Available via license: CC BY-SA 4.0
Content may be subject to copyright.
anales de psicología / annals of psychology
2021, vol. 37, nº 3 (october), 412-423
https://doi.org/10.6018/analesps.483391
© Copyright 2021: Editum. Universidad de Murcia (Spain)
ISSN print: 0212-9728. ISSN online: 1695-2294.
https://revistas.um.es/analesps
Creative Commons
4.0: BY-SA
- 412 -
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral
responses to health promotion messages
Francisca González-Javier*, Jesús Gómez-Amor† and Juan R. Ordoñana
University of Murcia (Spain) and Murcia Institute of Biomedical Research (Spain).
Título: Un enfoque psicofisiológico de los mensajes de miedo. Respuestas
autónomas, subjetivas y conductuales a los mensajes de promoción de la
salud.
Resumen: Se diseñó un estudio para analizar los efectos que tienen las
apelaciones al miedo sobre las respuestas psicofisiológicas, subjetivas y
conductuales en la población diana. Para ello, se presentaron, a 98 mujeres
de 49-50 años de edad, tres mensajes sobre el cáncer de mama promovien-
do la realización de mamografía regularmente. Los mensajes fueron elabo-
rados de manera similar a los utilizados por los programas de promoción
de la salud. Los tres tenían la misma longitud, formato y estructura, pero
variaban en determinadas claves que diferenciaban su carácter (Amenaza,
Sorpresa y Estándar/control). Durante la exposición a estos mensajes, se
registraron, de manera continua, las respuestas psicofisiológicas (frecuencia
cardíaca y frecuencia de respuestas electrodérmicas inespecíficas). Después
de ver los estímulos, se tomaron medidas de autoinforme y de personalidad
(STAI y EPQ-A). Se encontraron respuestas significativas a los mensajes
para todas las medidas psicofisiológicas. Independientemente del mensaje
presentado, el patrón de respuesta psicofisiológica se relacionó significati-
vamente con la conducta preventiva de detección del cáncer.
Palabras clave: Apelaciones al miedo. Mensajes de promoción de salud.
Respuesta Autonómica. Respuesta de orientación. Atención. Cáncer de
mama. EPPM.
Abstract: A study was designed in order to analyze the effects of fear ap-
peals on psychophysiological, subjective and behavioral responses on the
target audience. Three messages on breast cancer, promoting regular
mammography screening, elaborated in a similar way to those used by
health promotion programs, were presented to ninety-eight women aged
49-50. Messages were of equal length, format and structure but varied in
specific clues which distinguished their character (Threat, Surprise, and
Standard/control). Psychophysiological reactions (heart rate and frequency
of non- specific skin conductance responses) were recorded continuously
during message exposure. Self-report measures and personality traits
(STAI and EPQ-A) were obtained after viewing the stimulus. There were
significant responses to the messages for all psychophysiological measures.
The pattern of psychophysiological response, independent of the eliciting
message, was significantly related to cancer preventive/detection behavior.
Keywords: Fear appeals. Health promotion messages. Autonomic re-
sponse. Orienting response. Attention. Breast cancer. EPPM.
Introduction
The use of messages threatening people with adverse conse-
quences as a means to induce adherence to recommended
behaviors has a long history, especially though not limited to,
the public health domain. Yet the effectiveness and efficacy
of this strategy to promote an increase in frequency or inten-
sity of specific cognitions, attitudes, behavioral intentions, or
actual behaviors, remain controversial (Fishbein & Ajzen,
2010; Green & Witte, 2006; Ruiter, Verplanken, Kok, &
Werrij, 2003; Ooms, Jansen, Hommes, & Hoeks, 2017) and
there is considerable room for further scrutiny. Among the
models that have been proposed to explain the processing
and effects of fear appeals and the relationship between the
level of threat and efficacy in the message and the ac-
ceptance of the recommendation contained in it, the Ex-
tended Parallel Process Model (EPPM; Witte, 1992a) has a
fundamental theoretical and practical role, during the last
decades. The EPPM integrates previous research on fear ap-
peals, being able to reconcile apparently contradictory pre-
dictions and findings; it addresses specifically the question of
why this communication strategy sometimes appears to fail
and sometimes appears to succeed; and it has a structure ori-
* Correspondence address [Dirección para correspondencia]:
Francisca González Javier, Area of Psychobiology, Department of Human
Anatomy and Psychobiology, Murcia University, 30100 Espinardo-Murcia
(Spain). E-mail: fgonzal@um.es
(Article received: 13-6-2021, revised: 15-6-2021, accepted: 4-7-2021)
ented to the translation of theoretical constructs into practi-
cal decisions, which facilitates its application to public com-
munication campaigns. Finally the EPPM provides a theoret-
ical framework that fosters research and it has served as a
foundation for a great number of empirical studies (Chen,
Yang, Fu, Liu & Yuan, 2019; Doyore, Birhanu, Kebede, De-
jene & Jara, 2013; Keller, Austin & McNeill, 2017; McKay,
Berkowitz, Blumberg & Goldberg, 2004; Zonouzy, Nick-
nami, Ghofranipour & Montazeri, 2019).
