If I know how to change, I will:
Investigating the mediating role of certainty and self-efficacy
theory in the relationship between disgust and health behavior
change
By
Ismay Schaaij
If I know how to change, I will:
Investigating the mediating role of certainty and self-efficacy
theory in the relationship between disgust and health behavior
change
By Ismay Schaaij
University of Groningen Faculty of Economics and Business
Thesis MSc Marketing Management Completion date: January 24, 2021
Tuinbouwstraat 107A 9717 JE Groningen i.schaaij@student.rug.nl
Abstract
With health and wellbeing becoming an increasingly important issue in today’s society, health promoters are constantly looking for the most effective methods to reduce people’s health-damaging behaviors, which can be achieved through for example so-called fear appeals.
Research shows that adding disgust-eliciting elements to the commonly used fear appeal would enhance its effectiveness due to the strong avoidance reaction disgust elicits. This study aims to determine how this process of disgust influencing behavioral change exactly takes place. Specifically, it investigates whether the concepts of certainty and self-efficacy theory can be ascribed as the underlying mechanisms. To test the hypotheses that perceived level of self-efficacy and outcome expectancies, part of self-self-efficacy theory, play a mediating role in the relationship between disgust and behavioral change, an online survey was constructed.
Moreover, it was tested whether certainty is a mediator between the concepts of disgust and self-efficacy. Respondents (N = 135) were invited to participate in a study which showed them either a fear appeal or disgust appeal. Results indicated that disgust actually led to less behavioral change. Moreover, the mediating roles of perceived level of self-efficacy and outcome
expectancies were not supported. Furthermore, even though certainty did not play a mediating part in the relationship between disgust and self-efficacy, it turned out that it actually was a mediator between disgust and behavioral change; disgust led to an increased feeling of certainty, which in turn resulted in less behavioral change, meaning that disgust had a negative impact on behavioral change. Overall, this study presents interesting findings that could be used in future research to increase understanding of the role of disgust in behavioral change.
Preface
Hereby, I proudly present to you my thesis, which is the final part of my Master’s in Marketing Management. In 2014, I moved to Groningen to start a Bachelor’s in International Business and by handing in this thesis, I say goodbye to my time as a student. This project has made me realize that I am really interested in health advertising and that this might be a path I wish to pursue. Even though I have had many ups and downs during the process of writing this thesis, I can look back at a very instructive and rewarding experience.
I would like to take this opportunity to thank my supervisor, Jan Andre Koch, for his endless support during this project. I sometimes struggled quite a bit during this process and without his excellent guidance, I could not have done it. Beforehand, I was quite nervous to start writing my thesis, but I have experienced it as a really pleasant cooperation, for which I am very thankful. Furthermore, I would like to thank my friends as well for their support throughout the journey of writing my thesis.
I hope you enjoy reading this thesis!
Ismay Schaaij
Table of Contents
1. Introduction
... 12. Literature review ... 4
2.1 Fear vs. Disgust appeals... 4
2.2 Self-efficacy theory ... 7
2.3 Disgust and self-efficacy theory ... 9
2.4 Conceptual model ...11
3. Methodology ...12
4. Results ...15
5. Discussion ...19
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1. Introduction
The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP, 2020b) supports several programs to educate Americans on how to stay healthy, including campaigns about the risks of smoking, obesity, and a lack of physical activity. Besides media campaigns, the Center seeks to make the public aware of their health by using for example social media and press releases. An illustration of their work is a campaign called ‘Tips from Former Smokers’, which shows videos of people who are chronically ill due to years of smoking (NCCDPHP, 2020a). In one video we meet Terrie, who talks about getting ready for the day after treatments for throat cancer caused her to lose her hair and teeth. She is bald, almost unable to speak, and you can clearly see the damage that the treatments have done to her, making her look unhappy and sad. The horrifying images in this campaign are intended to frighten people so that they realize what damage smoking can do to their body, encouraging them to quit smoking.
This is just an example of how health promoters try to reduce behaviors that are harmful for both individuals and society. In the past few years, the topic of well-being has gained enormous popularity, leading to initiatives to reduce destructive behavior including tobacco usage, alcohol consumption, and meat consumption (Apostolidis & McLeay, 2016; Pierce et al., 2012; World Health Organization, 2019). In order to change such behaviors in the interest of people’s health, developers of public health campaigns often seek to arouse an emotional response (Lupton, 2015). A fundamental strategy in health promotion is linking risk with negative emotion, as emotions influence decision-making (e.g., Grecucci et al., 2013; Lerner et al., 2015). This can be achieved through, for example, so-called fear appeals, which are
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they do not do what the message recommends (Witte, 1992). An example of this is the previously mentioned campaign ‘Tips from Former Smokers’.
Studies show that fear appeals are effective as a tool in establishing behavioral change (e.g., Stainback & Rogers, 1983; Tannenbaum et al., 2015; Witte & Allen, 2000). A study by Morales et al. (2012) argues that adding disgust-eliciting elements to a fear appeal would enhance its persuasiveness as disgust would offer a single solution: to avoid. These results indicate that disgust might be a key element in determining a fear appeal’s effectiveness, as message acceptance was significantly increased in conditions that elicited both fear and disgust compared to fear only (Morales et al., 2012). However, the process of how disgust would enhance fear appeals’ effectiveness is still unclear, as this has not been explicitly tested yet.
