Evolutionary Psychological Science (2018) 4:340–346

https://doi.org/10.1007/s40806-018-0145-9

RESEARCH ARTICLE

The Impact of Perceived Threat of Infectious Disease

on the Framing Effect
Barış Sevi 1,2 & Terry Eskenazi 2

Published online: 19 March 2018

# Springer International Publishing AG, part of Springer Nature 2018

Abstract
The framing effect is a heuristic bias, where the way a question is presented affects people’s response to it. This study (n = 924)
investigated the influence of the behavioral immune system on the framing effect. We tested the changes in people’s responses
towards two frames (i.e., losses and gains) when presented with a threat of disease and as a function of their perceived
vulnerability to disease (PVD) level. After being randomly assigned to one of three priming conditions—disease threat, negative
threat, and no-threat—participants were presented with one of the two-frame versions (gain or loss) of the damaged painting
problem where they chose between a safe and a risky option. Finally, participants responded to the PVD scale and to demographic
questions. Results revealed that when people were primed with disease threat, those with lower PVD had a higher likelihood to
take risks in the gain frame and a lower likelihood in the loss frame. This effect was not observed when participants were primed
with negative threat or no-threat, nor for those participants with high levels of PVD. This finding suggests a specific effect of
disease threat on the framing effect.

Keywords Behavioral immune system . Framing effect . Perceived vulnerability to disease . Decision-making

