour changes. They found that health interventions based on the HBM created greater behavioural change when those interventions were focused on the susceptibility and severity of sexual transmitted diseases (Montanaro & Bryan, 2013).

The Theory of Reasoned Action - The Theory of Reasoned Action (TRA) focuses on intention as the major predictor of subsequent behavior, it has been used to model many health behaviours, such as smoking tobacco, drinking excessive alcohol and engaging in sexual behaviours without adequate protection (Morrison, Golder, Keller, & Gillmore, 2002). Intentions are based on a person's attitude toward presenting the health behavior and perceived social norms about presenting the behavior (Morrison et al., 2002). Attitude is based on a set of outcome beliefs about the consequences of that health behavior, the positives and negatives of the outcome, and how often the behaviour is to occur (Morrison et al., 2002). A perceived social norm is focuses on a set of normative beliefs: whether certain individuals or groups approve or disapprove of the behavior and how motivated the person is to comply with each of these groups or individuals (Morrison et al., 2002). All other variables that affect intention work through attitude, perceived norms, or both, and attitude and perceived norms affect behavior only through intention (Morrison et al., 2002). A person will look at a variety of consequences when faced with a fear appeal pertaining to their current health behaviour which go further than the actual risks that health behaviour poses (Morrison et al., 2002). Researchers and health experts will often look at how a person came across cognition's in relation to their health behaviour, identify the normative and outcome beliefs that a person has that could be changed, and then act on those by delivering an intervention that could change those beliefs about that health behaviour (Morrison et al., 2002). Unlike the other models for fear appeals, TRA focuses heavily on social influences and how that can affect the effectiveness of fear appeals (Morrison et al., 2002).

Transtheoretical Model - A transtheoretical model on health behaviours examines the systematic processes that occur when fear appeals create a change in behaviour, and that these processes can be broken down into 'stages of change' (Herzog, 2008). There are five of these stages, and the model suggests that when a person changes from one to another of these stages, they do so by making rational coping processes, which are called processes of change (Herzog, 2008). The five stages are:

Pre-contemplation - There is no change in behaviour or intention to change behaviour
Contemplation - A person is weighing the advantages and disadvantages of changing their behaviour
Preparation - They have decided to change their behaviour
Action - The individual enacts on their decision to make a behaviour change
Maintenance - The person attempts to have this new behaviour part of their lifestyle (Herzog, 2008)

When an individual decides to go through these processes, they take into account the benefits and negatives associated with the different and new health behaviour, and they will usually not enact on the new behaviour unless their perceived positives are greater than the perceived negatives (Herzog, 2008). Researches have found that change is on ongoing process with health behaviours, that the transtheoretical model is very effective at examining the dynamics of change in behaviour, and due to it's great utility, it can effectively understand the processes behind change in health behaviours from fear appeals (Herzog, 2008).

Protection motivation and health

These five theories all share the core belief that a person's motivation protection resides from a perceived threat and the desire to avoid any negative consequences from said threat (Floyd, Prentice-Dunn, & Rogers, 2006). The theories also share a cost-benefit component in which the person weighs the costs of taking the precautionary action up against the expected positives of undertaking that action (Floyd et al., 2006). PMT has been shown to be a viable model on which to base individual and community health interventions, and these will be discussed in further detail soon (Floyd et al., 2006). A major reason this is so is because the PMT model provides an understanding of why attitudes and behaviour can change when people are confronted with threats, it is after all an attitude-based model (Floyd et al., 2006). For example the decision an individual makes to take protective action is a positive result of severity because a person must believe that there is some harm from this health behaviour, such as lung cancer for smokers, and that they are susceptible to this threat (Floyd et al., 2006).

There are rewards though for this behaviour, both intrinsic and extrinsic which must both be overcome; an example of an intrinsic reward would be the pleasure of inhaling tobacco smoke, and an example of an extrinsic reward would be friends approval of that individual smoking with them (Floyd et al., 2006). PMT is similar to other forms of motivation as it arouses, directs and sustains activity (Floyd et al., 2006). This appraisal of threat contains the motivation for an individual to start the coping process and behavioural change (Floyd et al., 2006). To decide to adopt the recommended coping response, a person has to believe that fulfilling the coping response will avoid the threat and that they have the ability and will power to perform the response (Floyd et al., 2006). Of course these considerations also have to outweigh the costs of performing the coping response and behavioural change, and continuing with the smoking example one such cost would be withdrawal symptoms (Floyd et al., 2006).