Fear in Fear Appeals
Fear is not only part of the name in fear appeals. It rep-
resents, along with efficacy, a key concept in the field and,
specifically for the EPPM. According to the EPPM, fear
would be the result of the threatening information contained
in the message. If a first appraisal of the information pro-
duces the perception of threat, fear is elicited, what would
initiate and motivate message processing. If the threat is not
perceived to be high enough, fear is not elicited and there
would be no motivation for further processing of the mes-
sage, what means that no action would be taken. However,
when threat is perceived, the subject would experience fear
and such fear would motivate a second appraisal about the
efficacy of the recommendations to avert the threat and,
consequently, reduce the intensity of the unpleasant emotion
of fear. Depending on the result of this second appraisal, the
subject may engage in either danger control processes (e.g.,
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral responses to health promotion messages 413
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
actively reduce the risk), when efficacy is perceived high; or
fear control processes (e.g., deny the risk) if efficacy is per-
ceived low (Witte, 1992a; 1994). Further, threat communica-
tion should only instil a moderate amount of fear in the in-
tended recipient. Should the amount of fear become over-
whelming, people tend to ignore the details and, instead of
rationally determining how to manage the potential threat
(i.e., danger control processes), opt to become defensive and
deny the threat exists (i.e., fear control processes) (Marett,
Vedadi & Durcikova, 2019).
Therefore, according to the EPPM, threatening commu-
nications only appear to work when the amount of fear pro-
duced is not insurmountable and efficacy of recommenda-
tions to avert the threat, and reduce fear, is high in the rele-
vant behavior- population combination, either at baseline or
introduced by the message. If not, or when mere recom-
mendations at best enhance response efficacy, but without
high self- efficacy, threatening communication will have no
effect, or worse, it may backfire diverting attention automat-
ically from the message (Carrera, Muñoz & Caballero, 2010;
Chen et al., 2019; Kessels, Ruiter & Jansma, 2010; Marett,
Vedadi & Durcikova, 2019; Peters, Ruiter & Kok, 2013).
In summary, fear is the fuel of the system and its pres-
ence would be needed for the whole process to take place.
But fear is not a mere activating system acting as a reflex,
that can be switched on and off easily. Fear is a complex
emotion, and most researchers use the concept of fear, ac-
knowledging its multifactorial (cognitive, physiological and
behavioral) character (Lang, Davis, & Öhman, 2000;
Sánchez-Navarro, Martínez-Selva, Torrente, & Román,
2008). Yet the measurement itself of this variable in the fear
appeal literature frequently has not taken into account such
character. Induction of emotions like fear has been widely
used in human research to investigate the nervous system re-
sponse to different material presented as stimulus (Bradley
& Lang, 2007; Chadwick, Zoccola, Figueroa & Rabideau,
2016; Davydov, Zech, & Luminet, 2011; Hagenaars, Roelofs
& Stins, 2014; Kessels, Ruiter & Jansma, 2010; Kreibig, Wil-
helm, Roth, & Gross, 2007; Palomba, Sarlo, Angrilli, Mini, &
Stegagno, 2000; Seligowski et al., 2019). However, despite
several authors having stressed that research should include
continuous monitoring of physiological responses during the
whole study (Carey, McDermott & Sarma, 2013; Dillard,
1994; Popova, 2011; Ruiter, Abraham, & Kok, 2001; Witte,
1998), to the best of our knowledge, psychophysiological re-
actions to fear appeals have been nearly absent of the field
for the last three decades.
Two early studies within the fear-appeal literature gath-
ered objective indicators of autonomic arousal during the
exhibition of the stimulus (Mewborn & Rogers, 1979; Wat-
son, Pettingale, & Goldstein, 1983). Both found an increase
in the physiological measures associated to the high fear
stimulus. Additionally, Mewborn and Rogers found that
physiological (cardiovascular and electrodermal activity) and
self-report measures of fear were correlated. This single and
non-replicated result led to the neglect of a promising re-
search line on psychophysiological reactions to fear appeals,
and to assume that “…for the purpose of measuring fear as
a result of the EPPM based interventions, self-report
measures of fear have the highest utility because they have
high validity and are the easiest to administer” (Popova,
2011, p. 3). Thus, most of the research in this area uses sim-
ple self-report measures to analyze fear appeals (Carrera et
al., 2010; Doyore et al., 2013; Gore & Campanella, 2005;
McKay et al., 2004; Ooms et al., 2017).
A Psychophysiological Perspective
None the less, psychophysiological responses associated
with emotional reactions to fear appeals offer a more com-
plex perspective. The above mentioned approach seems to
assume that fear appeals should necessarily provoke an in-
tense arousal reaction, characterized, among others, by in-
creased hear rate (HR) and skin conductance responses
(SCR) (Witte, 1998). Thus, early studies used either an ex-
tremely unpleasant film (Mewborn & Rogers, 1979) or a
high-involvement stimulus (Watson et al., 1983), in an at-
tempt to elicit fear in the subjects, which was regarded as an
increase in these autonomic measures. However, despite in-
tense psychophysiological research over the last century,
there is no clear evidence of such emotional specificity of au-
tonomic response (Bradley & Lang, 2007; Kreibig, 2010;
Sánchez-Navarro et al., 2012). Actually psychophysiological
literature has consistently found that response to unpleasant
pictures or films leads to an increase in electrodermal activity
(Bradley, Codispoti, Cuthbert, & Lang, 2001; Gomez, Zim-
mermann, Guttormsen-Schär, & Danuser, 2005; Lang,
Greenwald, Bradley, & Hamm, 1993; Sánchez-Navarro et al.,
2008; Verschuere, Crombez, De Clercq, & Koster, 2004).