Given the fact that still little is known about the use of disgust as a tool in behavioral change and that its occurrence is high in consumer settings and advertising (Morales et al., 2012), it is crucial to increase the understanding of how disgust impacts basic consumer processes such as persuasion. Several real-life campaigns that included imagery of disgust-eliciting elements such as blood and fat proved to be more successful in establishing behavioral change in comparison with campaigns that did not contain such images (Morales et al., 2012). The effects of disgust were found to be especially strong in increasing compliance for fear appeals that were stimulating avoidant behaviors instead of approach behaviors, because the avoidance reaction elicited by disgust was strongly aligned with avoidance behaviors (Morales et al., 2012). However, a theory on how this process behind the concepts of disgust, avoidance and behavioral change exactly takes place has not been established yet.
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2. Literature review
2.1 Fear vs. Disgust appeals
Fear is an emotion that motivates and prepares a person to escape from a threat; it is
characterized by heightened autonomic nervous system activity in the body, feelings of high tension and activity, and the tendency to avoid or escape the threat/object (Izard, 1977).
A fear appeal can be described as ‘a persuasive communication attempting to arouse fear, promoting precautionary motivation and self-protective action’ (Rogers, 1983). It attempts to instigate fear by presenting a severe threat to which the individual is susceptible, after which it recommends a specific action. Fear appeals have been a popular method in health
communication for a long time already to persuade consumers to change their behavior because their current behavior (e.g., smoking) is likely to have harmful consequences (Doeken & Geurts, 2005). Fear appeals have been used to address a variety of health issues, including smoking, alcohol consumption, drug use, poor eating habits, and AIDS (Ruiter et al., 2014).
Keller and Block (1996) concluded that there are several message and individual
variables that determine whether a fear appeal will be effective or not, such as how the message has been constructed and whether it is aimed at the right audience (who is susceptible to the threat). Moreover, there is a maximum effective value of fear, meaning that when a moderate amount of fear is elicited by a message, it is not beneficial to add more fear (Tannenbaum et al., 2015). Additionally, the fear appeal should contain high levels of threat and high levels of
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Morales et al. (2012) proposed that the effectiveness of fear appeals can be enhanced by adding the element of disgust. In line with this, Jónsdóttir et al. (2014) found that campaigns that showed disgusting images which elicited both disgust and fear were more effective compared to campaigns that did not contain such imagery due to the fact that these did not trigger the two aforementioned emotions. Moreover, disgust alone can aid in (positive) behavioral change (Porzig-Drummond et al., 2009) and can increase intention to memorize and actual memory of message content (Leshner et al., 2011).
Although fear and disgust share some conceptual overlap as they are both fundamentally a defensive response to highly arousing, unpleasant stimuli (Newhagen, 1998), they are generally considered to be two distinct emotions with different behavioral consequences such as avoidance reactions. First of all, disgust can be defined as an emotion characterized by a mild physiological manifestation of nausea, feelings of revulsion, and withdrawal from the disgusting object
(Davey, 1994; Rozin et al., 1993). Studies argue that disgust has been developed as a defensive response to potential contamination from dirty items (Lazarus, 1991; Rozin et al., 1993). It has thus been linked to ideas of revulsion, deviation, and physical contact, as contact between the human body and the disgusting object is aimed to be avoided (Morales et al., 2012).
The feature that disgust dominantly distinguishes from fear, is the perception that a stimulus is repulsive (Woody & Teachman, 2000). Therefore, fear and disgust lead to different types of avoidance behaviors (Rosen & Schulkin, 1998). Fear avoidance can be seen as a multi-step process suggesting that fear should initially make people freeze up and that as a next multi-step, one will only take action as the danger comes inevitably near (Lang et al., 1997; Rosen & Schulkin, 1998). Research shows that people freeze up when they are confronted with
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leads to the very strong impulse to avoid, expel or distance oneself directly from the object (Lazarus, 1991; Smith & Ellsworth, 1985). A person’s first reaction when coming in contact with a disgust-eliciting object, is to move as rapidly away from it as possible. Studies show that this reaction to avoid disgust is so strong that it has also been found in other contexts, such as when a non-disgusting item is merely associated with a disgust-eliciting object (Rozin & Fallon, 1987).
Another important factor that is crucial in understanding behavior after a person is presented with either fear- or disgust-eliciting stimuli, is certainty. As Smith and Ellsworth (1985) argue, fear has been associated with a state of maximum uncertainty, which is consistent with its function as a reaction to a threat. Due to the dangerous nature of threatening situations, a frightened person is insecure over what to do and whether it will be possible to escape or avoid the fear-eliciting object. On the contrary, disgust has been linked to a strong sense of certainty; a disgusted person knows what the problem is, how to deal with it, and is convinced of his/her ability to do so (Smith & Ellsworth, 1985).
Overall, one can conclude that the emotion disgust consists of the perception that a
stimulus is repulsive, leading to the fact that a person is certain what to do as the only option is to avoid the disgusting object. Morales et al. (2012) argue that due to this immediate distancing reaction that disgust elicits, disgust enhances the persuasiveness of fear appeals; however, it is still unclear how this process exactly works.
Considering the fact that disgust elicits a state of certainty, which is in stark contrast to fear, one could argue that this could play a role in explaining why disgust would lead to
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process. A psychological theory that could possibly explain how the process of disgust and behavioral change takes place, is the theory of self-efficacy.
2.2 Self-efficacy theory
Self-efficacy theory, which is part of Social Cognitive Theory (Bandura, 1986), has been widely used in the health literature to understand behaviors and elicit behavioral change (Chin & Mansory, 2018; McCauley et al., 2003; Saksvig et al., 2005).