A recent meta-analytic review was conducted by Milne, Sheeran, and Orbell (2006) which sought to investigate the success PMT had in predicting health behaviours and health intentions. They sought to discover how effective threat and coping appraisal were in predicting attention, how well the PMT variables were associated with intention, how effective variables of PMT were at predicting current and subsequent health behaviours, and finally how successful had manipulations of those variables been in creating changes in beliefs (Milne et al., 2006). The data examined in this research followed strict selection criteria, the studies analysed measured behavioural intentions, contained applications of PMT, and the behaviour studies had to relate to a health behaviour (Milne et al., 2006). Specifically there were two types of studies collected in this research, and these were detection which are conducted to enable a person to discover if they had a behaviour which could result in a health risk, and preventive behaviours which as it sounds enabled a person to continue or stop a certain behaviour that will reduce the risk of a health threat (Milne et al., 2006). They found that PMT variables were significantly associated with current behaviour, that threat and coping appraisals were associated with intention, though coping appraisals were more strongly correlated with intention than threat appraisals (Milne et al., 2006).

As they had predicted, health related intentions were significantly associated with subsequent behaviour, and this supports the model of PMT as the model itself predicts that intention is the one of the strongest and immediate predictors of behavioural change (Milne et al., 2006). This supported previous research, and another finding also supported previous research; this finding was that as mentioned above both appraisals affect intention (with coping affecting it more), but even with threat appraisal affecting intention, it is still a lacklustre predictor of behaviour and intention (Milne et al., 2006). This could be because once a person feels vulnerable towards a health threat they can then create a protective behaviour and thus a positive relationship between perceived personal risk and perceived behaviour; whereas once the protective behaviour is adopted, that person may no longer feel susceptible towards that risk, thus it will result in a negative relationship between perceived personal risk and perceived behaviour (Milne et al., 2006). Finally self-efficacy was found to be strongly associated with intention and current behaviour as it is a major factor in the coping appraisal of PMT (Milne et al., 2006).

Everyday protection motivation

Nearly everybody enjoys going to the beach, kicking back and enjoying passing a ball around or laying in the sun, despite the fact the beach is fun and getting a tan is attractive, skin cancer is a serious health risk. For example Ch’ng and Glendon (2013) examined in their research how effective PMT could be in predicting sun protection behaviours. In this study they measured typical reported behaviours, previous reported behaviours, current sunscreen use and current observed behaviours (Ch’ng & Glendon, 2013). When looking at the variables of PMT in relation to predictors of sun protection behaviours, they found that:

People who reported high perceived vulnerability to skin cancer were more likely to account for their chances of developing the disease in the future, which leads them to engage in sun protection behaviours (Ch’ng & Glendon, 2013)
There were extrinsic and intrinsic perceived rewards associated with the maladaptive behaviour, for example people felt that for their social life they preferred to show off a tan, and that bathing in the sunlight was a relaxing thing to do (Ch’ng & Glendon, 2013)
People had perceived barriers and costs to using sunscreen, for example those who were aiming for a tan, sunscreen reduced the overall effect of tanning (Ch’ng & Glendon, 2013)
They discovered other coping appraisals which acted as barriers to sun protection as well, such as image issues and forgetfulness (Ch’ng & Glendon, 2013)
Finally they looked how self-efficacy supported a better health behaviour, that when an individual believed that using sunscreen reduced the risk of melanoma, they were more likely to engage in a protective behaviour (Ch’ng & Glendon, 2013)

The research showed that perceived vulnerability, response costs and response efficacy were strongly associated with protection motivation, though perceived severity was less associated with sun protection (Ch’ng & Glendon, 2013). This could be because perceived severity of skin cancer was of low importance for this sample which would result in little to no motivation to engage in protective behaviour; the sample being a convenience sample taken from Queensland beaches who had stayed within the sun for 30 minutes for the duration of the interview (Ch’ng & Glendon, 2013). The researchers suggest that unlike perceived vulnerability which emphasises a definite health risk, perceived severity does not exhibit those individual's awareness of that health risk (Ch’ng & Glendon, 2013). For example participants might have been unaware of the different varieties of skin cancer, or they were unable to ascertain the risk of skin cancer compared with unspecified other threats to their health, such as major sun burn or heat stroke (Ch’ng & Glendon, 2013).