Parallely, this kind of stimuli tend to elicit heart deceleration,
instead of prompting a defensive HR acceleration (Christie
& Friedman, 2004; Gomez et al., 2005; Hagenaars et al.,
2014; Palomba et al., 2000; Sánchez-Navarro, Martínez-Selva
& Román, 2006), which would need very intense stimulation
to appear. In this sense, Lang, Bradley, and Cuthbert (1997)
proposed a model of defence cascade, according to which dif-
ferent physiological systems change at different rates de-
pending on the emotional intensity of the stimulus, the avail-
able contextual support and the organism’s learning history
(Bradley & Lang, 2007).
This defence cascade is characterized by a chain of reac-
tions starting with a bradycardia, signaling an attentional re-
sponse, that usually appears to both new and aversive stimuli
(Sánchez-Navarro et al., 2006). This attentional response has
an evolutionary meaning for its objective is the detailed eval-
uation of the stimulus potential risks (Lang et al., 1997; Brad-
ley & Lang, 2000).
Within this frame, a more recent study designed to rein-
troduce a psychophysiological perspective to the study of
fear appeals obtained a less straightforward figure reflecting
the complexity of this issue (Ordoñana, González- Javier,
Espín-López, & Gómez-Amor, 2009). Subjective and auto-
414 Francisca González-Javier et al.
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
nomic responses to a health promotion stimulus -tetanus
vaccination- with varying levels of threat (low vs. high) and
efficacy (low vs. high) were analyzed. Additionally, the effect
of these variables over subsequent behavior was ascertained
to evaluate the persuasive quality of the message. The results
showed that high threat stimuli produced an autonomic pat-
tern of response consisting of a significant heart rate de-
crease accompanied by higher skin conductance (i.e., an ori-
enting response pattern; OR), concomitantly with an in-
crease in self-reported fear and perceived threat. This pattern
of psychophysiological response has been associated with in-
creased attention to aversive stimuli that do not represent an
imminent danger requiring action by the subject (Lang et
al., 1997). The psychophysiological reaction was later related
to the main behavioral outcome to the extent that the pres-
ence of an orienting response was associated with an in-
creased probability of getting the tetanus vaccine.
These results could be explained using a more compre-
hensive view of the psychophysiological reactions elicited by
fear-arousing stimuli. According to this interpretation, the
physiological response to the high-threat message came clos-
er to a pattern related to increased attention than to a fight-
or-flight response of fear (Bradley & Lang, 2007; Cook &
Turpin, 1997). Thus, the information devoted to elicit a
scared response, actually would act generating attention to
the message and its content, rather than the emotional reac-
tion of fear. This increased attention would foster further
processing, which would increase the likelihood of compli-
ance with message recommendations. The relevance of at-
tention in the processing of narrative fear appeals has previ-
ously been highlighted (Ooms et al., 2017). As a matter of
fact, Witte already pointed out that threatening communica-
tions are only effective when they capture the attention of
the subjects, arguing “the greater the threat, the greater the
fear aroused, the more attention-getting the message” (Witte,
1992a, pg. 339). However such sort of automatic and parallel
link between attention and fear is what can be questioned,
and it can be argued that the emotion of fear would not be
always necessary for threat to be perceived on a sufficient
level, and motivation to further process the message would
depend on a cognitive risk assessment rather than on the ac-
tivation of an emotional response.
The Present Study
The present study was designed to validate these results
in a different sample and using different behaviors. While
the mentioned report was centred in getting a vaccine, we
choose attendance to mammography screening (MS). Both
behaviors represent a single action and are easily accom-
plished and measured. However, while getting a vaccine is a
preventive behavior which has no or rare emotional conse-
quences, MS is a detection-oriented behavior bearing, by it-
self, a high potential of evoking anxiety in the audience due
to the uncertainty of the results. This fact could have a rele-
vant effect both, in the subjective and psychophysiological
reactions to the messages, as well as in the subsequent health
behavior.
Another variation was included in the experimental de-
sign. Following the hypothesis that the threatening content
of the stimulus actually could arouse an attentional response
instead of an emotional one, we introduced a new message,
labelled surprise. According to Ooms et al. (2017) attention is
a crucial concept in the processing of narrative fear appeals
and was positively associated with four emotions: fear, sad-
ness, surprise, and compassion.
This new stimulus intended to provoke attention without
appealing to the classical threatening resources. Surprise is
the result of experiencing novelty (Dillard & Nabi, 2006),
and it is associated, along with fear, to increased attentional
responses (Ooms et al., 2017). Our aim in this case was to
evaluate whether a message with different characteristics but
eliciting a similar psychophysiological response could have
the same effects as the classical fear appeal on the behavior
of the audience.
In summary, based on the empirical evidence, we hy-
pothesized that:
1.
When subjects are confronted with a usual fear appeal in
health messages or health education and health promo-
tion programs (i.e., not extremely intense) their psycho-
physiological reaction would be most likely of an orient-
ing nature (OR), including cardiac deceleration and skin
conductance increase. This reaction, suggesting increas-
ing attention, resource allocation and sensory intake.
Thus, in our study we posit that a message designed to
capture attention of the audience by focusing either on
threatening information (threat message) or information
novelty/salience (surprise message) will provoke a similar
psychophysiological response of an orienting nature.
2.