Bandura (1977) states that changes are derived from a common cognitive mechanism. All processes of psychological alteration operate through changes in self-efficacy, which is
especially applicable to avoidant and fearful behavior (Bandura, 1977). Self-efficacy can be described as ‘an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments’ (Bandura, 1977). Self-efficacy theory is based on the principle that psychological procedures, in any form possible, serve as a way of creating and strengthening expectations of personal efficacy (Bandura, 1977).
Two independent expectancies play a role in this model of personal mastery (Bandura, 1977). First of all, an outcome expectation is defined as a person’s estimate that a given behavior will have certain outcomes as a result. Secondly, an efficacy expectation is the belief whether a person can successfully perform the behavior or not.
The difference between these expectations can be seen in Figure 1:
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This figure shows that these expectations are two distinct concepts as one can believe a certain behavior leads to specific outcomes, but as long one does not have faith in one’s ability to perform this behavior, such information does not influence behavior. Therefore, we can conclude that self-efficacy is a crucial concept in behavioral change and in order for health promoters to make an appeal effective, eliciting efficacy expectations is something that should be strived for.
Simply put, behavioral change is partly determined by how effective a person believes he/she can be in executing the behavior.Expectations of self-efficacy can influence both
initiation and persistence of the coping behavior (Bandura, 1977). Several studies suggest that a person’s perceived self-efficacy in dealing with a threat plays an important role in determining one’s response to an appeal (e.g., LaTour & Rotfield, 1997; Ruiter et al., 2001; Snipes et al., 1999).
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2.3 Disgust and self-efficacy theory
We can conclude from Section 2.2 that if a person believes in his or her ability to perform a behavior and knows what the consequences are, he or she will be more likely to adopt the behavior. This theory can actually be linked to the principle definitions of the emotions of fear and disgust and describe how these may influence behavioral change. Putting the concepts discussed above together, the theory of self-efficacy could explain why adding a disgust-eliciting element increases the effectiveness of fear appeals as argued by Morales et al. (2012). As we know, a disgusted person is convinced what the problem is, knows how to handle it, and is confident in his/her ability to do so (Smith & Ellsworth, 1985). Thus, disgust provides one clear path on how to act, likely resulting in a feeling of certainty; disgust will leave an individual with no other option than to avoid. This would lead to a higher level of perceived self-efficacy as the person knows exactly what to do and is thus convinced of his/her ability to do so. This is in stark contrast to fear, as this elicits a state of uncertainty (Smith & Ellsworth, 1985). On these grounds, the following hypotheses can be proposed:
H1: A disgust appeal leads to an increased feeling of self-efficacy compared to a fear appeal, thereby leading to behavioral change.
H2: The relationship between a disgust appeal and level of perceived self-efficacy is mediated by a feeling of certainty.
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which a behavior can be tainted and be made immoral (Wisneski & Skitska, 2017). For example, once a person is confronted with disgusting images of how smoking near children can influence them, this could lead to an increase in moral awareness that smoking is bad and immoral due to the effect it can have on others in his/her environment. As engaging in immoral behavior is bad, one should strive for stopping that particular behavior, in this case, health-damaging behaviors. If one does not cohere to attitudes one has towards a behavior and acts exactly in the opposite direction of the attitude, cognitive dissonance will occur (Festinger, 1957). This refers to the state of discomfort felt once one is not consistent in attitudes, beliefs or behaviors which will lead to alteration in one of these to reduce the discomfort and restore the balance (Festinger, 1957). Thus, if disgust leads to a belief that a behavior is immoral, one will likely start acting more morally responsible. Realizing that a behavior is immoral will set the behavior in a negative light and one will start thinking about all the negative outcomes of performing the behavior, such as drinking alcohol. The emphasis on these negative consequences of the behavior may lead to intentions to quit the immoral (health-damaging) behavior. This is a straight-forward outcome as the outcome expectancies of the behavior will be evaluated as more negative than positive, which will in turn lead to a change in behavior.
On the other hand, fear elicits an uncertain feeling and might evoke many different outcomes and reactions (Smith & Ellsworth, 1985); therefore, it is hard for one to judge what the positive and negative outcomes of a behavior exactly are and will in turn not lead to behavioral change due to this state of uncertainty. Put together, this leads to the following hypothesis:
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2.4 Conceptual model
Based on the aforementioned hypotheses, two conceptual models can be formed. The first one, regarding H1 and H2, is a sequential mediation model and can be seen in Figure 2. H3 is included in a mediation model in Figure 3.
Figure 2: Conceptual model: H1 and H2.
Figure 3: Conceptual model: H3.
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3. Methodology
Participants (N = 135, MAge = 28.76, SDAge = 13.07, 67.4% female) were invited to participate in
the study, which was introduced by explaining that due to the COVID-19 pandemic, alcohol intake worldwide has increased and that governments are looking for ways to combat this undesirable behavior. The participants were asked to visualize that they had indeed increased their alcohol consumption. Afterwards, a warning label was shown, aimed at eliciting either fear (n = 63) or disgust (n = 72), which can be seen in Figure 4 and 5.
Figure 4: Fear appeal. Figure 5: Disgust appeal.
