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Paradoxical Effects of Fear on Health Behavior

There's a 1999 article titled "converting the unconverted" by psychologist Punam Keller, which demonstrates that health behavior change strategies based on fear don't work. For instance, someone with high blood pressure who is told about the risk of heart disease is actually less likely to take their medication the more strongly the potential health risks of untreated hypertension are emphasized. This is because fear creates cognitive dissonance, which naturally motivates people to resolve the perceived conflict between facts and behavior. The easiest way to do that is often to mentally discount the facts. The more a new fact provokes fear, the stronger the motivation someone will have to ignore it.

An example of bad public health policy based on fear involves putting horrible pictures on cigarette packs. This strategy is used in many countries around the world, and involves photos of diseased lungs, blackened teeth, tracheotomy tubes, etc. to emphasize the health risks of smoking. The U.S. Congress last proposed putting this type of picture on U.S. cigarette packs in 2009, but the move was blocked by tobacco companies on First-Amendment grounds. A new effort to use similar packaging started in 2019. Tobacco companies around the world have tried to prevent disturbing images from being required, because such labeling does in fact raise smokers' awareness and concern about the negative health consequences of smoking, gives them negative views of cigarettes, and even increases their intention to quit smoking. Unfortunately, there is much weaker evidence that graphic labels reduce people's actual cigarette-purchasing behavior or number of cigarettes smoked, with weaker effects the more strongly addicted to nicotine a smoker is. Even in some studies that suggest an effect the percentage of quit attempts is quite small, in the 3-5% range. The one bright spot is for occasional smokers or adolescents who haven't yet started smoking regularly; in these lower-risk groups, there is good evidence that graphic warnings reduce the chance of a person developing a more serious smoking habit. But for the serious smoker they provoke defensiveness, and might even make them feel like they need a smoke.

This is a clear intention-behavior gap of the type predicted by Two Minds Theory: Graphic warnings affect the Narrative mind and make smokers more attuned to smoking's health risks, but they have much weaker effects on the Intuitive mind that affect the person's actual behavior. One might think that fear, as an emotion, would be more likely than strictly factual information to reach the Intuitive level of thinking where behavior originates. The problem is that people have well-developed mental defenses that prevent them from taking fear-provoking information seriously. They find ways not to attend to the frightening information in the first place, which prevents it from being assimilated into the Intuitive production of behavior.

Another example of fear's paradoxical effect comes from a clever 1991 study by psychologists Robert Croyle and Julie Hunt. The investigators drew some blood from their participants and took it into a back room for an "enzyme test." The scare quotes are because no test was actually performed -- instead, the investigators flipped a coin to determine whether the participant had a "positive" or "negative" enzyme test result. Regardless of that outcome, the investigators gave the participant some standard information about the supposed enzyme deficiency, which they said would predispose people to long-term pancreatic health risks. For the outcome variable, the investigators asked participants how important it was to educate the general public about the purported enzyme deficiency. So what happened? Contrary to what you might think, people who were told that they themselves had long-term health risks from the enzyme deficiency said that it was less important to tell other people about the problem! The reason for this is likely because people who were told they had the problem were more afraid, and were therefore more strongly motivated to ignore or minimize the information. They might have reasoned, for instance, that because they had never heard of this problem before it couldn't be very serious. The people who were not personally at risk were better able to objectively weigh the risks and benefits.

These examples came to mind recently during a conversation with my wife about how to promote routine COVID surveillance testing among schoolchildren. This public health approach is designed to catch asymptomatic cases and to prevent outbreaks in schools from happening, but it relies on getting children who don't have current symptoms to get regular tests as part of a normal routine. This is not how we usually approach health-related tests, and it's complicated by the fact that COVID tests were initially seen as scary and painful, and that a positive COVID test result has been associated with blame or stigma from other people. Even though the data suggest benefits of routine COVID testing, there are clear reasons why someone would not want to get a test. Providing positive information about the public health benefits of surveillance testing is therefore likely to have little effect on behavior. Even though COVID tests have become more convenient and much less likely to cause pain, most people's original information about them came from horror stories that were widely publicized in 2020. People who had to get a COVID test themselves, either to travel or because of symptoms, have had alternate experiences since then and might be less concerned about testing. But children who stayed at home during the pandemic might never have had a COVID test, and their parents might still have a very high level of emotionally tinged concern about what the experience will be like. A fact-based FAQ about routine testing is not likely to have any effect because people's defenses are already primed to reject any new information in this area.

The strategy that we decided on was to circumvent people's prior expectations by interviewing children themselves about their COVID-19 testing experiences. (Yes, a couple of them were planted in the audience from our own household!) This had two benefits: First, it allowed for the presentation of factual information in a social context, which is more appealing to the Intuitive mind than a fact-based presentation. Second, it drew people in by asking "what is a COVID test really like for kids?" and let them draw their own conclusions. People are more convinced by narratives that they create for themselves. The article includes factual risk-benefit information and how-to instructions at the end, after the more engaging back-and-forth questions with the kids at the beginning. You can read the article here and judge its effectiveness for yourself.

More indirect and case-based communication strategies are consistent with Two Minds Theory, and are intended to get past the intention-behavior gap. But they are also nothing new. The National Cancer Institute has a "Pink Book" that summarizes effective principles and strategies for public health behavior change campaigns. The CDC similarly has guidance on how to communicate effectively during a public health crisis. Unfortunately, public health agencies have not followed their own advice during the pandemic, frequently presenting the public with heavily fact-based information in a way that is not well-timed or consistent across Federal authorities. Those features make the information especially easy to discount, especially for people who are more at risk and are therefore subconsciously motivated to avoid the fear that might result from taking the message seriously.

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