The presence of this kind of response (OR) will be asso-
ciated with an increased probability of adopting the be-
havior recommended in the message, regardless of the
eliciting stimulus. Conversely, when the message elicits in
the subject a pattern of defensive response (DR), charac-
terized by HR and SC increases, fear control responses
will be elicited, and message rejection measures will in-
crease.
Method
Pilot test
We conducted a pilot test of the procedures, messages
and instruments using 15 female undergraduated Psychology
students. The average age of participants in the pilot test was
21.20 (SD = 1.014). In addition to performing initial ma-
nipulation checks, we sought feedback on the wording of
items and the manipulations during the pilot test. The pro-
cedures were considered among the audience as correct and
objective and no substantial changes to the procedures were
required for the main data collection.
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral responses to health promotion messages 415
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
Participants
Ninety eight asymptomatic women aged 49-50 years
agreed to participate. The sample was obtained through the
database of a public Breast Cancer Prevention Program. Age
was selected specifically because women enter into the pub-
lic mammogram schedule when they become 50. Hence,
these women were going to be appointed to a free public
mammogram during the next year. Contact began by a per-
sonal letter mailed to the subjects’ home address inviting
them to participate in the study. Approximately 10 days after
sending the letters, the women were contacted by telephone,
explained the procedures of the study and asked to partici-
pate. Women who reported having had a mammogram with-
in the past 24 months, and women with a prior breast neo-
plasm or any relevant illness were excluded from the study.
The study was approved by the university ethics committee.
Stimulus Materials
Three health promotion messages on breast cancer,
which encouraged regular mammography screening, were
prepared. One was regarded as threat while the others were
labelled surprise and standard.
Films were presented on a 21-inch colour TV positioned
1.5m in front of the subject. Each was 260 s long and was
divided in three phases: introduction (I = 20 s), manipulation
(M = 180 s) and recommendation (R = 60 s); only the cen-
tral part of the stimuli (manipulation) was different.
The threat film emphasized the severity and susceptibility
of breast cancer and the possible negative consequences if
early detection practices are not carried out regularly. Thus,
threatening images were used (e.g., a woman taking a wig off;
mammography images where a tumour was signalled; a
simulation of a cancer expanding for the whole body; or the
image of a cemetery) along with a locution emphasizing, for
example, that breast cancer is “one of the leading killers of
women”. Although this message was regarded as threat, the
information offered was always real and at no moment was
the presentation overstated to artificially increase the per-
ceived threat. Special care was also taken to avoid unneces-
sary disgust in the subjects. These precautions were taken in
order to preserve ecological validity and not to design an ex-
aggerated message that would be unviable for use in institu-
tional campaigns.
The surprise film was a standard low threat message but
including unexpected sequences that interrupted the course
of the stimuli. At certain moments, the screen turned sud-
denly and unexpectedly into black and a text emphasizing
the key ideas of the message was displayed. This produced
an abrupt change, interrupting the message flow, and in-
creasing the salience of specific ideas.
The standard film avoided, where possible, negative in-
formation (text or images) about breast cancer. However, at
no moment was necessary information hidden. The film
emphasized the advantages of early detection using sentenc-
es as: “mammography is a good means of early detection and
gives us an opportunity to diagnose breast cancer in its very
earliest stages”. This standard film served as a control stimu-
lus.
Apparatus and Physiological Recordings
Electrodermal Activity (EDA) was recorded by a con-
stant voltage of 0.5 V by the bipolar placement of 7- mm di-
ameter Ag/AgCl standard surface electrodes, attached by
adhesive collars to the thenar and hypothenar eminences of
the non-dominant hand. Electrodes were filled with 0.068-M
NaCl Unibase electrode paste (Fowles et al., 1981), which
was used as the contact medium. The raw signal was
acquired with Cibertec (Madrid, Spain) Biosig-CP1 module
and calibrated to detect activity in the 0-100 µSiemens (µS).
This module provided a double output in order to obtain
Skin Conductance Level and Skin Conductance Responses
in two separate channels (with AC coupling).
Changes in finger pulse volume (FPV) were registered
through an ADInstruments (Castle Hill, Australia) Pow-
erLab-MLT1010 piezo-electric pulse transducer kept in place
by attaching the Velcro strap firmly around the distal phal-
anx of the index finger of the non-dominant hand. The
transducer was connected directly to the input of an
ADInstruments PowerLab/8Sp recording system. HR was
extrapolated on line from the direct FPV sign by the soft-
ware Chart v.4.1.2. for Windows of ADInstruments, provid-
ing a pondered mean of beat to beat HR.
The PowerLab/8SP data acquisition system, with a range
of voltage of ± 10 V, controlled by an internal microproces-
sor 68340 of 32 bits at 16 MHz and a maximum sample rate
of 20 KHz on eight channels, was used in the acquisition,
amplification and filtering of the EDA and FPV signs. This
system converted analogue signals to digital signals by means
of a 16-bit A/D converter. The recording unit was connect-
ed to a PC through a USB port (500 KB/s, maximum data
transfer rate). Control of the system of acquisition, as well as
that of the parameters registration and the storing of the data
was carried out by Chart v.4.1.2. of ADInstruments for
Windows. All the psychophysiological signals were sampled
continuously at 1000 Hz throughout the experimental ses-
sion.
Self-Report Measures
Self-report measures and instruments were based on
those used previously in a study on psychophysiological re-
actions to fear appeals (Ordoñana et al., 2009). They were
composed of questions (between 3-6) for every self-report
measure ranked by a 9- point Likert scale. The reliability of
the scales was analyzed with the Cronbach’s reliability coeffi-
cient (α).