First of all, two statements were proposed to measure certainty: (1) ‘After seeing the warning label, I am certain what I would have to do.’ (M = 2.83, SD = 1.18), (2) ‘After seeing the warning label, I know what my next steps should be.’ (M = 2.83, SD = 1.18). The
respondent’s answers were measured on a 5-point Likert scale, from (1) Strongly disagree to (5) Strongly agree. The two statements were averaged into one as the measure of internal
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Furthermore, the level of perceived self-efficacy was measured on a 5-point Likert scale based on the Brief Situational Confidence Questionnaire (BSCQ) developed by Sobell et al. (1996). Different situations were stated for which people had to indicate whether they would be able to resist the urge to drink heavily after seeing the warning label: when experiencing
unpleasant emotions, physical discomfort, pleasant emotions, conflict with others, social pressure to use, and pleasant times with others. Two situations, testing control over one’s alcohol use, and urges and temptations, were left out in the survey because these are primarily relevant to people struggling with a longtime addiction (Breslin et al., 2000). The statements were combined into one variable (∝ = 0.76, M = 3.43, SD = 0.88).
Additionally, the dependent variable behavioral change was measured on a 5-point Likert scale in terms of intentions to change. The three items used to test this variable were based on measurements of the Theory of Planned Behavior by Fishbein and Ajzen (2010): (1) ’After seeing this advertisement, I intend to drink less alcohol.’ (M = 3.10, SD = 1.24), (2) ’After seeing this advertisement, I plan to drink less alcohol.’ (M = 3.03, SD = 1.30), (3) ’After seeing this advertisement, I want to drink less alcohol.’ (M = 3.20, SD = 1.28). One variable was created to measure intentions to change (∝= 0.89, M = 3.11, SD = 1.15).
Moreover, items constructing outcome expectancies were based on the Alcohol Outcome Expectancies Scale (AOES) developed by Leigh and Stacy (1993). It lists both positive (social facilitation, fun, sex, tension reduction) and negative (social, emotional, physical,
cognitive/performance) outcomes of drinking alcohol. As the AOES is a relatively long
questionnaire, and to maintain the concentration of the participants, a total of five items was left out. These items were related to sex and driving, which might not be applicable to each
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negative expectancies are associated with less drinking. The respondent’s answers were measured on a 6-point scale how likely an outcome is to happen: 1 (no chance) to 6 (certain to happen). As Leigh and Stacey (1991) indicate that the different scales of this questionnaire are not independent and act as joint predictors of alcohol use, the positive outcome expectancy statements (e.g., when I drink alcohol I feel happy, I enjoy the buzz) were reversed as scales so that 1 (certain to happen) and 6 (no chance). Afterwards, both positive and negative statements were combined into one variable for negative outcome expectancies since ∝ = 0.79 (M = 2.99,
SD = 0.66).
Another item that was measured is morality, which can be seen as a manipulation check in order to test the literature that disgust indeed influences moral conviction, which would lead to behavioral change. This variable was constructed in the following statement: ’I would feel bad about myself if I would drink heavily.’, measured on a 5-point Likert scale (M = 3.66, SD = 1.26).
To test whether the respondent actually perceived the appeal to be respectively fear-eliciting or disgusting, a manipulation check took place. In order to not give away to the respondent which reactions were aimed at, a total of 20 statements, representing 5 different emotions, were measured based on the Discrete Emotions Questionnaire (Harmon-Jones et al., 2016): disgust, fear, happiness, sadness and anger. The respondent had to indicate to what extent he/she experienced the statement on a scale of 1 (not at all) to 7 (an extreme amount). As an internal consistency analysis of these statements showed ∝ = 0.51 for fear and ∝ = 0.71 for disgust, only disgust was combined into one variable (M = 4.65, SD = 1.58).
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4. Results
In order to be able to test the hypotheses, a dummy variable was created for the two conditions. Afterwards, a manipulation check was conducted to see if the expected emotions were elicited in the two conditions. It turned out that, in stark contrast to our expectations, people in the fear condition (M = 5.31, SD = 0.20) reported higher levels of disgust than people in the disgust condition (M = 4.07, SD = 0.15; F(1,133) = 4.962, p = 0.001). Therefore, we have to differentiate between disgust and the disgust condition.
A serial mediation analysis was conducted to test whether self-efficacy is a mediator in the relationship between disgust and behavioral change (H1), and if certainty plays a mediating role in the relationship between disgust and self-efficacy (H2). The following can be concluded based on Model 6 in the SPSS function PROCESS, with a 95% confidence interval and a bootstrap sample of 10,000.
The disgust manipulation decreased the amount of certainty a person experienced (𝛽 = -0.439, t = -2.361, p = 0.020), whereas the fear manipulation (eliciting disgust) increased the amount of certainty a person experienced (𝛽 = 0.439, t = 2.361, p = 0.020). However, neither the disgust condition (𝛽 = 0.109, t = 0.701, p = 0.485) nor certainty (𝛽 = -0.094, t = -1.311, p = 0.192), influenced the perceived level of self-efficacy. Disgust, elicited in the fear condition, also did not influence the perceived level of self-efficacy (𝛽 = -0.109, t = -0.701, p = 0.485). The level of perceived self-efficacy had an insignificant effect on behavioral change (𝛽 = 0.200, t = 1.859, p = 0.065).
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experienced a feeling of certainty in what to do, they actually intended to change less. We can conclude that people in the fear condition, who experienced more disgust, were less likely to change their behavior (𝛽 = -0.415, t = -2.143, p = 0.034); as mentioned previously, these people experienced more certainty in what to do, which in turn had a negative effect on behavioral change (𝛽 = -0.197, t = -2.210, p = 0.029). Therefore, we can conclude that disgust leads to fewer intentions to change due to the concept of certainty.
Overall, we can conclude that the first two hypotheses can be rejected (See Figure 6 for the results of the fear condition, eliciting disgust). Self-efficacy does not play a mediating role between disgust and behavioral change, and disgust does not influence self-efficacy through the concept of certainty.
