Prediction and Intervention in Health-Related Behavior: A Meta-Analytic Review of Protection Motivation Theory
Lniversi/y of Barli Bath, United Kit~gdum
P A S C H A L SHEERAN A N D S H E l N A O R B E L L LniverJity of She/fkld Sheffield Lnrted hingdom
Protection motivation theory (PMT) was introduced by Rogers i n 1975 and has since been widely adopted as a framework for the prediction of and intervention in health-related behavior. However. PMT remains the only major cognitive model of behavior not to ha\ K been the subject o f a meta-analytic review. A quantitative revieh o f P M T i s important to assess its overall utility as a predictive model and to establish which o f its variables would be most useful to address health-education interventions. The present paper provides a comprehensive introduction to PMT and its application to health-related behavior, together with a quantitative review o f the applications of P M T to health-related intentions and behavior. The associations beween threat- and coping-appraisal variables and intentions, and all components o f the model and behavior were assessed both by meta-analysis and by vote-count procedures. Threat- and coping-appraisal components of PMT were found to be useful in the prediction of health-related intentions. The model was found to be useful in predicting concurrent behavior, but o f less utility in predicting future beha\ior. The coping-appraisal component of the model was found to have greater predicti\ e validity than was the threat-appraisal component. The main findings are discussed in relation to theory and research on social cognition models. The importance ot'the main findings to health education is also discussed, and future research directions are suggested.
Protection motivation theory (PMT; Rogers, 1975, 1983) provides an important social cognitive account of protective behavior. Rogers first introduced the theory in 1975. Since then. there have been many studies applying the model to predict and understand protective behavior, particularly health-related behavior. Other social cognition models have also been applied to the understanding and prediction of health behavior, including the health belief model (Becker, 1974; Rosenstock, 1966), the theory of reasoned action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), and the theory of planned behavior (Ajzen, 1988, 1991).
'Correspondence concerning this article should be addressed to Sarah Milne, Department o t Psychology. University o f Rath, Claverton Down, Bath B A 2 7AY, United Kingdom. c-mail: s.e.miIne@!bath.ac.uk.
Journal ofApplied Social Psychology, 2000,30, 1 pp. 106-143. Copyright 0 2000 by V. H. Winston & Son, Inc. All rights reserved.
PROTECTION MOTIVATION THEORY
It is important to assess the utility of these models in the prediction and understanding of health-related behavior in order to establish which components to use as targets for health-education interventions. One way of doing this is to conduct a meta-analysis, in which the results of all the studies testing a model are combined in an overall assessment of the model’s performance. Although PMT has been the subject of recent literature reviews (Boer & Seydel, 1996; Rogers & Prentice-Dunn, 1997), it remains the only model not to have been the subject of a meta-analytic review. Meta-analytic reviews have been conducted for all of the other social cognition models commonly used in the prediction of health-related behavior, including the health belief model (Harrison, Mullen, & Green, 1992). the theory of reasoned action (Sheppard, Hartwick, & Warshaw, 1988), and the theory of planned behavior (Armitage & Conner, 1996; Godin & Kok, 1996). The aim of the present paper is to combine the results of studies testing PMT in a meta-analysis to provide a quantitative review of applications of the model to health-related behavior. Protection Motivation Theory The original version of PMT (Rogers, 1975) grew out of research on fear appeals. Afear appeal is an informative communication about a threat to an individual’s well-being. Along with details of the threat itself, the communication suggests measures that can be taken to avoid it or to reduce its impact. For example, a fear appeal could be a health-education pamphlet outlining the threat of breast cancer with a recommendation to perform breast self-examination as a means to detect the cancer early, thereby reducing its potential impact. A central issue in fear-appeals research is establishing the way in which a feararousing communication can change attitudes and, subsequently, change behavior. A major problem in this area is that, although it was widely accepted that fear appeals were multifaceted stimuli, there had been little progress in identifying the variables involved, as well as their cognitive mediational effects (Rogers, 1975). Rogers introduced PMT in order to address this difficulty. It was originally developed in an attempt to provide conceptual clarity in the area of fear appeals and to bridge the gap between research on fear appeals and research on attitude change. PMT was designed to specify and operationalize the components of a fear appeal in order to determine the common variables that produced attitude change. It was assumed that each component of a fear appeal would initiate a corresponding cognitive mediating process. These processes would, in turn, influence protection motivation, in the form of an intention to adopt the recommended behavior contained within the fear appeal. Protection motivation was said to be an intervening variable that “arouses, sustains, and directs activity” (Rogers, 1975, p. 94). In 1983, Rogers revised his theory into a more general theory of cognitive change. The revised PMT included a broader spectrum of information sources
108 MILNE ET AL.
that could initiate a coping process. Fear appeals remained one such source of information, but observational learning, personality, and prior experience were also included as information sources capable of initiating cognitive activity leading to protection motivation. Additional cognitive mediating processes were added, including an account of the appraisal processes leading to maladaptive coping responses, such as continuing or adopting smoking cigarettes. The coping-appraisal section of the model was also expanded. The revised theory acknowledged the importance of social learning theory (Bandura, 1977. 1986, 1991) by incorporating Bandura’s ( 1977, 1986) construct, perceived selfefficacy, into the model. The PMT Model’s Structure and Variables The structure of PMT was influenced by expectancy-value theory (Edwards, 1954). This is central to the major social cognition behavioral models, as well as to the models that were influential in the formulation of PMT (e.g., the parallel response model: Leventhal, 1970; and the drive-reduction model: Janis, 1967). In expectancy-value theory, the tendency to adopt a given behavior is said to be a function of expectancies regarding the consequences of the behavior and the value of those consequences. Hovland, Janis, and Kelley’s ( 1 953) expectancyvalue theory suggested that there are three main stimulus variables in a fear appeal: (a) the magnitude of noxiousness of a given event, (b) the probability that the given event will occur if no protective behavior is adopted or existing behavior modified, and (c) the availability and effectiveness of a coping response to reduce or eliminate the noxious stimulus (Rogers, 1975). Rogers adopted these three components as the basis for the original formulation of PMT. He proposed that each of these constitutes a cognitive mediational process: The magnitude of noxiousness initiates perceived severity; the probability of occurrence initiates perceived vulnerability; and the efficacy of the recommended response initiates perceived response efficacy. These cognitive mediational processes could be characterized as having two form-threat appraisal and coping appraisal. Threat appraisal concerns the process of evaluating the components of a fear appeal that are relevant to an individual’s perception of how threatened he or she feels. The PMT variables that capture threat appraisal are perceived vulnerability, perceived severity, and fear arousal. Perceived vulnerability assesses ho\v personally susceptible an individual feels to the communicated threat. It is typically measured by items such as “Considering all of the different factors that may contribute to AIDS, including your own past and present behavior, what would you say are your chances of getting AIDS?’ (answered on a Likert scale with endpoints J am almost certain J will to J am almost certain I will not; Aspinwall, Kemeny, Taylor, Schneider, 8~Dudley, 1991). Perceived severity assesses how serious the individual believes that the threat would be to his or her own life. This