Decisions are choices selected from a variety of options that
are driven by their anticipated outcomes. Decision-making
process is approached from two viewpoints. The economics
viewpoint states that joy, pleasure, or satisfaction derived from
an outcome of a decision is its utility, and an outcome that
brings the most utility is normative. Accordingly, people will
strive to make the decision with the most normative option
(von Neumann and Morgenstern 1944). The other viewpoint,
which is advocated by psychologists, argues that people are
not all that rational. They posit that outcomes and their asso-
ciated values are not identical for every person (Kahneman
and Tversky 1979). Instead, individuals assess their options
from their own subjective perspective, which relativizes the
value they assign to decision outcomes, and ultimately their
final decisions (Vohs and Luce 2010). Among the various
factors that influence this, the way the problem is portrayed
* Barış Sevi
bs0059@mix.wvu.edu
1
Department of Psychology, West Virginia University, PO Box 6040,
Morgantown, WV 26506-6040, USA
2
Department of Psychology, Koç University, Istanbul, Turkey
or perceived can particularly impact which decision outcome a
person will choose.
Tversky and Kahneman (1981, p.453) showed this framing
effect with their famous Asian disease problem. In the prob-
lem, participants make a decision about which of two pro-
grams to be implemented against an unusual Asian disease.
One program has a sure and the other has a risky outcome, yet
both programs have the same overall expected value. When
the problem is presented in a positive frame, people tend to
avoid the involved risk, whereas they tend to seek the risk
when the problem is presented in a loss frame. Follow-up
studies done with various different experimental paradigms
(e.g., gambling, the tax evasion design, the clinical reasoning)
demonstrated that framing effects can be modulated by many
different factors (Kühberger 1998) such as language, contex-
tual ambiguity, and stress (Keysar et al. 2012; Osmont et al.
2015; Pabst et al. 2013). Individual differences such as gender,
age, and personality also influence the framing effect (Best
and Charness 2015; Kiene et al. 2005; Levin et al. 2002).
Framing effects in nonhuman species have also been subject
to curiosity (e.g., Krupenye et al. 2015; Marsh and Kacelnik
2002). Chen et al. (2006) designed an experimental token
economy paradigm in which capuchin monkeys could trade
tokens with human experimenters in exchange for food.
Evolutionary Psychological Science (2018) 4:340–346
Monkeys could do the exchange with two experimenters who
gave on average the same amount of apple pieces but differed
in how they framed the final payoff. The gain-framed exper-
imenter started by showing one apple piece and sometimes
added another piece, and the loss-framed experimenter who
started by showing two pieces and sometimes removed one.
Monkeys showed a greater preference for the gain-framed
experimenter over the loss-framed experimenter. This finding
suggests that framing biases have evolutionary roots that are
shared across species (Santos and Rosati 2015).
Adaptive evolutionary mechanisms are manifest in
decision-making processes. According to the error manage-
ment theory (Haselton and Buss 2000), which concerns per-
ception and cognitive biases in decision-making, when under
uncertainty if the costs of false-positive and false-negative
errors are different, an effective strategy would be going with
the least costly error (Johnson et al. 2013). To illustrate, when
deciding between whether a car is approaching when actually
there is not, and assuming no cars are approaching when a car
actually is, it is strategic to act as if there is a car approaching
whenever we cross the road (McKay and Dennett 2009). The
behavioral immune system (BIS) refers to a set of evolved
mechanisms that adopts the same principle for biases in de-
tection of pathogens (Schaller and Park 2011).
Infectious diseases are powerful threats to human health
and fitness (Schaller and Murray 2008). In an attempt to in-
crease the adaptive fitness of the human body, there evolved a
range of mechanisms designed to fend off this threat.
Although effective, the physiological immune system is a
metabolically costly safeguard against diseases (Schaller and
Park 2011). To minimize these metabolic costs, an additional
set of mechanisms have evolved which promote specific be-
havioral responses preventing contact with and transmission
of infectious diseases. BIS serves as the first defense barrier
against pathogens (Schaller and Park 2011).
The behavioral immune system is sensitive to pathogenic
cues. When detected by the BIS, pathogenic cues activate
adaptive psychological responses, such as attitudes, cogni-
tions, and behaviors as a protection against possible disease
threats (Brown et al. 2017). A considerable amount of litera-
ture has accumulated in the recent years studying how disease
threats, and the way they are perceived, affect behavior at both
individual and group levels.
Eliminating possible contaminations and perceiving these
cues are an essential part of BIS. Therefore, people can quick-
ly detect morphological cues of infection (e.g., rashes) and
display behavioral reactions to those cues (Ackerman et al.
2009). The avoidance produced by pathogen cues has been
shown to influence individuals’ self-image. People who are
chronically more averse to germs are found to value their
physical appearance more, as well as their showing intentions
improve their appearance (e.g., purchasing facial products;
Ackerman et al. 2017). This influence of BIS has also been
341
depicted in interpersonal relations. In a study of people’s
avoidance tendencies of others, it was reported that when par-
ticipants were primed with disease people with higher PVD
levels facilitated higher levels of avoidant movement towards
faces, a behavior that serves to avoid sources of potential
infection (Mortensen et al. 2010). The motivation to avoid
possible contaminations also influences our personality. In
ancestral environments, where there were many hazardous
pathogens for human health, an adaptive tendency would have
been to avoid individuals who were possible carriers of con-
tagious diseases (Faulkner et al. 2004). Therefore, it has been
shown that extraverted people, who are at a high risk of path-
ogen transmission, tend to be less aversive to germs than
introverted people and are fewer in places with high preva-
lence of infectious diseases (Hamrick et al. 2002; Duncan
et al. 2009; Schaller and Murray 2008). In a similar vein,
prejudice against individuals who are possible pathogen car-
riers has an adaptive utility to avoid a possible transmission of
disease through contact (Kurzban and Leary 2001; Park et al.
2003). As an outcome, BIS predicts xenophobic responses, as
these responses tend to increase by temporary contextual cues
that make disease threat salient (Faulkner et al. 2004).
The literature indicates that the BIS serves to protect indi-
viduals from harm, avert losses, and biases their decisions
accordingly. The current study addresses the question of