Subjective fear was measured by having subjects rate the
following mood adjectives (not at all to very much): scared,
tense, anxious, uncomfortable, nervous and fearful. These
items have been used in other threat appeal studies (Witte,
416 Francisca González-Javier et al.
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
1992b). A total score is obtained by simply adding the six
component subscales, (α = .96).
Perceived threat (α = .80) comprised of two underlying di-
mensions: perceived susceptibility to the threat, which refers
to individual’s beliefs about their risk of experiencing the
threat, and perceived severity of the threat, which refers to
beliefs about the magnitude or significance of the harm ex-
pected from the threat (Witte & Allen, 2000). Perceived suscep-
tibility was assessed with three questions like “How likely is it
for you to get breast cancer?” - not at all likely to extremely like-
ly - (α = .78). Perceived severity was measured with four ques-
tions (e.g., “How serious do you believe that breast cancer
is?”) - not at all serious to extremely serious - (α = .67).
Perceived efficacy (α = .72) was also composed of two di-
mensions: perceived response efficacy, which refers to the
effectiveness of the recommended response in averting the
threat, and self-efficacy, which refers to the audience’s ability
to carry out a recommended response (Witte & Allen, 2000).
Perceived response efficacy was assessed with five questions (e.g.,
“How effective do you believe mammography screening is in
detecting breast cancer?”) - not effective to extremely effective - (α
=.79). Self-efficacy was determined by three questions such as:
“Do you believe that it would be easy for you to have a
mammography?” - absolutely not easy to extremely easy - (α =.59).
Fear control reactions. Using the same methodology, scores
were obtained for three factors. Defensive avoidance: defined as
a tendency to ignore or deny the negative consequences
shown in a message (Hale & Dillard, 1995; Witte, 1992a,
1994). Participants were asked to respond to the following
question in three ways, “When I saw the message, my first
instinct was to”: (a) “want to/not want to think about breast
cancer”; (b) “want to/not want to do something to prevent
breast cancer”; and (c) “want to/not want to protect myself
from breast cancer” (α =.69). Message minimization: measured
by assessing the degree to which subjects derogated or min-
imized the information received through the adjectives: in-
teresting, objective, appropriate and accurate referred to the
message (α = .86). Perceived manipulation: the degree to which
subjects perceived that the message was trying to manipulate
them. Subjects were asked whether they felt “manipulated”,
“exploited”, or whether the message “deliberately tried to
manipulate my feelings” (α = .90).
Perceived surprise was measured by assessing the degree to
which the information presented in the film was valued by
the women as: new, surprising and striking (α = .85).
In order to analyze if the messages had produced a re-
sponse in the women of the study, their real behavior was
analyzed through the database of the Breast Cancer Preven-
tion Program, where assistance to the scheduled appoint-
ment is recorded. Additionally, three months later, women
who did not attend to the program’s appointment were in-
terviewed by telephone in order to collect information about
whether they have got the MS in a different facility or did
not want to take a mammogram and the reasons for rejec-
tion.
Personality Traits
Because subjective and physiological responses to affec-
tive stimuli may be influenced by personality traits (Gross,
Sutton, & Ketelaar, 1998), participants completed the Span-
ish versions of the Spielberger´s State and Trait-Anxiety In-
ventory (STAI; Spielberger, Gorusch, & Luschene, 1970)
and the Eysenck Personality Questionnaire (EPQ-A; Ey-
senck & Eysenck, 1975).
Procedure
Participants were randomly allocated to one of three
conditions (threat, surprise, and standard film). They attend-
ed a 1h long laboratory session and were tested
individually.
After their arrival, a 20-minute period of accommodation
gave participants
the opportunity to become familiar with
the laboratory environment. During this period, the trait-
anxiety inventory (STAI-T) was given prior to the experi-
mental session. After
washing their hands, they were seated
in a comfortable armchair in front of a television screen. The
procedure was then explained and the physiological sensors
were attached.
In the last 3 minutes of the accommodation
period subjects were directed to rest quietly. The formal test-
ing session started with a 5-min rest period in order to ob-
tain physiological basal levels. Then, one of the films (threat,
surprise, or standard) was presented. Physiological responses
were recorded continuously during rest, film presentation
and a 1-min post film period. Total recording time consisted
of 14 min-20 sec. Finally, the subjects completed the self-
report measures, the state anxiety inventory (STAI-S) and
the different scales of EPQ-A.
Data reduction
Any artefact-free change in skin conductance equal to or
higher than 0.05 µS was considered a response. Frequency of
Non-specific skin conductance responses (NSR) was record-
ed in number of responses per minute. FPV was expressed
in volts and HR in beats per minute, with the latter being
extrapolated from FPV data by Chart software. HR was cal-
culated from the interbeat interval (IBI; i.e., the difference in
time of the peak voltage between one finger pulse and the
peak voltage of the next). The data were converted from
beat-to-beat values of IBI to HR in beats per minute.