The revised PMT includes self-efficacy and response costs in the coping-appraisal component of the model. Because of a lack of data. “I intend to cany out a breast self-examination in the next month”. & Spears.PROTECTION MOTIVATION THEORY
is measured by items such as “Osteoporosis is a very serious disease” (strongly agree to strongly disagree. Protection motivation is a key mediator of the relationship between behavior and threat and coping appraisal. (d) the individual is able to perform the recommended response. Maddux & Rogers. the more likely a behavioral intention to adopt a protective behavior will be formed. To our knowledge.. Rogers’ (1983) revision of PMT includes a component appraising the rewards of not adopting the recommended coping response as part of the threat-appraisal process. Hodgkins & Orbell. Response ejicacy concerns beliefs about whether the recommended coping response will be effective in reducing threat to the individual and is measured by such items as “If I quit smoking I will greatly increase my chances of living a longer life” (strongly agree to strongly disagree. for example. The greater the perceived threat. Self-efficacy concerns an individual’s beliefs about whether he or she is able to perform the recommended coping response. strongly agree to strongly disagree. only one PMT study has attempted to include rewards (Abraham. Hodgkins & Orbell. Hodgkins & Orbell. 1983). The higher the rewards of not adopting the coping response. 1998). and is a negative linear function of the belief that (e) the perceived
. 1998). An example of how this was done is “Sex would be more exciting without a condom” (strongly agree to strongly disagree). Rogers ( 1983) identified response efficacy as the main determinant of coping appraisal. 1994). Fear is seen as an intervening variable. (c) the recommended response is effective. Response costs concern beliefs about how costly performing the recommended response will be to the individual. “1 would feel awkward examining my breasts” (likely to unlikely. A typical measure of self-efficacy is “Sticking with a regular program of exercise would be very difficult for me to do” (strongly agree to strongly disagree. the less likely the individual is to adopt it. the more vulnerable an individual feels to a threat and the more serious he or she believes it to be. In the original formulation of the theory. Wurtele & Maddux. Sheeran. 1988). Protection motivation is synonymous with the intention to perform a behavior (e. (b) the individual is personally vulnerable to the threat. Fear arousal assesses how much fear the threat evokes for the individual and is measured by items such as “The thought of breast cancer makes me feel” (very anxious to not at all anxious. 1987). the more fear will be aroused and the greater the appraised threat will be. that is. the more likely the individual is to be motivated to protect himself or herself. Abrams.g. Wurtele. Coping appraisal evaluates the components of a fear appeal that are relevant to an individual’s assessment of the recommended coping response to the appraised threat. 1998) and is a positive linear function of the beliefs that (a) the threat is severe. the rewards component of the model will not be assessed in the present review.
denial (Abraham et al.and coping-appraisal processes may result in maladaptive coping responses.. Rippetoe & Rogers.and coping-appraisal variables). & Stephan. and response efficacy (Umeh. self-efficacy and response efficacy have been found to be negatively correlated with maladaptive coping responses (e. 1989). & Owen. Pratt. threat. Taal.. 1994.. t 986). Because of insufficient data. Umeh. 1987). Fruin el al. Tanner. stronger fear appraisal. maladaptive coping responses (avoidance.. 1991.
. Rippetoe & Rogers.2 A schematic representation of the PMT is shown in Figure 1. 1983). Tanner. it has since been adopted as a more general model of decision making in relation to threats (Maddux. Applications of the Model Although PMT was originally developed as an extension of fear-appeal research. Syme. 1994. increasing earthquake preparedness (Mulilis & Lippa. & Crask. 1994). and hopelessness (Fruin et al. 1987: IJmeh. such as denial or avoidance.
costs of the recommended coping response would be high. fatalism (Abraham et al.. 1991 ). Aims of the Present Review The first aim of the present review is to establish the overall success of PMT as a predictive model of health-related intentions and behavior. 1987). However. Wolf. and higher perceived severity (Umeh. 1992). in press. & Gutteling. Rippetoe & Rogers. maladaptive coping responses will not be addressed in the present review.. the majority being health-related threats. Rippetoe & Rogers. 1994. Only applications of PMT to health-related threats will be included in this review. 1991. where the model has been used to understand and predict protective health behavior. 1987). Maladaptive coping has been operationalized in terms ofavoidance (Fruin. Meta-analysis and vote-count procedures will be used to evaluate the success of each of the model’s components in predicting intention (threat. and coping with burglary (Weigman et al. Van den Bogaard. 1991. van der Velde & van der Pligt. 1991. wishful thinking (Abraham et al. in particular) have been found to inhibit protection motivation (Abraham et al. 1992). Eppright. 1994. 1990). 1987.. avoidance has been shown to inhibit severity.g. 1994. coping with technological and environmental hazards (Weigman. 1991). a brief sunimary of the main findings concerning maladaptive coping is offrred here. in press. Rippetoe & Rogers. Other protective behaviors to which PMT has been applied include antinuclear behaviors (Axelrod & Newton. outlined in PMT itself. Abraham et al. 1987). & Nesdale. and behavior (all components of the model) will be assessed to identify those best to
*In addition to their influence on protection motivation.110
MILNE ET AL. & Hunt. in press). Thrcat appraisal has been found to be positively correlated with maladaptive coping responses. water conservation (Kantola.. In addition. Gregory. self-efficacy (Rippetoe & Rogers. In general. 1991 ). Day. 1993). in press).. 1987. 1987. van der Velde & van der Pligt. Rippetoe & Rogers. indicating that high threat perception makes one likely to adopt some coping response.Abraham et al. either adaptive or maladaptive ( e g . van der Velde & van der Pligt. 1994. PMT has been applied to a number ofthreats. For example. It has also been found that a tendency toward maladaptive coping affects the coping process. and hypervigilance has been found to lead to increased self-efficacy and response efficacy. Rippetoe & Rogers.
Schematic representation of protection motivation theory (adapted from Rogers. -ve = negative association.Cognitive mediating processes Behavior
Environmental Communication Observational Learning
Intraoersonal Personality variables Prior experience
Perceived self-efficacy Perceived response-efficacy Perceived response-cost
Denial Fatalism Wishful thinking
Health &protective behavior
. 1983). +ve = positive association.
1975). These techniques complement one another since meta-analysis establishes the overall strength of association between two variables. Meta-analysis will be used to determine the average correlation between each PMT variable and intention and behavior. Medline. an additional search was carried out to identify all papers citing Rogers (1975. the theory ofreasoned action (Ajzen & Fishbein. Unpublished research was also included. and the theory of planned behavior (Ajzen. A keyword search was conducted using the expressions protection and motivation to identify all papers including these words in their title or abstract. 1988.and coping-appraisal variables and intentions to perform health-related behaviors? 2. What is the association between threat.
Criteria for Inclusion
The following criteria were used to select studies suitable for inclusion in the analysis:
. 1980. Rosenstock. and a vote count will be used to see how often these associations are significant across studies. The second aim of this paper is to review the methods by which PMT variables have been manipulated in experimental studies and to assess the success of such manipulations in producing belief change. What is the association between PMT variables and measures of concurrent health behavior?
3. whereas a vote count shows how often these associations are significant. 1991) in that it has been consistently subjected to experimental tests. What is the association between PMT variables and health behavior in prospective studies?