how BIS affects decision-making vis-a-vis the framing effect.
We ask if people’s tendency to take or avoid risk depending on
the way the question is framed (i.e., loss or gain) will be
affected when they are primed with a disease threat. For this
study, we have two hypotheses. In a framing question, the
risky option involves the chance of harm, and when in loss
frame, the harm is perceived more pronounced. Given that the
aim of BIS is to avoid harm, we expect people in a loss frame,
when primed with disease threat, to take less risk. Further,
with individuals who have a more sensitive BIS, this effect
is expected to be stronger.
Method
Participants and Procedure
A total of 924 participants contributed in the study (678 fe-
male; age range 18–70 years, Mage = 24.18 years, SDage =
5.81). The participants were reached using the social media
and the Koç University Subject Pool. The social media partic-
ipants were included to a lottery for 25 TL worth gift card
from a bookstore. Koç University students were offered extra
course credit. The study was run with Qualtrics, an online
stimulus presentation program. Participants were told they
would participate in a study about individual differences and
decision-making. The study consisted of two sections: the
experimental section and the survey section. In the
342
experimental section, the participants were told that one of the
aims of this study is to understand how information is present-
ed, and were told that they will see some slides and asked to
carefully view them. Then, the software randomly assigned
the participants into one of the three priming conditions: dis-
ease threat, negative threat, and no-threat. Following this, the
participants were again randomly assigned to one of the two-
frame versions (gain or loss) of the damaged painting problem
where their assignment was to choose between a safe and a
risky program. Then in the second section, participants
responded to the PVD scale and to demographic questions.
Materials
Priming Manipulation We used a priming manipulation to
induce threat. Priming was included as a between-subjects
variable. Participants were randomly assigned to either of
the disease threat, negatively valenced (or negative) threat,
and no-threat conditions. In each condition, a slideshow con-
taining eight colored pictures was presented. The disease
threat prime condition had photographs of people with mor-
phological (e.g., red eyes) or behavioral symptoms of infec-
tious diseases (e.g., coughing). The negative threat prime con-
dition had photographs of anger, riots, and people holding
guns. In the no-threat condition, household furniture was
shown. Participants viewed each slide for a minimum of 5 s
before they chose to move onto the next slide. As a manipu-
lation check, we asked participants to write what they thought
the slideshow was about.
A pretest was conducted to avoid arousal as confound be-
tween negative and disease threat conditions. To make sure
that the photographs included in the disease threat condition
were equally physiologically arousing as those include in the
negatively valenced threat condition, we matched their per-
ceived levels of arousal. A separate sample of 38 people was
asked to rate how arousing they found an initial pool of 41
pictures (21 for negative, 20 for disease conditions). Then, 10
pairs of pictures were selected, which were matched for their
perceived level of arousal.
Framing Question To avoid any possible confounds related to
our disease threat manipulation, we chose to use the Turkish
translated version of the damaged painting problem to assess
the framing effect (Rönnlund et al. 2005). In the damaged
painting problem, participants were given the following infor-
mation, “A large museum is ravaged by fire. 600 of the
world’s most famous paintings run the risk of being destroyed.
Two alternative programs have been proposed to rescue the
paintings.” Then, participants were asked to choose between a
risky and a safe option. The frame of the options was random-
ly assigned between participants as loss (n = 467) or gain (n =
457).
Evolutionary Psychological Science (2018) 4:340–346
Perceived Vulnerability to Disease Participants completed the
Turkish translated version of the PVD scale (Duncan et al.
2009; Cronbach’s alpha = 0.78) to assess individual differ-
ences in perceived vulnerability to disease. The original ques-
tionnaire consists of two subscales: Germ Aversion and
Perceived Infectability. Germ Aversion subscale includes
eight items measuring the discomfort of individual in situa-
tions that imply high likelihood of pathogen transmission
(e.g., “It really bothers me when people sneeze without cov-
ering their mouths.”). Perceived Infectability subscale consists
of seven items assessing their personal susceptibility to dis-
ease and illness (e.g., “I am more likely than the people around
me to catch an infectious disease.”). All ratings were made on
7-point scales (1 = strongly disagree, 7 = strongly agree). The
scale was translated into Turkish with back translation meth-
od. The item “I avoid using public telephones because of the
risk that I may catch something from the previous user” of the
germ aversion subscale was discarded because public tele-
phones are not frequently used in Turkey. When the subscales
were included separately in the analysis, we did not observe
any significant relationship with other variables. Since both
subscales were correlated (p < 0.001) and averaging of the
factors has been a used method in the literature (see Tybur
et al. 2014), we used the PVD scale as a composite measure.
Results
A chi-square analysis was carried out as a preliminary analysis
to test if the framing question worked. To test the exclusive
effect of framing, this test was performed only with partici-
pants who were in the no-threat condition. The relationship
between frame type (gain vs. loss) and the option chosen
(risky vs. safe) was found significant (X 2 (1) = 18.43,
p < .01). The cross-tab analysis revealed a trend, such that
people in the loss frame condition were more likely to choose
the risky option (56.6%) while people in the gain frame con-
dition were more likely to choose the safe option (67.5%).
To test our hypotheses, we ran a two-level hierarchical
binary logistic regression analysis. We used the chosen deci-
sion, the selection of the risky vs. safe decision, as the depen-
dent variable. The dependent variable was arranged as 0 for
the times the safe option was chosen and 1 for the times the
risky option was chosen. The independent variable frame was
arranged as 1 for the loss frame and 0 for the gain frame. The
other independent variable, priming was also entered as dum-
my codes and as two different dummy variables (disease and
negative). The no-threat condition was entered as 0 for both
times. While the negative threat was entered as 1 for the neg-
ative and disease threat was entered as 1 for disease. Negative
threat was entered as 0 for the disease while disease threat was
entered as 0 for the negative. The continuous independent
variable PVD was mean centered before added to the analysis.
Evolutionary Psychological Science (2018) 4:340–346 343