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The following can be concluded after conducting a mediation analysis for the effect of negative outcome expectancies on the relationship between disgust and behavioral change, conducted in Model 4 in SPSS PROCESS, with a 95% confidence interval and a bootstrap sample of 10,000. First, a second manipulation check was performed to test whether disgust influences moral conviction, which was part of the argumentation for H3. An independent samples t-test showed that this is indeed the case, t(133) = -2.302, p = 0.023; people in the fear condition (eliciting disgust) would feel worse about themselves if they would drink heavily after seeing the warning label (M = 3.40, SD = 1.41) than people in the condition that experienced less disgust (M = 3.40, SD = 1.07).
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Figure 6: Results H1 + H2.
Figure 7: Results complementary mediation analysis.
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5. Discussion
Contrary to our expectations, none of the hypotheses could be supported. First of all, the
manipulation check showed that the fear condition led to more disgust than the disgust condition, which was a completely unexpected result and difficult to justify. This failed manipulation check results in the fact that the conclusions drawn from the study are also a bit more complicated to understand than initially anticipated. As the pictures clearly did not lead to the desired emotions, it could be that the same research with different pictures would have resulted in different
outcomes. What could have been done differently to prevent this, is conducting a pilot
manipulation check on a small sample, in which only questions related to emotions elicited by the two different warning labels were discussed. By doing this beforehand, the researcher will have certainty about whether the manipulation does what it is expected to do. It could also be that these results are partly due to the sample, for example that the respondents were actually so disgusted by the disgust condition that they immediately skipped to the next page and failed to answer the questions to the manipulation check adequately. However, we can say that the manipulation worked, as the emotion of disgust was elicited, just not in the way we expected it to. Therefore, there are still some interesting conclusions that can be drawn from the conducted study.
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result. Psychological reactance can be described as a motivational state that provokes individuals to seek to restore their threatened or lost freedom (Brehm, 1966), which can be experienced as a result of a persuasive-based communication such as warning labels used in this study. It is a commonly used framework for understanding people’s resistance to persuasive health messages (Reynolds-Tylus, 2019). Even though public health campaigns are often effective in changing people’s behavior (Anker et al., 2016), it can be the case that the message results in the audience adopting behavior opposite of the advocated action (Byrne & Hart, 2009). It is possible that the audience understands the message the ad is trying to convey, whereas at the same time, they might perceive it as eliminating their free choice (Reynolds-Tylus, 2019).
A possible limitation of the study is that the sketched COVID-19 situation at the beginning of the survey could have actually contributed to this feeling of psychological
reactance. People are probably well aware if they have increased their alcohol intake but might actually feel good about this because it makes them forget about the miserable situation that we are in. After reading the situation and seeing the warning label, they might experience a threat to their self-image and become insecure. In order to protect themselves from these negative
feelings, they do not intend to change. Thus, after seeing the warning label that elicited most disgust, psychological reactance might have led to fewer intentions to change behavior, as reactance can result in decreased intentions towards the advocated behavior (Rains & Turner, 2007).
Another reason for the negative impact of disgust on behavioral change could be the respondent’s questioning of causality, as drinking too much alcohol over a long period is mostly well known to lead to for example liver diseases (World Health Organization, 2014).
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drink alcohol and do not have mouth cancer or rotten teeth or know anyone who has this due to alcohol, after which they responded to the statements accordingly in terms of intentions to change. As a person’s perceived susceptibility to the threat is an important factor in determining an appeal’s effectiveness (De Hoog et al., 2007), different results could be expected for a
message that achieves a high level of perceived susceptibility. Therefore, the exact message used in this study’s warning labels could be seen as a possible limitation since it might fail to lead to a feeling of susceptibility as causality can be questioned.
Besides the outcome that disgust does not influence behavioral change, the mediating role of self-efficacy has also not been proven. There is research indicating that persuasive messages that let the target audience know that they can perform the recommended behavior are more effective than messages that do not (Tannenbaum et al., 2015) and that appeals should contain messages stimulating efficacy in order to be effective (Witte & Allen, 2000). These results indicate that perceived self-efficacy plays an important role in behavioral change, a finding that this study does not support. It could therefore be that it would be more effective to actually include an efficacy message in the appeal as these studies indicate, instead of assuming that disgust in itself would trigger more feelings of self-efficacy as hypothesized in this study. However, since disgust would result in the feeling that a person is confident in his/her ability to execute the (avoidance) behavior as argued by Smith and Ellsworth (1985), the relationship between disgust and self-efficacy might be an interesting direction to pay attention to in future research as the present study was the first one to investigate this according to the author’s knowledge.
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people experience more certainty in what to do and what their next steps should be, which is in line with the definition of disgust as an emotion (Smith & Ellsworth, 1985). As a next step, certainty leads to fewer intentions of behavioral change. This is a counterintuitive finding as one would expect that if one knows what to do, one will start acting like it. Due to the fact that this is not the case, this outcome could also be ascribed to psychological reactance. A person knows how to act and what his/her next steps should be because this sense of certainty is triggered by the disgusting image; however, the person does not intend to change his/her behavior. It could be that the recipient is indeed disgusted by the image and knows he/she should stop drinking
alcohol and how he/she could do that, but that the individual feels hindered in his/her freedom or choice and therefore does not follow to the recommended action (Reynolds-Tyler, 2019). Again, questioning causality of the message could also be a reason for the result that certainty leads to less behavioral change. A respondent might know that drinking alcohol is bad for the body and how she/he could lessen alcohol intake, but if he/she does not perceive mouth cancer and rotten teeth as a consequence of drinking alcohol, the person might ask him/herself whether he/she should really drink less.