4. Fishbein & Ajzen. The following four questions will be addressed by the review:
1.112 MlLNE ET AL. 1966).and coping-appraisal variables in bringing about cognitive change?
Data Collection and Selection
Published studies were identified using the computer databases PsychLit. researchers have presented communications designed to manipulate PMT variables and then measured the effects of the communication on PMT variables. 1974. and Social Sciences Citation Index (BIDS [Bath Information Data Service]). PMT has an advantage over the health belief model (Becker. TO ensure that no applications of PMT were missed using this search strategy. In these studies.
target in health-education interventions. 1983). How successhl are manipulations of threat. PMT review papers and book chapters were also consulted to identify any papers that were missed from the computer databases.
the present review included only PMT studies in order to ensure that all components were operationalized and used according to the framework of the model. The study must be an empirical application of PMT.
3Although other studies have looked at associations between variables included in PMT with intention and behavior. no education). and concurrent or subsequent behavior included in the analysis. breast self-examination. while the control group watched a program on an unrelated topic. smoking cessation. health education). Detection behaviors influence health only if the individual takes further preventive action after learning the result of the detection behavior (Maddux. This type of design measures an individual’s cognitions that have been established through general life experience. For the purpose of the analysis. and cancer. Health-education intervention (health education vs.. These behaviors may play a preventive role in a range of illnesses such as stroke. mammography. There must be a measure of behavioral intention. Taal. moderate alcohol consumption. This information addresses several PMT variables and presents facts in such a way that protection motivation will be encouraged. 1993). and no prior information concerning the health threat or protective behavior is provided. Maddux. behavior. 1993).
3. studies were classified according to three main types of research design. breast selfexamination. and Weigman (1990) showed an experimental group an educational-television film about cancer.3
2. Detection behaviors are conducted to enable an individual to discover whether he or she has a specific condition that could be a threat to health (e. scores on PMT variables are correlated with intentions. Examples of these behaviors include increased exercise. variables are measured after one group of participants (the experimental group) has received information about the health threat and recommended protective action (Le. Here. all participants receive a questionnaire measuring PMT variables. For example. PMT studies can also be characterized according to research design. The behavior used in the study must be a health-related behavior (e. sunscreen use. and dietary improvements. The control group does not receive this information. Prevention behaviors are behaviors that an individual adopts or ceases in the belief that doing so will reduce the risk of developing disease in the future. Correlational design. Seydel.. No experimental manipulation is involved. or both. smoking cessation. heart disease.PROTECTION MOTIVATION THEORY
. adopting a healthy diet). In this design. Rather. testicular self-examination).g.. Tjpes of Studies Included There are two main types of health-related behavior explored in the studies collected: detection behaviors and prevention behaviors (cf. Pap test.g.
No groups were given low information on the PMT variables. while the other group receives information designed to decrease vulnerability (low vulnerability). Wurtele. Analyses for individual PMT variables were not reported. a comparison is drawn between an experimental group that receives information and a control group that receives no information about the threat. information about the effectiveness of such an exercise program in enhancing health and physical attractiveness). For example. one.114
MILNE ET AL. In most experimental manipulation studies. such as vulnerability (high vulnerability). Health-education studies present general factual information about a health threat and coping response..g. manner. Comparisons are made between the high-vulnerability group and the lowvulnerability group.
4 A n ~ t h e exception r is a study by Sturges and Rogers ( I 996) that included a no-message control group in an experimental manipulation. there is no control group that does not receive any information regarding the target variable. There are two distinctions between these studies and the general manipulations of health-education intervention studies.4 In the health-education intervention studies. 198 1 .e. and the other group receives unrelated information. low) in a communication prior to their measurement. this study is not included in the present review because the PMT variables were combined into threat and coping for the manipulation checks and data analysis. In this design. the difference between the two subject groups is that one group receives general information about a health threat. three. For example. or none of the PMT variables. In this case.
Experimental manipulations ojspecific PMT variables. Second. two. Stanley and Maddux (1986) gave participants a written communication containing a combination of (a) high or low self-efficacy information (i.e. Beck & Lund. First. Wurtele’s ( 1988) high-vulnerability group was given information on the incidence of bone loss in young women. based on the PMT variables. 1988) also included correlational measures of PMT variables that were not manipulated in the communication. along with several reasons why younger women may be at risk from osteoporosis. experimental manipulations are more direct in that they manipulate information about one or more particular PMT variables. one group receives information designed to increase the strength of a belief. and (b) high or low response-efficacy information (i. information regarding the individual’s ability to complete an exercise program).
. The low-vulnerability group was given information stressing that younger women are at low risk from osteoporosis. particular PMT variables are manipulated (high vs. However. There is no group receiving low information. that is. For example.. experimental manipulations present information that is manipulated in a high or IOU. The exception to this is Wurtele and Maddux ( 1987) who gave their participants written communications containing high information on four. Each individual variable is not directly addressed.. These measures will be treated as correlational measures in the review. there was a control group that was given a passage on an unrelated topic. Some experimental manipulation studies (e.
Those studies where bivariate relationships were available were included in the meta-analysis. There were four replies. All studies were included in the vote counts. and all PMT variables with behavior. Lyman. All hypotheses from the studies reporting bivariate relationships or where authors subsequently provided such data were included in the meta-analysis. & Prentice-Dunn. 1995.694 participants.PROTECTION MOTIVATION THEORY
Details about all studies included in the analysis are shown in Table 1. workers exposed to harmful noise levels: Melamed. Meta-analyticprocedure. and 6 of these included measures of both intention and subsequent behavior. 1996). Pearson’s correlation). and 1 measured subsequent behavior but not intention (Taylor & May. Most of the studies (14) used samples of high-school. 15 involved correlational designs. One study (Seydel et al. or university students. 1990) measured intention. college.. Of these studies. 1994. Where a study addressed more than one hypothesis using the
. 1991. Statistics such as F and t values were converted to r values. There were 19 cross-sectional studies. 1996. and patients of a university-based sports-injury clinic: Taylor & May. & Ribak. and 3 measured both intention and concurrent behavior. 1986). General population samples were used in 7 studies. parents of children with muscular dystrophy: Flynn. low. 8 employed specific experimental manipulations. Vote counts were used to examine how often these associations were significant across the individual studies. homosexual men: Aspinwall et al.
Two methods of data analysis were used: meta-analysis (Rosenthal. concurrent behavior. Thus. The average correlation gives an overall effect size. & Phillips. correlations from larger samples were given more weight in the metaanalysis than were those from smaller samples. 1 I of which measured intention only. with 29 independent samples and a total of 7. The weighted average correlation (r+) was then calculated by multiplying each r-to-ztransformed correlation by its sample size and dividing by the total sample size. Twenty-seven studies. fulfilled the criteria for inclusion.and coping-appraisal variables and intention. Feiner. such as regression analysis. and the relevant correlation matrices were requested. For metaanalysis. Meta-analysis was used to examine the overall strength of associations between threat. nurses: Millard. while 7 targeted specific groups (dental patients: Beck & Lund. Authors of such papers were contacted. and 3 compared health education versus no education. Rabinowitz.and high-risk drinkers: Ben-Ahron. Weisberg. which was conducted using Schwarzer’s (1988) computer program Meta.. 5 measured concurrent behavior only. White. 1984) and vote count (Cooper. Seven studies were longitudinal. 1996). Many studies reported multivariate relationships. 1981. all associations between variables needed to be bivariate relationships that could be converted to a single effect size (viz. and subsequent behavior. 1995.