What this means is that while those individuals might have been aware of the seriousness of skin cancer and the negative consequences it presents, they might not necessarily have associated that perception with their own personal health (Ch’ng & Glendon, 2013). This study did have limitations though which need to be taken into account, for example this was a convenience sampling and may not of represented the target population, which reduces the generalisability of Ch’ng and Glendons (2013) findings. From this information, if you find yourself a regular beach goer, you may wish to focus on the vulnerability you place on yourself by not enacting sun protective behaviours, focus on reducing barriers and response costs such as forgetting to apply sunscreen, and focus on response efficacy, such as learning about how sunscreen protects you from risk of skin cancer.

Now looking at another health behaviour, this research is taking a different spin on PMT by applying it to anti-speeding messages and how they affect a young persons' intention to speed and place themselves and others at risk. Anti-speeding fear appeals usually focus on the negative consequences of taking up the behaviour of speeding, and these message attempt to motivate drivers, particularly young drivers, to adopt the desired behaviours seen in these messages (Glendon & Walker, 2013). Glendon and Walker (2013) examined the various models PMT presents with threat and coping appraisals in relation to exceeding posted speed limits, and these are:

For perceived severity a person may believe that having a car accident would be much worse whilst speeding than while driving at the posted speed limit (Glendon & Walker, 2013)
For perceived vulnerability a person would believe they are more likely to have an accident whilst speeding (Glendon & Walker, 2013)
For perceptions about rewards an individual may simply find enjoyment from speeding (Glendon & Walker, 2013)
Anti-Speeding message
With self-efficacy a person may believe they have the ability and constraint to drive within the speed limit (Glendon & Walker, 2013)
With response efficacy that person may believe that driving within the posted speed limit will reduce their risk of a car crash (Glendon & Walker, 2013)
And finally the potential costs associated with carrying out the maladaptive behaviour, for example a person my be running late and speeding would be a solution to this problem (Glendon & Walker, 2013)

A major hurtle in their research was that male drivers were prone to adopting speeding behaviours over female drivers, luckily it was found that PMT based anti-speeding messages were consistent for both genders in their effectiveness at creating the intention to drive within the speed limit over jurisdictional anti-speeding messages (Glendon & Walker, 2013). The table provides some examples of PMT and jurisdiction messages (Glendon & Walker, 2013):

Table 1. PMT Message Examples

PMT Variable	PMT Message	Jurisdictional Message
Severity	Kill your speed, not yourself	Every K over is a killer
Vulnerability	Speeding? You are not safe from a speed camera	You speed you pay!
Rewards	Speed! The thrill that kills	Slow down stupid
Self-efficacy	You can save a life. You can drive the speed limit	Focus on speed - slow down
Response efficacy	Don't speed and you won't get a fine	10kph less will save lives
Response Cost	Running late? Speeding is never worth the risk	Drive safe - what's your rush?

(Glendon & Walker, 2013, p. 71)

Another finding in the research was that PMT messages that focused on threat appraisals, specifically severity and vulnerability, rather than coping appraisals resulted in stronger associations with intent to drive within the speed limit; where as there were no differences in threat and coping appraisals in jurisdictional messages (Glendon & Walker, 2013). Unlike preventive action that focused on coping appraisals, such as educational essays and short media advertisements and speeding in previous research, the mediums for this study were basic messages which comprised of a small amount of text with no accompanying image or sound (Glendon & Walker, 2013). This resulted in these messages producing poignant anti-speeding behaviours which focused more on vulnerability and severity of the risks of speeding, while also reducing the impact coping appraisals may of had on predicting intentions to speed (Glendon & Walker, 2013).