Table 1 Hierarchical logistic

regression analysis for predicting Variable β SE β (Exp) β Negelgerke R2
the choice of risky option
Model 1 0.048
Frame 0.998** 0.235 2.713
Negative 0.121 0.245 1.129
Disease 0.17 0.239 1.186
Frame × negative − 0.387 0.334 0.679
Frame × disease − 0.359 0.329 0.698
Model 2 0.059
Frame 0.992** 0.236 2.697
Disease 0.164 0.246 1.115
Negative 0.109 0.241 1.178
Frame × negative − 0.371 0.336 0.69
Frame × disease − 0.346 0.332 0.708
PVD 0.097 0.195 1.102
PVD × frame − 0.27 0.267 0.763
PVD × negative − 0.261 0.281 0.77
PVD × disease − 0.441 0.272 0.644
PVD × negative × frame 0.34 0.374 1.4052
PVD × disease × frame 0.919* 0.382 2.506

*p < 0.05; **p < 0.01

In the analysis, the risky option was regressed on prime, disease threat and loss frame condition. Next, to thoroughly
frame, PVD, and their interactions. At stage one, factors frame examine the moderating effect of PVD, we divided the sample
and prime and their interactions were entered. At the second in to two groups according to PVD levels as relatively high
stage, PVD and its interactions were added. The log of odds, (above median) and relatively low (below median) PVD, and
standard errors, odds ratios, and the effect sizes of the models ran another logistic regression analysis (see Table 2).
are demonstrated in Table 1. Table 3 demonstrates the cell means and standard devia-
Both the framing effect (β = 0.992, p < 0.01), and a signif- tions for the risky options chosen separately for low- and high-
icant three-way interaction of disease, frame, and PVD (β = PVD participants in priming and frame conditions.
0.919, p = 0.016) were found to be present. This result indi- In the loss frame, disease threat led people with low PVD to
cates that the odds of choosing the risky option increased by take less risks compared to people similar in PVD and other
2.5 in a one-unit increase of PVD level for participants in the priming conditions (β = − 1.251, p = 0.007). This result sug-
gests that for people with low PVD the odds of choosing the
Table 2 Hierarchical logistic regression analysis for predicting the
choice of risky option for low- and high-PVD samples Table 3 Means and standard deviations for risky option chosen in
priming and frame conditions, shown for low- and high-PVD participants
Variable β SE β (Exp) β Negelgerke R2
PVD level Priming Frame N M SD
Low PVD 0.049
Frame 1.258** 0.338 3.52 Low PVD No-threat Loss 73 0.60 0.49
Negative 0.376 0.343 1.457 Gain 83 0.30 0.46
Disease 0.683* 0.332 1.98 Disease Loss 80 0.46 0.50
Frame × negative − 0.763 0.484 0.466 Gain 76 0.46 0.50
Frame × disease − 1.251** 0.467 0.286 Negative Loss 67 0.50 0.50
High PVD 0.073 Gain 70 0.39 0.49
Frame 0.75* 0.329 2.116 High PVD No-threat Loss 86 0.53 0.50
Negative − 0.163 0.350 0.849 Gain 71 0.35 0.48
Disease − 0.377 0.352 0.686 Disease Loss 76 0.58 0.49
Frame × negative 0.000 0.465 1.000 Gain 81 0.27 0.44
Frame × disease 0.555 0.474 1.743 Negative Loss 85 0.49 0.50
Gain 76 0.32 0.47
*p < 0.05; **p < 0.01
344
risky option decreases by 0.286 when people were in loss frame
and are primed with disease threat, than when they were in
other conditions. However, an effect of disease threat was not
observed for people with high PVD (p > 0.05). The mean levels
for the risky options chosen in priming and frame conditions for
low- and high-PVD participants are illustrated in Fig. 1.
Discussion
In this study, the possible effects of disease threat and peoples’
perceived vulnerability to disease on the framing effect was
investigated. Our study revealed three major findings: (a) the
framing effect was replicated, (b) an interaction of PVD and
framing was only present in the disease threat condition, and
(c) in the disease threat condition people with low PVD were
more inclined to choose the opposite option than the general
sample.
People in the no-threat condition showed a standard fram-
ing effect, which is a replication of previous studies (Tversky
and Kahneman 1981; Cassotti et al. 2012). This finding
showed that people tend to seek risks when in a loss frame,
while they become risk averse when in a gain frame. The
framing effect was previously been replicated in Turkey using
the Asian disease problem (Klein et al. 2014), yet this was the
first time it was replicated using the damaged painting prob-
lem. This result showed that this problem could also be used
as a material to assess framing effect in Turkish samples.
We observed that when primed with disease threat and in