N = 507. Reducing number of longitudinal study homosexual men. M age = 33 of anonymous years sexual partners. M sexual partners age = 16. cross. ( 1994)
Aspinwall et al. N = 389. age range = 18-57 reducing number years.Table 1
Applications of Protection Motivation Theory to Health-Related Behaviors
Authors Yes No
Measure of Measure of Measure of concurrent subsequent intention behavior behavior
Abraham et al. and reducing number of partners for unprotected anal and receptive intercourse Yes
. (1991) Yes
Correlational. HIV sectional study female school test. sexual partners. reducing pupils above 16.8 years Correlational. male and Condom use.
sexual years behavior. cross. random assignment into experimental conditions Ben-Ahron et al. cross-sectional study
. and university dental plaque disclosure clinic. sectional study heterosexual preventive adults. male and Tooth flossing and female patients of brushing. cross. male and Moderate drinking (1 995) sectional study female high-risk and lower risk drinkers HIV-related Bengel et al.
= 80. reduction of sexual partners and behavior change
.N = 196. condom use. aged 20-45 behavior. Correlational. age range = 17-81 years.N = 468.Beck & Lund (1981)Experimental manipulation of PMT variables. (1996) Correlational.
avoidance of sharing body fluids. reducing sexual partners. adaptive students information seeking. ( 1994)
Health-education N = 360. condom use Yes
Table 1 (Continued)
Measure of Measure of Measure of concurrent subsequent intention behavior behavior
Boer & Seydel ( 1996)
Eppright et al. females. 50-70 years longitudinal study over 2 years Correlational. Breast-cancer manipulation (pro.-. male and AIDS-preventive sectional study female university behavior.invited to screening vision of health participate by education to exper.letter. cross. selecting infectionfree partners. age range = imental group).N = 33 I .
female Breast self( 1998) longitudinal study psychology examination over 1 month students and staff.Yes Yes
Flynn et al. male and Exercise manipulation of female high-school PMT variables. students. cross. age cross-sectional range = 13. ( 1991) Experimental N = 6 15. cross. families Parents’ compliance sectional study attending clinics with child’s sponsored by the muscular Muscular Dysdystrophy trophy Association physiotherapy Fruin et al. male and Sunscreen use and sectional study female underuse of sungraduate psyprotective clothing chology students Hodgkins & Orbell Correlational.N = 115. M age = 14 study years 5 months. M age = 2 1 years
I rn 0 R
< (ruble continues)
.17 years. random assignment into experimental groups Hayes (1 996) Correlational. N = 89. (1995) Correlational. age range = 17-40 years.N = 74.
random assignment into experimental conditions Correlational. wearing gloves when giving in. Yes
.N = 28 1 . etc. Israeli men Use o f a hearing sectional study exposed to harmful protection device noise levels at work Correlational. ( 1996)
Millard ( 1 994)
female undergraduate students. cross-sectional study
Melamed et al. male and
Sample details Smoking cessation
Measure of Measure of Measure of concurrent subsequent intention behavior behavior
Maddux & Rogers ( 1983)
Experimental manipulation of PMT variables.
153. cross.Table 1 (Continued)
. recapping needles after use.jections. N = I05 male and Nurses’ safety belongitudinal study female quali tied havior in relation and unqualified to AIDS and Hepanurses titis-B prevention. renewing sharps bin when it reaches its maximum fill. taking the sharps bin to the patient.
Plotnikoff & Higginbotham (1 995) Yes Yes
No Yes No No
Yes Yes Yes
Correlational. males and Reduce dietary fat sectional study females identified from Federal Electoral Roll Rippetoe & Rogers Experimental N = 163. cross. tooth flossing. (1 996) Correlational. cross. age breast selfexamination. random study assignment into experimental groups Ronis et al.N = 622. manipulation 132 females going to see doctor applied to take part when suspecting (provision of health education to following cancer. and dental check-ups Seydel et al. adults over Frequencies of sectional study 18 years in Detroit toothbrushing. group). A (subsequent years cancer behavior based on orders of leaflets) (table continues)
. psychology cross-sectional students. (1990) Health-education N = 124 males and Checking for cancer. range = 19-73 4 age = 38 ordering leaflets on longitudinal study years. female Breast selfundergraduate examination (1987) manipulation of PMT variables. experimental newspaper ad. Pap test.N = 800.
Measure of Measure of Measure of concurrent subsequent intention behavior behavior
Sheeran & Orbell ( 1996)
Correlational.Table 1 (Continued)
-. male and Tooth flossing and sectional study female condom use undergraduate psychology students N = 195.N = 200. male Testicular selfmanipulation collegepsychology examination (provision of students. random assignment into experimental conditions Steffen (1990) Health-education N = 198. cross. undergraduate cross-sectional psychology study students. M age = health education to 2 1.2 years. random experimental assignment into group) experimental conditions Yes No
. male and Signing up for an Stanley & Maddux Experimental ( 1986) manipulation of female exercise program PMT variables.
M age = 2 1. male and female college students
Condom use Yes
Taylor & May ( 1996) Yes
Correlational.N = 885. cross. male and Substance use/ Umeh (in press) sectional study female secondary misuse.17 consumption. years. exercise. fatty food age range = 13. age range = 18-30 years Yes
. N = 62. 68% male. school females. (1989) Experimental manipulation of PMT variables
N = 202.Tanner et al. students Compliance with the longitudinal study involved in sports recreational or physiotherapist’s competitive sports prescribed and patients of a modalities and university-based prescribed rest sports-injury clinic.N = 23 I .7 years Correlational. cross. 147 male Condom use der Pligt ( 1991) sectional study homosexuals and 84 male and female heterosexuals. M age = 14 unprotected sex years van der Velde & van Correlational.
random assignment into experimental groups Wurtele & Maddux Experimental N = 160.5
Table I (Continued)
Measure of Measure of Measure of concurrent subsequent intention behavior behavior Yes
D ! -
Wurtele ( 1 988)
Experimental N = 89. female Aerobic exercise (1 987) manipulation of undergraduate PMT variables. random longitudinal study assignment into over 2 weeks experimental groups Yes
. age increasing dietary longitudinal study range = 17-26 calcium intake over 1 week years.2 years. M age = 19. female Taking calcium manipulation of psychology supplements and PMT variables. students. students.
05. A significant result shows that the effect sizes show greater variability than chance. Findings for different designs were also combined to produce an overall significance ratio. A chi-square test of homogeneity was conducted (Hunter. and findings for relationships between PMT variables and intention.