What this can mean for the general public and the individual is that perhaps big campaigns which focus on bombarding demographics with information, statistics and images in an attempt to change speeding behaviours can be not as effective as short, acute messages focused on vulnerability and severity of speeding. This has started to be seen on roads, there are signs with basic text which focus on the use of phones whilst driving, not taking adequate breaks while driving and drinking and then driving. What speeding messages based around PMT can offer though is important insight on crucial areas that should be targeted during the training and education of young drivers, as well as being a factor in other driving related media messages (Glendon & Walker, 2013).

How it can help you

So we've now had a look at fear appeals, how they affect behavioural changes in the face of a health risk, some theories which also postulate behavioural changes, in particular protection motivation theory. In summary it is the ability of the PMT to highlight and evaluate the intention behind the behavioural change that makes it such a successful model of providing positive protective health behaviours and for also effectively understanding fear appeals. So perhaps if you become faced with a health risk dilemma, to overcome becoming stuck with the negative consequences, you could always look at the threat and coping appraisals the PMT puts forth and apply them to your own situation, look at how effective each of those variables are in predicting your behaviour and begin the journey of a healthier and happier lifestyle.

Quiz time

References

Ch’ng, J. M., & Glendon, A. (2013). Predicting sun protection behaviors using protection motivation variables. Journal of Behavioural Medicine. doi:10.1007/s10865-012-9482-5

Floyd, D., Prentice-Dunn, S., & Rogers, R.W. (2006). A Meta-Analysis of Research on Protection Motivation Theory. Journal of Applied Social Psychology, 30(2), 407-429. doi: 10.1111/j.1559-1816.2000.tb02323.x

Glendon, A., & Walker, B. L. (2013). Can anti-speeding messages based on protection motivation theory influence reported speeding intentions?. Accident Analysis and Prevention, 5767-79. doi:10.1016/j.aap.2013.04.004

Hatchell, A. C., Bassett-Gunter, R. L., Clarke, M., Kimura, S., & Latimer-Cheung, A. E. (2013). Messages for men: The efficacy of EPPM-based messages targeting men's physical activity. Health Psychology, 32(1), 24-32. doi:10.1037/a0030108

Herzog, T. A. (2008). Analyzing the transtheoretical model using the framework of Weinstein, Rothman, and Sutton (1998): The example of smoking cessation. Health Psychology, 27(5), 548-556. doi:10.1037/0278-6133.27.5.548

Ireland, J. L. (2011). The importance of coping, threat appraisal, and beliefs in understanding and responding to fear of victimization: Applications to a male prisoner sample. Law and Human Behavior, 35(4), 306-315. doi:10.1007/s10979-010-9237-1

Keller, P. (1999). Converting the unconverted: The effect of inclination and opportunity to discount health-related fear appeals. Journal of Applied Psychology, 84(3), 403-415. doi:10.1037/0021-9010.84.3.403

McQueen, A., Vernon, S. W., & Swank, P. R. (2013). Construct definition and scale development for defensive information processing: An application to colorectal cancer screening. Health Psychology, 32(2), 190-202. doi:10.1037/a0027311

Milne, S., Sheeran, P., & Orbell, S. (2006). Prediction and Intervention in Health-Related Behavior: A Meta-Analytic Review of Protection Motivation Theory. Journal of Applied Social Psychology, 30(1), 106-143. doi: 10.1111/j.1559-1816.2000.tb02308.x

Montanaro, E. A., & Bryan, A. D. (2013). Comparing Theory-Based Condom Interventions: Health Belief Model Versus Theory of Planned Behavior. Health Psychology. doi:10.1037/a0033969

Morrison, D. M., Golder, S., Keller, T. E., & Gillmore, M. (2002). The theory of reasoned action as a model of marijuana use: Tests of implicit assumptions and applicability to high-risk young women. Psychology of Addictive Behaviors, 16(3), 212-224. doi:10.1037/0893-164X.16.3.212

Sturges, J. W., & Rogers, R. W. (1996). Preventive health psychology from a developmental perspective: An extension of protection motivation theory. Health Psychology, 15(3), 158-166. doi:10.1037/0278-6133.15.3.158