Moreover, outcome expectancies also do not play a mediating role in the relationship between disgust and behavioral intentions to change. Disgust does not affect the perception of negative outcomes after performing the behavior and one is also not likely to change after considering these negative outcomes. This is in stark contrast with theory that states that
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Klingemann, 2001). Frequently drinking large quantities of alcohol is especially a common issue under young people and young adults (aged 18-35), who mainly associate drinking with a state of well-being, joy, fun and freedom, and who perceive getting drunk as a fashion and a source of pride (Fauci et al., 2019). The mean age of the study’s respondents was relatively low (28.76 years old) as numerous students participated, who might therefore not think about outcomes of their behavior too much, especially negative ones. Sampling was mainly done through the researcher’s own network which led to this relatively young-aged sample; for future research, in order to be able to generalize results, it would be an idea to conduct a study that targets more layers of the population. Additionally, it might be an interesting idea to test this hypothesis with other health-damaging behaviors that are not as socially acceptable as drinking alcohol, such as drug use. It could be that this results in people placing more emphasis on negative outcomes after seeing a disgusting image.
Furthermore, another reason for the rejected hypotheses could be the fact that the warning label was only shown one time to the respondents due to time constraints for this study, whereas research indicates that repeated exposure to an appeal will increase the respondent’s perceived susceptibility to the threat (Shi & Smith, 2016). A longitudinal study might be an interesting direction for future research to discover whether disgust has an increased effect on (intentions to) change when an individual is exposed multiple times to the appeal and whether certainty and self-efficacy theory play a role in this.
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behavioral change for one-time behaviors. Current research focuses mainly on repeated
behaviors (Tannenbaum et al., 2015), as was the case in this study with drinking alcohol heavily. Our aim was to reveal the process of how disgust can be seen as a persuasion-enhancing element in behavioral change. However, even though this current study has not provided clear insights into how this process exactly takes place, it has brought up some interesting findings that might be helpful for future research. With health and wellbeing becoming increasingly important in today’s society, it is crucial to increase understanding of how persuasive health
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6. References
Anker, A. E., Feeley, T. H., McCracken, B., & Lagoe, C. A. (2016). Measuring the effectiveness of mass-mediated health campaigns through meta-analysis. Journal of Health Communication,
21(4), 439–456. https://doi.org/10.1080/10810730.2015.1095820
Anthenien, A. M., Lembo, J., & Neighbors, C. (2017). Drinking motives and alcohol outcome expectancies as mediators of the association between negative urgency and alcohol consumption.
Addictive Behaviors, 66, 101–107. https://doi.org/10.1016/j.addbeh.2016.11.009
Apostolidis, C., & McLeay, F. (2016). Should we stop meating like this? Reducing meat consumption through substitution. Food Policy, 65(C), 74-89.
https://doi.org/10.1016/j.foodpol.2016.11.002
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change.
Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
Block, L. G., & Williams, P. (2002). Undoing the effects of seizing and freezing: Decreasing defensive processing of personally relevant messages. Journal of Applied Social Psychology,
32(4), 803-830. http://dx.doi.org/10.1111/j.1559-1816.2002.tb00243.x
Brehm, J. W. (1966). A Theory of Psychological Reactance. Academic Press.
Breslin, F. C., Sobell, L. C., Sobell, M. B., & Agrawal, S. (2000). A comparison of a brief and
long version of the Situational Confidence Questionnaire. Behaviour Research and Therapy,
38(12), 1211–1220. https://doi.org/10.1016/s0005-7967(99)00152-7
Byrne, S. & Hart, P. S. (2009). The boomerang effect: A synthesis of findings and a preliminary theoretical framework. Annals of the International Communication Association, 33(1), 3-37. https://doi.org/10.1080/23808985.2009.11679083
Carels, R. A., Darby, L. A., Rydin, S., Douglass, O. M., Cacciapaglia, H. M., & O'Brien, W. H. (2005). The relationship between self-monitoring, outcome expectancies, difficulties with eating and exercise, and physical activity and weight loss treatment outcomes. Annals of Behavioral
Medicine: A Publication of the Society of Behavioral Medicine, 30(3), 182–190.
26
Chin, J. H., & Mansori, S. (2018). Social marketing and public health: A literature review.
Journal of Marketing Management and Consumer Behavior, 2(2), 48-66.
Davey, G. C. L. (1994). Disgust. In V. S. Ramachandran (Ed.), Encyclopedia of human behavior (Vol. 2, pp. 135-143). Academic Press.
Doeken, H., & Geurts, D. (2005). The influence of exemplars in fear appeals on the perception of self-efficacy and message acceptance. Information Design Journal + Document Design, 13(3), 238-248. https://doi.org/10.1075/idjdd.13.3.09hoe
La Fauci, V., Squeri, R., Spataro, P., Genovese, C., Laudani, N., & Alessi, V. (2019). Young people, young adults and binge drinking. Journal of Preventive Medicine and Hygiene, 60(4), E376–E385. https://doi.org/10.15167/2421-4248/jpmh2019.60.4.1309
Feather, N. T. (1982). Expectations and actions: Expectancy-value models in psychology. Lawrence Erlbaum.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press.
Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action
approach. Psychology Press.