.PROTECTION MOTIVATION THEORY
same sample. 12 studies (1 3 individual samples) involving a total of 52 hypotheses were suitable for use in the meta-analysis. the average correlation within that study was employed. resistant to unretrieved studies).e. This allows the meta-analytic results to be considered in relation to unretrieved or future studies.I . study details. Schmidt.and Coping-Appraisal Variables a n d Intention Twenty-one studies with a total of 206 individual hypotheses were included in the vote count.. with k being the total number of independent correlations included in the analysis. correlational studies. Guidelines developed by Cohen (1992) were used to interpret the effect sizes generated by the meta-analysis: r+ = . Rosenthal (1991) suggests a tolerance level of 5k + 10. Each variable was looked at in turn.and coping-appraisal variables with intention and all PMT variables with concurrent behavior and subsequent behavior are shown in Table 2. The ratio of times that a hypothesis was significant in the predicted direction to the number of times that it was tested was calculated as a percentage to produce a significance ratio. Thefail-safe N (FSN) is the number of studies giving null results that would be needed to change the conclusion that two variables are significantly correlated at p < .5 Relationship Between Threat. concurrent behavior. 1986) was conducted on all retrieved studies. a finding can be seen as robust (i. Each individual association between a variable and a dependent measure constitutes a hypothesis in this context. Results The results of the meta-analyses correlating threat.50 is interpreted as a large association.and coping-appraisal variables) and behavior (all PMT variables) was counted. When the FSN exceeds the tolerance level. Vote-count procedure. health-education intervention studies. and rt = . and the number of times it significantly predicted intention (threat. and experimental manipulation studies were looked at individually in order to draw comparisons between them. and subsequent behavior are available from the authors upon request. The vote count (Cooper. The fail-safe N was also calculated. The degrees of freedom for the chi-square statistic are k . For this analysis.I0 is interpreted as a small association. The results of the vote count of these associations are summarized in Table 3. Of these.
5Tables of hypotheses.30 is interpreted as a medium association. 1982) to ascertain whether variation among the correlations was greater than chance. rt = . & Jackson.
ns 512 .196 .34***
22 (60) 12 ( 5 5 ) 12 (30)
74 (75) 57 (70) 23 (30)
Associations with concurrent behavior Threat appraisal Vulnerability 5 6 Severity 1 Fear Coping appraisal Sel f-efficacy 7 Response efficacy 6 4 Response costs Intention 2 Associations with subsequent behavior Threat appraisal Vulnerability 4 Severity 4 1 Fear Coping appraisal Self-efficacy 5
1.07.20*** 2.186 257 .181 .20.16*** 1. Concurrent Behavior.33*** 1.87***
14.04.90.507 1.08.96.426 1.08*** 3.90***
MILNE ET AL. ns
9 4 13
1.lo*** 157 A**
8 (35) 6 (40) 1(15) 42 (45) 15 (40) 18 (30) 31 (20)
76. and Subsequent Behavior
FSNi (tolerance value)
Variables Associations with intention Threat appraisal Vulnerability Severity Fear Coping appraisal Self-efficacy Response efficacy Response costs
30.366 .36*** . ns 194 -.79*** 631 -.81*** 22.lo*** 411 .82*** 2.12** 372 .98. ns 9.02.67*** 45.756 . ns 52.95** 17.78*** 30.32*** .13*** 1.29* 0. ns
Meta-Analysis of Correlations Between PMT Variables and Intentions.22***
5 (30) 2 (30) 1(20) 17 (35)
.17*** -.211 . ns 74.391 .
and at r+ = . cf.26* 0. A FSN value greater than the tolerance value (i.79.21. Self-efficacy had a significance ratio of 70% and was the variable that was most often significantly associated with intention in the predicted direction across studies..ns
4 2 4
388 . The association between severity and intention was small (r+ = . Self-
. Vulnerability ( 3 1%) and severity (23%) were least often associated with intention across studies.I). the FSN for the association between self-efficacy and intention was only 1 away from reaching the tolerance level. Overall. Both self-efficacy (r+ = .20). KeyJindings. the association between response efficacy and intention could be interpreted as medium. N = total number of subjects. 1991) indicates that the average correlation is likely to be resistant to unretrieved and future null results at p < .
Meta-analyticfindings.001).lo).05. Rosenthal. * p < . Sk + 10.34) had medium associations with intention. ns 194 -.PROTECTION MOTIVATION THEORY
Table 2 (Continued) FSNI (tolerance value)
Variables Response efficacy Response costs Intention
10.***p<. Self-efficacy was found to be significantly associated with intention in all hypotheses tested by experimentally manipulating variables. fear. However. Threat-appraisal variables were less often associated with intention than were coping-appraisal variables in correlational studies. r + = sample weighted average correlation (effect size). All PMT variables were found to be significantly correlated with intention in the predicted direction (all p s < . r+ = . Vote-count results. coping-appraisal variables proved to be more strongly and consistently associated with intention than did threat-appraisal variables.OOl. All other associations between threat-appraisal variables and intention were small to medium (vulnerability. providing a test of the null hypothesis that the average effect size is a result of sampling error alone (df= k . threat-appraisal cognitions proved to be more successhl in predicting intention in experimental studies. * * p < .29. k = number of hypotheses.e.09. Chi square is a homogeneity statistic.16. FSN = Failsafe N. Unfortunately.40***
3 (30) 8 (20) 28(30)
Note. r+ = . However. O S . This suggests that the association between self-efficacy and intention is the most robust of all associations between PMT variables and intention. Fear and response efficacy were associated with intention in both health-education interventions testing these hypotheses. and the one most likely to prove resistant to unretrieved and future null results. with an FSN of 74.33) and response costs (r+ = -.ns 3.25*** 432 . O I . the FSN for all variables failed to reach Rosenthal’s (199 1) tolerance level of 5k + 10. with k = 13.
Concurrent Behavior: and Subsequent Behavior
Healtheducation interventions k Ratio Manipulated variables k Ratio k
Correlated variables Variables Threat appraisal Vulnerability Severity Fear Coping appraisal Self-efficacy Response efficacy Response costs +/-
Associations with intention
27 24 20 29 21 10
9 9 2
11 22 100 87
66 50 0 6 100 50 0
45 39 24 43 44 11
31 23 46 70 47 45
Associations with concurrent behavior Threat appraisal Vulnerability + 15 66 Severity + 20 20 Fear + 5 60 Coping appraisal Self-efficacya + 23 70 Response efficacy + 19 21 Response costs 5 100 Intention + 2 100 Associations with subsequent behavior Threat appraisal Vulnerability + 15 3 Severity + 13 8 Fear + 6 0
21 26 5
52 19 60 76 30 100 100
29 23 5 6
21 17 6
14 12 0
Vote Counr Significance Ratios for PMT Variables and Intentions.128
MILNE ET AL.
k = Number of hypotheses. Mefa-analyficfindings. + =positive association.