The time course of each response was analyzed (Table 1),
for the above-described physiological measures and for each
stimulus, by dividing the 260-s stimulus period into variable 60,
40, 35, 20 and 15-s epochs in order to preserve the emotional
content and the continuity of the sequences. The mean of the
300-s of the rest period was used as baseline score. This resulted
in 11 average measures for each subject, 1 measure correspond-
ing to the rest period, 9 average measures for the film periods (1
for introduction [I]; 6 for manipulation [M1 to M6] and 2 for
recommendation [R1 and R2]); and 1 average measure for the
post film period. For analysis, difference scores were calculated
by subtracting the baseline scores from the average of the film
epochs (Gomez et al., 2005; Palomba et al., 2000).
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral responses to health promotion messages 417
- 403 -
Table 1
Recording periods and number of averaged measures of psychophysiological responses.
TOTAL RECORDING TIME (14 min-20 sec)
Acommodation Period
(3 min)
Rest Period
(5 min)
Stimulus Period (4 min-20 sec)
Post Film Period
(2 min)
Introduction
(I)
Manipulation
(M)
Recommendation
(R)
Measures
1
1
6
2
1
Analysis
For every cognitive variable and personality trait one-way
analysis of variance (ANOVA) was applied, with message
type (high threat, low threat or surprise) as between-subjects
factor. Partial eta squared is provided for effect size. The
homoscedasticity assumption was assessed with the Levene
test. When this assumption was not met, the Welch correc-
tion of the F test was applied.
For physiological variables, a mixed ANOVA was ap-
plied to analyze the rest period, where the between-subjects
factor was the message type and the repeated measures fac-
tor was the time of measurement for each psychophysiologi-
cal index.
Mixed ANOVAs were also applied for every psycho-
physiological outcome, where the between-subjects factor
was the message type and the repeated measures factor the
difference score calculated for each moment. The homosce-
dasticity and sphericity assumptions were assessed with the
Levene and the Mauchly tests, respectively. When some of
these assumptions were not met, Greenhouse-Geisser ad-
justments for degrees of freedom were carried out. Paired t-
tests were applied to analyze the variation between rest and
introduction periods. In this case, direct scores for both
epochs were used. Since the three messages varied only in
the “manipulation” period (from M1 to M5), we designed
planned comparisons by the Sidak procedure between mes-
sages for each of those time periods.
All statistical analyses were performed with SPSS 22.0 for
Windows, and the alpha level for all comparisons was set at p
< .05.
Results
Preliminary Analyses
One-way ANOVAs revealed no significant differences
between groups in the STAI-T and in the different scales of
the EPQ-A inventory. Mean scores and standard deviations
were similar for all conditions (Table 2). No group differ-
ences in baseline physiological measures were found for
heart rate, F(2, 97) = 1.13, p = .32; or for frequency of NSR,
F(2, 97) = 1.75, p = .17.
Table 2
Mean (SD) and comparisons (ANOVAs) of personality traits by experimental group.
Threat
(n = 33)
Standard
(n = 32)
Surprise
(n = 33)
df1
df2
F
p
STAI – Trait
21.15 (11.3)
21.53 (11.2)
23.12 (10.5)
2
97
0.13
.71
EPQ
Neuroticism
11.33 (6.6)
11.34 (6.9)
12.59 (5.9)
2
97
0.40
.67
Extroversion
11.61 (4.1)
9.94 (4.2)
9.70 (4.2)
2
97
2.05
.13
Psychoticism
1.30 (1.6)
1.22 (1.0)
1.59 (1.5)
2
97
0.56
.57
The absence of statistically significant differences in
these analyses before the experimental session allowed us to
conclude that the assignment of subject to the experimental
groups had been carried out successfully.
Stimuli Effects on Psychophysiological Responses
Regarding the electrodermal activity, frequency of NSR
displayed a reliable and statistically significant increase from
rest to introduction period in all films, threat, T(32) = -3.74,
p = .001; surprise, T(32) = -5.36, p < .001; and standard,
T(31) = - 6.631, p < .001; followed by a progressive decrease
(Figure 1). After that, responses tended to return to baseline
levels although always remaining above them. A significant
effect for Time, F(155.16, 629.95) = 14.37, p < 0.001; ηp2 =
.13; was obtained. No differences were apparent between
groups, and analyses failed to reveal any significant effect for
Film, F(2,95) = 0.49, p = .61; ηp2 = .010, and Film x Time
interaction, F(13.26, 629.95) = 1.14, p = .31; ηp2 = .024.
HR also showed an initial increase between baseline and the
introductory period and diminished afterwards for all mes-
sages. The mixed ANOVA revealed a significant effect for
Time, F(3.62, 343.87) = 13.34, p < .001; ηp2 = .12; but non
significant differences on HR response for Film, F(1, 95)
=.56; p = .57; ηp2 = .01; or for Film x Time interaction,
F(7.24, 343.87) = 13.49, p = .36; ηp2 = .02. However, in
spite of the absence of global significant differences, HR re-
sponses showed a distinctive pattern between groups (Figure
2), concurrent with the moments at which stimuli were dif-
ferent (M1 to M5).
418 Francisca González-Javier et al.
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
Figure 1
Mean of NSR frequency changes over time for the experimental groups.
Figure 2.
Mean heart rate changes over time for the experimental groups.