Grecucci, A., Giorgetta, C., Van 't Wout, M., Bonini, N., & Sanfey, A. G. (2013). Reappraising the ultimatum: An fMRI study of emotion regulation and decision making. Cerebral Cortex,
23(2), 399–410. https://doi.org/10.1093/cercor/bhs028
Harmon-Jones, C., Bastian, B., & Harmon-Jones, E. (2016). The Discrete Emotions
Questionnaire: A new tool for measuring state self-reported emotions. Public Library of Science
ONE, 11(8), Article e0159915. https://doi.org/10.1371/journal.pone.0159915
de Hoog, N., Stroebe, W., & de Wit, J. B. F. (2007). The impact of vulnerability to and severity of a health risk on processing and acceptance of fear-arousing communications: A
meta-analysis. Review of General Psychology, 11(3), 258–285. https://doi.org/10.1037/1089-2680.11.3.258
27
Jónsdóttir, H. L., Holm, J., Poltavski, D., & Vogeltanz-Holm, N. (2014). The role of fear and disgust in predicting the effectiveness of television advertisements that graphically depict the health harms of smoking. Preventing Chronic Disease, 11(12): E218.
https://doi.org/10.5888/pcd11.140326
Keller, P. A., & Block, L. G. (1996). Increasing the persuasiveness of fear appeals: The effect of arousal and elaboration. Journal of Consumer Research, 22(4), 448-459.
https://doi.org/10.1086/209461
Klingemann, H. (2001). Alcohol and its social consequences - The forgotten dimension. World Health Organization Regional Office for Europe.
https://apps.who.int/iris/bitstream/handle/10665/108554/E76235.pdf?sequence=1&isAllowe d=y
Lang, P. J., Bradley, M. M., & Cuthbert, B. N. (1997). Motivated attention: Affect, activation, and action. In P. J. Lang, R. F. Simons, & M. T. Balaban (Eds.), Attention and orienting: Sensory
and motivational processes (pp. 97-135). Lawrence Erlbaum Associates.
LaTour, M. S., & Rotfeld, H. J. (1997). There are threats and (maybe) fear-caused arousal: Theory and confusions of appeals to fear and fear arousal itself. Journal of Advertising, 26(3), 45–59. https://doi.org/10.1080/00913367.1997.10673528
Lazarus, R. (1991). Emotion and adaptation. Oxford University Press.
Leigh, B. C., & Stacy, A. W. (1991). On the scope of alcohol expectancy research: Remaining issues of measurement and meaning. Psychological Bulletin, 110(1), 147–154.
https://doi.org/10.1037/0033-2909.110.1.147
Leigh, B. C., & Stacy, A. W. (1993). Alcohol outcome expectancies: Scale construction and predictive utility in higher order confirmatory models. Psychological Assessment, 5(2), 216–229. https://doi.org/10.1037/1040-3590.5.2.216
Lerner, J. S., Li, Y., Valdesolo, P., & Kassam, K. S. (2015). Emotion and decision making.
Annual Review of Psychology, 66, 799–823.
https://doi.org/10.1146/annurev-psych-010213-115043
Leshner, G., Bolls, P., & Wise, K. (2011). Motivated processing of fear appeal and disgust images in televised anti-tobacco ads. Journal of Media Psychology: Theories, Methods, and
28
Lupton, D. (2015). The pedagogy of disgust: The ethical, moral and political implications of using disgust in public health campaigns. Critical Public Health, 25(1), 4-14.
https://doi.org/10.1080/09581596.2014.885115
McAuley, E., Jerome, G. J., Elavsky, S., Marquez, D. X., & Ramsey, S. N. (2003). Predicting long-term maintenance of physical activity in older adults. Preventive Medicine, 37(2), 110–118. https://doi.org/10.1016/s0091-7435(03)00089-6
Morales, A. C., Wu, E. C., & Fitzsimons, G. J. (2012). How disgust enhances the effectiveness of fear appeals. Journal of Marketing Research, 49(3), 383-393.
https://doi.org/10.1509/jmr.07.0364
National Center for Chronic Disease Prevention and Health Promotion. (2020a, October 15). Tips from former smokers: About the campaign. Retrieved December 30, 2020, from
https://www.cdc.gov/tobacco/campaign/tips/about/index.html
National Center for Chronic Disease Prevention and Health Promotion. (2020b, November 2). Media Campaigns. Retrieved November 28, 2020, from
https://www.cdc.gov/chronicdisease/programs-impact/campaigns/index.htm
Newhagen, J. E. (1998). Approach-avoidance and memory for images of anger, fear, and disgust on television news. Journal of Broadcast and Electronic Media, 42(2), 265–276.
https://doi.org/10.1080/08838159809364448
Nikčević, A. V., Alma, L., Marino, C., Kolubinski, D., Yılmaz-Samancı, A. E., Caselli, G., & Spada, M. M. (2017). Modelling the contribution of negative affect, outcome expectancies and metacognitions to cigarette use and nicotine dependence. Addictive Behaviors, 74, 82–89. https://doi.org/10.1016/j.addbeh.2017.06.002
Pierce, J. P., White, V. M., & Emery, S. L. (2012). What public health strategies are needed to reduce smoking initiation? Tobacco Control, 21(2), 258-264.
http://dx.doi.org/10.1136/tobaccocontrol-2011-050359
Porzig-Drummond, R., Stevenson, R., Case, T., & Oaten, M. (2009). Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests. Social Science &
Medicine, 68(6), 1006-1012. https://doi.org/10.1016/j.socscimed.2009.01.013
Rains, S. A., & Turner, M. M. (2007). Psychological reactance and persuasive health communication: A test and extension of the intertwined model. Human Communication
29
Reesor, L., Vaughan, E. M., Hernandez, D. C., & Johnston, C. A. (2017). Addressing outcomes expectancies in behavior change. American Journal of Lifestyle Medicine, 11(6), 430–432. https://doi.org/10.1177/1559827617722504
Reynolds-Tylus, T. (2019). Psychological reactance and persuasive health communication: A review of the literature. Frontiers in Communication, 4(56).
https://doi.org/10.3389/fcomm.2019.00056
Rogers, R. W. (1983). Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In J.T. Cacioppo & R.E. Petty (Eds.), Social
psychophysiology: A sourcebook (pp. 153-176). Guilford Press.