Relationship Between PMT Variables and Concurrent Behavior
Studies measuring behavior in a cross-sectional design. with the exception of fear ( p < .
efficacy had the most robust and the most consistent association with intention of all the PMT variables and was also one of the strongest correlates of this variable. Both
. that is. aThe vote-count results for self-efficacy include the behavior-specific hypotheses tested by Ronis et al. finding a small-to-medium association (rt= .g..36 for self-efficacy and r+ = -.PROTECTION MOTIVATION THEORY
Table 3 (Continued) Healtheducation interventions
Correlated variables Variables
Ratio 3 0
Coping appraisal Self-efficacy + Response + efficacy Response costs Intention +
66 66 -
42 29 43 66
8 25 7 4 3 11 64
Note. findings for the regression of toothbrushing on selfefficacy and response efficacy to perform flossing are not included in the vote count). Of these.01). Twelve studies (13 individual samples) with a total of 58 individual hypotheses were included in the vote count. Only one study tested the relationship between fear and concurrent behavior. The largest association was found between intention and concurrent behavior (r+ = . were used to assess the relationship between PMT variables and concurrent behavior. Response efficacy had a small-to-medium association (rt= .All PMT variables were significantly correlated with concurrent behavior in the predicted direction at p < . The FSN for this association was above Rosenthal’s (1991) 5k + 10 (FSN = 3 1) indicating the result to be robust and resistant to unretrieved results and future research. 8 studies (9 independent samples) were suitable for use in the meta-analysis.001. using measures of behavior taken at the same time as measuring the PMT variables. .82). (1996) only (e. the percentage of times a PMT variable was significantly associated with concurrent behavior in the predicted direction. The remaining coping-appraisal components had medium-to-large associations (r+ = .26).17) with concurrent behavior. Ratio = significance ratio.32 for response costs).= negative association.
and coping-appraisal variables most strongly and frequently associated with concurrent behavior. Intention was the variable that was most often associated with subsequent behavior and had a significance ratio of 66%. with significance ratios equal to 43% and 42%. Of the threat. This was a small association with a very small FSN (FSN = 5).
vulnerability ( r t = .01). Intention had the strongest. Of these. with FSNs failing to reach Rosenthal’s (1991) tolerance level (FSN = 14 and 8 for self-efficacy and response costs. Self-efficacy (76%). while vulnerability and severity
. Both associations were small to medium and unstable. Self-efficacy and response costs were the threat. p < . l o ) had small associations with concurrent behavior.22) and response costs (r+ = -.13) and severity (I+ = . Intention had the largest correlation with subsequent behavior (r+ = .p < .findings. The FSN for this association was above Rosenthal’s 5k + 10 (FSN = 28) criterion. respectively). Vote-count results. Vote-count results.05. although self-efficacy (FSN = 42) was once again close to the stipulated level. The FSNs for all threat-appraisal components were very small.001). Of the coping-appraisal components.40. Relationship Between PMT Variables and Subsequent Behavior Eight studies with a total of 96 individual hypotheses were included in the vote count. 5 studies involving a total of 23 hypotheses were suitable for use in the meta-analysis. Intention was found to be significantly associated with concurrent behavior in all hypotheses testing the relationship.25) were significantly correlated with subsequent behavior. Meta-analytic. Only one health-education intervention study (with four hypotheses) involved concurrent behavior.and coping-appraisal variables. respectively. according to Cohen’s (1992) criteria. Perceived vulnerability was the only threat-appraisal variable to be significantly correlated with subsequent behavior (rf = . Keyfindings.OO 1. and fear (60%) were the threat.. the FSNs for all variables did not reach Rosenthal’s (1991) tolerance level. and only two hypotheses were tested in experimental studies. Fear did not have statistically significant associations in any of the hypotheses tested. and most consistent association with concurrent behavior.12. indicating that only a small number of null results would be needed to change the conclusion that these variables are significantly associated with concurrent behavior at p < . The association was moderate to strong. self-efficacy (rt = . With the exception of intention. indicating the result to be robust and resistant to unretrieved results and future research. response costs and self-efficacy were most often associated with subsequent behavior across all of the studies. both at p < .130
MlLNE ET AL.and copingappraisal variables that most often predicted concurrent behavior. response costs ( 1 OO%). most robust.
32). As PMT predicts..26). one receiving high self-efficacy information. self-efficacy. Findings from the meta-analysis of cognition changes following specific manipulations of threat. and one study.09. Perceived vulnerability. 1996. 1990) or a health-education brochure or leaflet (Boer & Seydel.63) and severity (r+ = . The remaining associations were medium to strong. Response costs and selfefficacy were the threat. With the exception of response costs (r+7 = . one receiving low vulnerability information. Health-education intervention studies were not included in the meta-analysis since there were too few studies to permit meaningful inferences. tested subsequent behavior following an experimental manipulation. included measures of subsequent behavior following a health-education intervention. he or she would use four experimental groups: one receiving high vulnerability information.and coping-appraisal variables that were most often significantly associated with subsequent behavior. intention had the strongest. and thus had a FSN of 1. if an experimenter wants to manipulate perceived vulnerability and perceived self-efficacy. t+ was employed here for reasons of consistency and ease of interpretation. 1990). Self-efficacy manipulations were moderately associated with subsequent changes in this belief (r+ = . a television program (Seydel et al. generating three hypotheses.6 Meta-analyticfindings. Cognition Changes Following Manipulations of PMT Variables Experimental manipulations of PMT variables usually involve a written communication focusing on a particular PMT variable. Information is presented in a manner that is more characteristic of health-education programs. and a medium association was found between these manipulations and subsequent change in belief (r+ = . There are usually several experimental groups-two (high or low) for each variable being manipulated.PROTECTION MOTIVATION THEORY
both had small overall significance ratios (14% and 17%. respectively).and coping-appraisal variables and subsequent cognition change were significant at p < . Manipulations in health-education studies are presented in a more realistic way. and response costs were the only threat. Response costs were manipulated in just one study. Steffen. all associations between manipulations of threat.and coping-appraisal variables that were associated with subsequent behavior.001.
6A table showing the types of information used to manipulate PMT variables and their success in bringing about cognitive change is available from the authors upon request. most robust. Fear was manipulated twice. also involving three hypotheses. 1992). and most consistent association with subsequent behavior.and coping-appraisal variables are shown in Table 4. Keyfindings. for example.
. Vulnerability (r+ = . 'Although the statistic d is the more commonly used measure of effect size in experimental studies.66) manipulations had large associations with subsequent cognition change (Cohen. Only one study. and one receiving low selfefficacy information. ns). For example.
. which has only been manipulated once [Fruin et al.