In the surprise and standard messages, the HR increase
continued until the first epoch of the manipulation period
(M1), and later decreased progressively to return to baseline
levels. However, in the threat message, after the initial in-
crease, HR decreased pronouncedly from the first epoch of
the manipulation (M1) and fell below baseline levels at
epochs M3 and M5, coincident with the most threatening
passages of the stimulus. During M3 women were viewing
images showing a cemetery and a simulation of the growth
of a tumour in a human figure. During M5, participants were
shown a mammogram and a simulation of the extension of
breast cancer. This decrease reached significance, compared
with the scores at introduction (p < .001) and M1 (p <.05) as
shown by the a posteriori Sidak comparisons. Furthermore,
the planned comparisons by the Sidak procedure between
the messages for the M1-M5 time periods, showed differ-
ences between messages in the registered response during
some of those periods. In particular, these differences were
statistically significant for threat vs. the surprise/standard
messages at epoch M3 (p = .05) and marginally significant
for M5 (p = .06).
To summarize, results for HR show that, when infor-
mation was the same in the three messages (Epochs: I, M6,
R1 and R2), profiles were very similar for all groups, but dif-
ferences were apparent during the manipulation period (M1
to M5), when information was different and statistically sig-
nificant when the most threatening information was present-
ed (M3) and marginally (M5).
Stimuli Effects on Self-Report Measures
ANOVAs for self-report measures revealed highly sig-
nifi-cant Film effects for subjective fear, F(2, 97) = 14.58, p<
.001; ηp2 = .23; response efficacy, F(2, 58.9) = 3.43, p =
.032; η2 = .063; behavioral intentions, F(2, 97) = 4.59, p =
.012; η2 = .08; defensive avoidance, F(2, 60.3, p = 4.63, p =
.022; ηp2 = .07; and surprise, F(2, 97) = 18.35, p < .001; ηp2
= .27. Also, a marginall effect was found for message min-
imization, F(2, 97) = 2.56, p = .082; ηp2 = .05; (Table 3).
The threat film was rated as significantly more objective,
clear and precise, and it generated more subjective fear than
the surprise and standard scenes. Likewise, women who
viewed the threat film were more confident that mammog-
raphy would detect breast cancer and showed less defensive
avoidance than those viewing the other messag-es. The
threat and surprise films were those that surprised the wom-
en more. However, no significant differences in perceived
threat were observed between messages.
Correlations between Self-Report of fear and Psy-
chophysiological Responses
Pearson correlation coefficients were calculated between
self-report and psychophysiological responses. There were
no significant correlations between average NSR frequency,
HR and any of the self-report variables. On the other hand,
subjective scores of fear were significantly, though moder-
ately, correlated with perceived susceptibility, perceived se-
verity, defensive avoidance and perceived surprise (Table 4).
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral responses to health promotion messages 419
- 403 -
Table 3
Means (SD) and comparisons (ANOVAs) of self-report responses to the messages by experimental group.
Threat (n = 33)
Standard (n = 32)
Surprise (n = 33)
df1
df2
F
p
Subjective fear
4.13 (1.60)
2.27 (1.21)
2.70 (1.52)
2
97
14.59
.000
Perceived susceptibility
5.91 (1.41)
6.01 (0.98)
5.85 (1.26)
2
62.2
0.17ª
.850
Perceived Severity
7.48 (0.98)
7.66 (0.61)
7.37 (0.62)
2
61.9
1.69ª
.192
Response Efficacy
7.22 (0.64)
6.63 (1.09)
6.99(1.06)
2
58.9
3.64ª
.032
Self-Efficacy
7.27 (0.70)
7.26 (1.00)
7.35 (1.15)
2
60.2
0.07ª
.930
Perceived Surprise
4.63 (1.43)
2.82 (1.22)
4.83 (1.64)
2
97
18.35
.000
Behavioral Intention
7.46 (1.46)
6.01 (2.18)
6.97 (2.16)
2
97
4.59
.012
Defensive Avoidance
7.23 (0.79)
6.49 (1.27)
6.75 (1.18)
2
60.3
4.64ª
.013
Message Minimization
7.83 (0.79)
7.30 (1.20)
7.69 (0.91)
2
97
2.57
.082
Perceived Manipulation
7.09 (1.06)
7.50 (1.12)
7.44 (1.19)
2
97
1.27
.286
Means (and standard deviations) are presented for messages. df: degrees of freedom. F: F test. p: probability level. ª F test with Welch correction was applied
because the homoscedasticity assumption was not met.
Table 4
Pearson intercorrelation coefficients between self-report and psychophysiological measures.
Fear
Suscep
Sever
Effic
Minim
Manip
Avoid
Surprise
HR
NSR
Subjective fear (Fear)
--
Perceived susceptibility (Suscep)
.34**
--
Perceived severity (Sever)
.24*
.52**
--
Perceived efficacy (Effic)
.15
.12
.63
--
Message minimization (Minim)
.16
.11
.14
.13
--
Perceived manipulation (Manip)
-.70
.21*
.01
.12
.12
--
Defensive avoidance (Avoid)
.21*
.22*
.10
.32**
.63**
.30**
--
Perceived surprise (Surprise)
.33**
.14
.12
.14
.43**
-.10
.11
--
HR
.02
.02
-.06
-.85
-.01
.07
-.13
-.34
--
NSRs
.01
.05
-.03
-.06
-.03
-.01
.11
-.06
.13
--
**p < .01; *p < .05
Outcome Variables: Assistance to Mammography
Screening
Actual assistance to MS was very high. Eight out of ten
(81.4%) women from the global sample went to a health
centre for preventive MS. In order to analyze this variable,
women were divided into three groups: (a) those who fol-
lowed the message recommendation and took a mammo-
gram when they received the scheduled appointment from
the Breast Cancer Prevention Program (SA); (b) those who
did not wait for the appointment and requested an MS ap-
pointment by themselves (RA); and (c) those who did not at-
tend to MS in spite of having received the appointment
(NA). This allowed us for a double comparison: assistance
vs. non assistance (A vs. NA); and, within the assistance
group, adherents to the recommended scheduled appoint-
ment vs. anticipated requested mammogram (SA vs. RA).