the loss frame, people were more inclined to choose the risky
option as a function of their PVD levels. The crucial part of
this finding was that the interaction effect was observed only
in the disease threat condition and not the negative threat
condition. This strongly indicates that our results were driven
by the perception of disease per se and not any negative mood
or cognition. Consistent with this, a previous study also did
Fig. 1 Mean risky option chosen
in priming and frame conditions,
separately shown for low- and
high-PVD participants
Risky Option
Evolutionary Psychological Science (2018) 4:340–346
not observe an effect of negative emotional context on fram-
ing effect, when compared to a neutral context (Cassotti et al.
2012). Although “disease” is inherently negative, we found an
effect between PVD and frame only in the for disease threat
priming condition, and not for the negative, nor for the con-
trol, priming conditions. This strongly suggests that people’s
perception of pathogen threat has a particular influence on
how they respond to risky decisions as a function of their
vulnerability to potential diseases.
When we explored the interaction between frame, prime,
and PVD, we observed that the disease threat only influenced
the decisions of people with low PVD. While people with high
PVD were more likely to choose the risky option in loss frame
like others, people with low PVD were less likely to choose
the risky option. This meant that the choice of risky option
was reversed for people with low PVD and in the disease
threat.
We believe that our finding can be explained by the theory
of fight or flight, a topic which prior research has suggested to
be linked with BIS (Stevenson et al. 2012). This theory con-
cerns the power of situational contingencies as a major factor
in guiding automatic behavior (Cesario et al. 2010).
Previously, BIS has shown to be related with aversion to pos-
sible contaminations, which is akin to a flight response.
However, our findings may be showing that in some situations
BIS might be weakening this flight response, and perhaps
creating a fight response. In our priming manipulation, we
used pictures that would pose a threat of disease. For those
who perceive themselves as relatively less vulnerable, this
prime could have prompted their sense of resilience to, or
strength against disease, instead of prompting a sense of
threat, resulting in a different decision. Potentially relevant is
the findings on attitudes towards vaccines and people’s dis-
gust sensitivity. Vaccines are composed of weakened or killed
forms of microbes, and are meant to protect against infectious
diseases. Yet, those with higher disgust levels are found to
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Loss Gain Loss Gain Loss Gain Loss Gain Loss Gain Loss Gain
No-Threat Disease Negative No-Threat Disease Negative
Low PVD High PVD
Evolutionary Psychological Science (2018) 4:340–346
have a stronger negative attitude against vaccines (Clay 2017).
This shows that people with high disgust sensitivity tend to
avoid vaccines as a possible source of contamination—a flight
response—while people with low disgust sensitivity choose to
have the vaccination—a fight response. Similarly, fear is an-
other factor biasing people’s decisions (Sadler et al. 2005), as
shown by a study where people were shown a clip of a threat-
ening terrorist and were asked to indicate what policy should
be adopted to defend against terror threat. Those who were
relatively more fearful preferred submission to the terrorist’s
demands, while those with less fear preferred to decline them
(Iyer et al. 2015). This suggests that the specific response
(fight of flight) that gets activated in a threating situation will
affect how people act subsequently. In our study, people with
low PVD when primed with disease threat could have shown a
weakened flight response, and thus favoring the safe option.
This study provides strong support for the role of BIS on
decision biases by showing how peoples’ PVD levels affect
risky decisions when a threat of disease is present. Yet, future
studies are needed to understand the link between PVD and
activation of fight and flight response in the context of disease
threat.
Acknowledgments We thank Scott Withrow, Ph.D. for his comments on
an earlier version of this manuscript.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
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