With the exception of self-efficacy (FSN = 27).58*** 4. **p < . There were very few hypotheses involving health-education manipulations. the associations were all above Rosenthal’s ( 1991 ) tolerance level. *p < .001. Chi square is a homogeneity statistic. There was a change in belief in one of the hypotheses measuring response efficacy and in the only study of se I f-efficacy. 1991) indicates that the average correlation is likely to be resistant to unretrieved and future null results a t p < . All variables had significance ratios greater than 50%.83***
.1).. The variables with the strongest relationships with intention and behavior were those that proved to be the hardest to manipulate to bring about belief change. Keyfindings. although
.and coping-appraisal variables are shown in Table 5 .09. FSN = Failsafe N.63***
.e. Experimental manipulations produced significant changes in belief in all of the hypotheses tested (with the exception of response costs.132 MILNE ET AL.52*** 54..and coping-appraisal variables-with the exception of response cost-were successfully manipulated in experimental manipulations.26**
58 (35) 49 (30) 8 (20) 27 (35) 37 (35) I(15)
. All threat. Table 4
Meta-Analysis of Changes in Cognitions Following Experimental Manipulations of PMT Variables
FSN (tolerance value)
Variables Threat appraisal Vulnerability Severity Fear Coping appraisal Self-efficacy Response efficacy Response costs
561 48 1 207 1. providing a test of the null hypothesis that the average effect size is a result of sampling error alone (+ k .32*** . Provision of health-education information did not lead to changes in any of the threat-appraisal variables.163 563
11. k = number of hypotheses. O l .18* 83. A FSN value greater than the tolerance value (i.05.42*** .163 1. r+ = sample weighted average correlation (effect size). N = total number of subjects. 5k + 10. Vote-count results. The association between response costs and subsequent change in belief.78* 46. Rosenthal. ***p < . The results of the vote count of cognition changes following manipulations of threat. cf. 19911 and unsuccessfully).
How well do PMT variables predict concurrent behavior and subsequent behavior?. Although none of the associations had FSNs reaching Rosenthal’s (199 1) tolerance level.
only tested once. and How successfi~l have manipulations of PMT variables been in bringing about changes in belief? The findings offer modest support for the threat. Ratio = significance ratio.and coping-appraisal variables were significantly associated with intention.and coping-appraisal components of the model in predicting health-related intentions. and of the significant belief changes.and coping-appraisal cognitions. Discussion This is the first meta-analytic review to evaluate the success of PMT in the prediction of health-related intentions and behaviors. Experimental manipulations appear to be more successful than healtheducation interventions in changing threat. The questions addressed were: How well do threat appraisal and coping appraisal predict intention?.= negative association. All threat. + = positive association. . the percentage of times a PMT variable was significantly associated with concurrent behavior in the predicted direction. coping-appraisal components of the model had stronger associations with intention than did the threat-appraisal cognitions. However.PROTECTION MOTIVATION THEORY
Vote Count Changes in Cognitions Following Experimental Manipulations of PMT Variables and Health-Education Interventions
Manipulated variables Variables Threat appraisal Vulnerabi 1ity Severity Fear Coping appraisal Self-efficacy Response efficacy Response costs
Ratio 100 100 100
Ratio 2 2
+ + +
57 66 100
5 5 1
43 7 1
Nofe. was nonsignificant. k = Number of hypotheses. the association between
. selfefficacy was the only one where the FSN failed to reach Rosenthal’s (1 991 ) tolerance level.
45 and . it was small and was not robust. The vote count supported these findings. This was a robust relationship. although with the exception of self-efficacy. then a positive relationship between the two variables will be obtained. Although the average correlation between perceived vulnerability and subsequent behavior was significant. or fear to produce a nonsignificant average correlation. health-related intentions were signifcantly associated with subsequent behavior. with coping-appraisal variables having much higher significance ratios than threat-appraisal cognitions. 1983). it would take only four studies finding nonsignificant relationships between perceived vulnerability. The strength of the association between intention and behavior was consistent with findings from previous meta-analytic reviews..g. these too had FSNs that were far from the tolerance level (Rosenthal. respectively. 1991). PMT variables were all found to be significantly associated with concurrent behavior. Maddux & Rogers. once the protective behavior has been
.. and the vote count showed good consistency in the relationship across PMT research.134
MILNE ET AL
self-efficacy and intention was very close to this threshold and is therefore more robust and resistant to future research than are the associations obtained for the other variables. The strength of the association that was found between intention and behavior supports PMT since the model predicts that intention will be the best and most immediate predictor of behavior. Randall and Wolf (1 994) and Sheeran and Orbell (1998) found average correlations of . and response costs. At most. 1994. This is because both positive and negative associations between risk and behavior are possible. Difficulties with statistical interpretation and measurement may have been responsible for the weak association obtained between threat-appraisal components and intention and behavior.. 1998. Abraham et al. they may decide to adopt a protective behavior. The vote count showed that this association was not generally significant across the studies. Weinstein and Nicolich (1993) highlight the problem of interpreting correlations between perceived personal risk and behavior in cross-sectional studies. in their meta-analyses of the intentionbehavior relationship. The present study supports previous findings showing that threat appraisal is a poor predictor of intention and behavior (e. For example.and coping-appraisal variables found to be significantly associated with subsequent behavior were perceived vulnerability. self-efficacy. with very small FSNs. Harrison et al. 1992. perceived severity. The only threat. The coping-appraisal components were more strongly associated with concurrent behavior than were threat-appraisal variables. Hodgkins & Orbell. If a person feels vulnerable to a health threat. As predicted by PMT. Intention had a medium-to-strong average correlation with subsequent behavior. The association between intention and concurrent behavior was the strongest and most consistent association found in the meta-analysis.44. However. The average correlations between threat-appraisal variables and concurrent behavior were small.
Janz & Becker. As well as the physical severity of the disease. Weinstein and Nicolich (1993) maintain that only in certain circumstances can a causal inference be made about the correlation between vulnerability and behavior.. Weinstein ( 1988) also highlights problems in measuring perceived vulnerability when participants are asked to estimate their personal vulnerability to a threat but are not given an option to say that they are unaware of the threat in question. therefore the association between perceived vulnerability and behavior will be negative. when future behavior is measured in a longitudinal study and perceived vulnerability is measured immediately after the threat communication has been presented to the participants. One possible reason why the average r+ and significance ratios for severity were poor may be that it is often very difficult to obtain variability in the data for perceived severity (Harrison et al. as predicted. the individual may no longer feel vulnerable to the threat. 1988. it is unlikely that this is the case in the present study. 1992. Thus. Therefore. this relationship needs to be tested further under the conditions stipulated by Weinstein and Nicolich before a conclusion can be reached about the ability of perceived vulnerability to predict behavior. This is followed by an assessment of how dangerous the threat is and how many people are likely to be affected. A related difficulty with cross-sectional studies is that it cannot be determined whether perceived-vulnerability beliefs influence behavior or vice versa. severity can be seen as a multidimensional construct. that is. All of the PMT studies included in the present review have measured vulnerability in this problematic way. This traditional operationalization of vulnerability assumes the variable to be static. Wurtele found a positive significant relationship. For example. before they have an opportunity to change their behavior. 1984). Weinstein proposes that this static conceptualization is misguided and that perceived vulnerability develops in a series of three stages. The individual hears of the threat and becomes aware that it exists. Two studies have tested the association between perceived vulnerability and future behavior under these conditions (Wurtele.PROTECTION MOTIVATION THEORY
adopted. such as pain or premature death. how much the disease is likely to interfere with social roles that are important to the
. Wurtele & Maddux. all of the associations between perceived vulnerability and concurrent behavior in the studies included in the vote count were positive. while Wurtele and Maddux found a nonsignificant association. One possible explanation for the small overall average correlation between perceived vulnerability and concurrent behavior in the individual PMT studies may be that both positive and negative relationships between the two variables exist among the data. few people would disagree that contracting cancer or AIDS would be serious for them. However. perceived severity can be assessed in terms of psychosocial severity-for example. It is not until the final stage that the threat is personalized and the individual can give an estimate of his or her own personal perceived vulnerability. However. 1987).