Rosen, J. B., & Schulkin, J. (1998). From normal fear to pathological anxiety. Psychological
Review, 105(2), 325–350. https://doi.org/10.1037/0033-295X.105.2.325
Rozin, P., & Fallon, A. E. (1987). A perspective on disgust. Psychological Review, 94(1), 23–41. https://doi.org/10.1037/0033-295X.94.1.23
Rozin, P., Haidt, J., & McCauley, C. R. (1993). Disgust. In M. Lewis & J. Haviland (Eds.),
Handbook of emotions. Guilford Press.
Ruiter, R. A. C., Abraham, C., & Kok, G. J. (2001). Scary warnings and rational precautions: A review of the psychology of fear appeals. Psychology & Health, 16(6), 613-630.
https://doi.org/10.1080/08870440108405863
Ruiter, R. A. C., Kessels, L. T., Peters, G. J., & Kok, G. J. (2014). Sixty years of fear appeal research: Current state of the evidence. International Journal of Psychology, 49(2), 63–70. https://doi.org/10.1002/ijop.12042
Saksvig, B. I., Gittelsohn, J., Harris, S. B., Hanley, A. J., Valente, T. W., & Zinman, B. (2005). A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children. The Journal of Nutrition, 135(10), 2392–2398. https://doi.org/10.1093/jn/135.10.2392
Shi, J. J., & Smith, S. W. (2016). The effects of fear appeal message repetition on perceived threat, perceived efficacy, and behavioral intention in the extended parallel process model.
Health Communication, 31(3), 275–286. https://doi.org/10.1080/10410236.2014.948145
Smith, C. A., & Elsworth, P. C. (1985). Patterns of cognitive appraisal in emotion. Journal of
30
Snipes, R., LaTour, M., & Bliss, S. (1999). A model of the effects of self-efficacy on the perceived ethicality and performance of fear appeals in advertising. Journal of Business Ethics,
19(3), 273-285. https://doi.org/10.1023/A:1005822414588
Sobell, L. C., Cunningham, J. A., Sobell, M. B., Agrawal, S., Gavin, D. R., Leo, G. I., & Singh, K. N. (1996). Fostering self-change among problem drinkers: A proactive community
intervention. Addictive Behaviors, 21(6), 817–833. https://doi.org/10.1016/0306-4603(96)00039-1
Stainback, R. D., & Rogers, R. W. (1983). Identifying effective components of alcohol abuse prevention programs: Effects of fear appeals, message style, and source expertise. The
International Journal of the Addictions, 18(3), 393–405.
https://doi.org/10.3109/10826088309039356
Tannenbaum, M. B., Hepler, J., Zimmerman, R. S., Saul, L., Jacobs, S., Wilson, K., & Albarracin, D. (2015). Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological Bulletin, 141(6), 1178-1204. https://doi.org/10.1037/a0039729
Van Duyn, M. A., Kristal, A. R., Dodd, K., Campbell, M. K., Subar, A. F., Stables, G., Nebeling, L., & Glanz, K. (2001). Association of awareness, intrapersonal and interpersonal factors, and stage of dietary change with fruit and vegetable consumption: A national survey. American
Journal of Health Promotion, 16(2), 69–78. https://doi.org/10.4278/0890-1171-16.2.69
Williams, D. M., Anderson, E. S., & Winett, R. A. (2005). A review of the outcome expectancy construct in physical activity research. Annals of Behavioral Medicine: A Publication of the
Society of Behavioral Medicine, 29(1), 70–79. https://doi.org/10.1207/s15324796abm2901_10
Wisneski, D. C., & Skitka, L. J. (2017). Moralization through moral shock: Exploring emotional antecedents to moral conviction. Personality & Social Psychology Bulletin, 43(2), 139–150.
https://doi.org/10.1177/0146167216676479
Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model.
Communications Monographs, 59(4), 329–49. https://doi.org/10.1080/03637759209376276
Witte, K. (1994). Fear control and danger control: A test of the Extended Parallel Process Model (EPPM). Communication Monographs, 61(2), 113-134.
31
Witte, K., & Allen, M. (2000). A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Education & Behavior: The Official Publication of the Society for
Public Health Education, 27(5), 591-615. https://doi.org/10.1177/109019810002700506
Woody, S. R., & Teachman, B. A. (2000). Intersection of fear and disgust: Normative and pathological views. Clinical Psychology: Science and Practice, 7(3), 291–311.
https://doi.org/10.1093/clipsy/7.3.291
World Health Organization. (2014). Global status report on alcohol and health.
https://apps.who.int/iris/bitstream/handle/10665/112736/9789240692763_eng.pdf;jsessionid =EEFA1BEFABB665D290349718E3C76924?sequence=1
World Health Organization. (2019, July 10). 10 areas governments could work with to reduce
the harmful use of alcohol. Retrieved November 28, 2020, from