Given the diffculties associated with measuring and interpreting findings for threat-appraisal
. 271). Their research combined components of the health belief model and subjective utility theory in a study of breast self-examination. low).. The rewards component of PMT was not included in the present review because only one study was obtained that included this variable (Abraham et al. (1994) operationalized perceived severity in terms of evaluating the fatality of AIDS: How many people who get the AIDS virus actually die of it? Hodgkins and Orbell ( 1 998) used items including those measuring psychosocial severity (e. and fear appraisal may be more strongly and consistently associated with intention and behavior for some people but not for others. Brouwers and Sorrentino ( 1993) found that an individual difference variable-uncertainty orientation-moderated the impact of perceived threat. Abraham et al.g. “Developing breast cancer would force me to change my goals in life”). it may be that the effects of threat-appraisal variables are mediated by other components of PMT. and rate of onset (gradual vs.
individual. including the immediacy of the onset of the disease (near vs.. Perceived severity has been operationalized in terms of both of these dimensions in applications of PMT to health-related behavior. p. Ronis and Hare1 ( 1 989) found that the effects of severity on intention were not direct but were mediated by another variable. had difficulties in trying to operationalize rewards within the context of giving up unprotected sex because “the conceptual distinction between the reward value of a risk behavior and cost of a preventative measure may not be clear” (Abraham et al. Where the threat is perceived as severe and the behavior is complex (e. Another possibility is that perceived vulnerability. The fact that sex is less exciting without a condom could also be viewed as a response cost. For example. This difficulty in operationalizing rewards may be the reason why it appears to have been neglected in most PMT research. sudden. They found that the effects of severity were entirely mediated by the component of the model concerned with benefits of adopting the recommended response. perceived severity. 1991). 1989). This suggests that intervening variables may be involved in the relationship between vulnerability and intention and behavior. an individual may perceive AIDS to be a serious disease and perceive that using a condom is a complex behavior). 1996).. A significantly greater effect of perceived threat was obtained for uncertainty-oriented compared to certainty-oriented participants.136
MILNE ET AL. Other dimensions of severity have been highlighted. the visibility of symptoms (high vs. Smith-Klohn & Rogers. Further research is needed in order to determine whether multidimensional measures of severity would be better predictors of intentions and behavior. Abraham et al. 1994.. For example. distant). 1994). such as the ability to work (Sheeran & Abraham. the role of perceived vulnerability may be diluted.. It has also been suggested that the severity of the disease and the complexity of the behavior may influence the role of perceived vulnerability (Montgomery et al.g.
with the exception of the association between intention and behavior.. Meta-analysis showed that self-efficacy was the variable that was most strongly related to intention and concurrent behavior.PROTECTION MOTIVATION THEORY
variables. since there was only a small number of studies using health-education manipulations. There were too few studies involving health-education manipulations to be included in the meta-analysis. and. Future studies might profit from employing Bandura’s recommended strategy. These findings support the view that health-education interventions should seek to enhance self-efficacy with regard to the behavior in question (Abraham et al. experimental manipulations of PMT variables were generally very successful in bringing about subsequent changes in belief. this was the only average correlation that was close to being robust. The provision of general health education did not bring about subsequent cognitive change as often as did manipulations of specific variables. This is important since coping appraisal was found to be more successhl in predicting health-related intentions and behavior than was threat appraisal. Bandura (1991) suggests that the optimal strategy for increasing an individual’s perceived selfefficacy is to provide direct experience with the behavior. through the use of role play. it would be desirable for further research to establish whether threat appraisal is of limited predictive utility or whether its effects are being masked by mediating or moderating variables. response costs were only manipulated once (with unsuccessful cognition change). An important strength of PMT research has been that predictions have often been tested in experimental studies. 1996). This provides an opportunity to establish how successful experimental manipulations have been in bringing about changes in beliefs. The vote count also showed that self-efficacy was the PMT variable that was most consistently associated with intentions and subsequent behavior (while response costs were slightly more frequently associated with behavior than selfefficacy. This suggests that future research is needed to establish the best way to enhance self-efficacy beliefs. 1994). However. large and highly significant effects were found for manipulations of all other variables. Although. While self-efficacy was the best predictor of intention and behavior. Research to date has tended to rely on persuasive communication to increase self-efficacy. However. It is interesting to note that manipulations of perceived severity and perceived vulnerability had stronger associations with subsequent changes in belief than did manipulations of coping-appraisal variables. Coping appraisal was found to be of greater utility than threat appraisal in the prediction of health-related intentions and behavior. The present study thus adds further support to the growing evidence suggesting that self-efficacy is a major factor in determining both motivation and health-protective behavior (Schwarzer 8~ Fuchs.
. for example. self-efficacy manipulations had only a medium association with subsequent cognitive change. these data come from just two studies).
By the time the behavioral measure takes place. If intention is measured in the laboratory shortly after the intervention. telling one group of participants that they are very likely to contract lung cancer from smoking and another group that they are very unlikely to do so) are more successful in bringing about subsequent changes in belief. A vote-count was conducted to compare the effectiveness of variables manipulated during experimental studies and those manipulated in health-education designs in changing intention and behavior.g. Further research is needed to establish how best to influence cognitive change using more factual health-education information. is not a successful method of bringing about cognitive change. It seems that health education. since only two studies tested the ability of the model to predict behavior. Wurtele and Maddux (1987) suggest that the persuasive messages used in experimental manipulations may be effective in enhancing intention to change behavior. The present review shows that the processes of threat and coping appraisal have modest utility in predicting intentions to protect oneself against a health threat. there were generally no control groups that received no information. in the form of providing balanced factual information.. Relatively few studies examined how well PMT predicted subsequent behavior. and examine subsequent behavior over longer periods. Future research will need to examine cognitive change over longer periods than immediate post-tests. Specific cognitive manipulations (e. Experimental studies have yet to explore how persistent the subsequent cognitive change is. but may be less useful in producing actual behavior change. Unfortunately.138 MILNE ET AL. just high. However. This procedure is antithetical to real-world health-education programs. not least because there is no information between high vulnerability and low vulnerability provided. coping-appraisal variables had greater utility in the prediction of intention and behavior than did threat-appraisal variables. our findings also show that intentions are satisfactory predictors of health behaviors-as PMT proposes-although other PMT variables have only small-to-medium average correlations with precautionary actions. comparisons between variables measured using the two types of experimental designs cannot be made with confidence. In the specific experimental manipulation studies included in the review. 1988). Both coping-appraisal variables measured following specific manipulations and those measured following health education predicted intention better than did correlational designs. the effects of the intervention may have worn off (Weinstein. Threat-appraisal variables measured following specific manipulations generally predicted intention better than did those measured following a health-education communication or measurements of existing cognitions. Overall.versus low-information groups.
these findings can only be taken as suggestive. Measures of cognitive change are invariably taken immediately after presenting the information. perhaps because of problems in
. This may explain why manipulated variables are often better associated with intention than with behavior. the effects of the manipulation are fresh in the minds of the participants.
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