T-tests for independent samples were used to compare
between the means of subjective variables in different out-
come groups. Results showed some differences between as-
sistance (A) and non assistance (NA) groups. Women who
took the mammogram showed significantly higher per-
ceived susceptibility, t(20.2) = 2.14, p = .04; higher per-
ceived threat, t(20.2) = 2.07, p = .05; higher behavioral inten-
tions, t(20.7) = 2.25, p = .03; and, marginally, less defensive
avoidance, t (20.2) = -2.04, p =.054. Among those who took
a mammogram, women who were compliant with message
instructions (SA) scored lower in trait anxiety, t(77) = -3.70,
p < .01; and neuroticism, t(77) = -2.15, p = .034; than those
who did not wait and requested a mammogram by them-
selves (RA) .
Later on, in order to go more deeply into the possible re-
lationship between psychophysiological reactions to the
stimuli and the probability of following the recommenda-
tions contained in the message, a categorization on the basis
of the main direction of psychophysiological responses was
carried out (Ordoñana et al., 2009). Subjects were divided in-
to three groups on the basis of their main psychophysiologi-
cal reactions, following the defense cascade model (Bradley
& Lang, 2007):
1.
Subjects who reacted with an average decrease in HR
combined with an increase in frequency of NSR were
categorized as showing a Stage I pattern (OR; n = 14;
17.7%).
2.
Those who showed an average increase in HR and fre-
quency of NSR while viewing the stimulus were catego-
rized as showing a Stage II pattern of response (DR; n =
49; 62.0%).
3.
Finally, subjects who did not show any of these profiles
were included in a third category named indefinite re-
sponse (IR; n = 16; 20.3%).
This a posteriori categorization expands the analyses to
include not only the magnitude of the autonomic reaction
but also its orientation.
Results showed that outcome behavior seemed to be in-
fluenced by the kind of psychophysiological response pattern
420 Francisca González-Javier et al.
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
developed by the subjects. Hence women who presented a
Stage I pattern of response (OR) were more likely to follow
message instructions and to attend the MS appointment de-
livered by the public prevention program,
2(1) = 4.723, p =
.03. However, the probability of making an appointment for
themselves rather than waiting for the scheduled appoint-
ment was higher for women who presented a Stage II pat-
tern of response (DR),
2 (1) = 7.498, p = .006 (Figure 3).
Figure 3
Percentage of outcome behavior (SA/RA/NA) according to the kind of psy-
chophysiological response pattern (OR/DR).
Discussion and Conclusions
The primary aim of this study was to analyze the role of psy-
chophysiological and subjective responses on the intentional
and behavioral effects of health promotion messages, includ-
ing fear or attentional appeals.
Support for the postulated hypotheses shows mixed re-
sults. Regarding psychophysiological response to the mes-
sages, all the stimuli provoked alterations in the autonomic
response. Hence, frequency of NSR profiles showed a signif-
icant increase as compared to the levels registered during the
rest period. This result is in consonance with studies which
concluded that the different measures of electrodermal activ-
ity show an increase in front of arousing stimuli (Bradley et
al., 2001; Gomez et al., 2005; Lang et al., 1993; Verschuere et
al., 2004). However, we were not able to find significant dif-
ferences between the three stimuli in this kind of response.
Cardiac response also behaved with an initial increase in
HR, as compared to basal levels. The magnitude of this vari-
ation was similar to that obtained by other studies (Baldaro
et al., 2001; Gomez et al., 2005; Harrison et al., 2000; Pal-
omba et al., 2000; Vögele, Coles, Wardle, & Steptoe, 2003).
After the increase, and immediately after the beginning of
the manipulation period, where differences between messag-
es were introduced, HR started to diminish progressively.
The magnitude of this decrease was associated with the more
threatening passages of the stimulus. Thus, it started earlier
during the “threat” film, and reached its minimum at two
moments (M3 and M5) where the contents of the message
were more impressive. Similar decreases in cardiac activity
are typically found during exposure to negative images
(Bradley et al., 2001; Gomez et al., 2005; Lang et al., 1993;
Palomba et al., 2000; Verschuere et al., 2004).
All in all, our experimental manipulations were not able
to generate clearly different psychophysiological responses
between the three messages. That is, despite some indication
of a differential effect for the threat stimuli, we cannot claim
success producing different levels of arousal associated to
the characteristics of the message. It is well known that mes-
sages designed to modify audience’s perceptions may not al-
ways be effective in doing so (Maloney, Lapinski, & Witte,
2011). There are at least two possible explanations that could
account for this lack of significance. Firstly, stimuli may not
have been sufficiently diverse to generate such differences. It
must be taken into account that breast cancer is in itself a re-
al threat to women. Although the surprise and standard mes-
sages tried to minimize threatening information, complete
elimination was not possible without distorting the message
and undermining the ecological validity of the information.
In fact, although subjective fear was greater for the threat
stimulus, perceived threat was not significantly different be-
tween messages. An alternative explanation concerns the
magnitude of the responses. Although they fall into the same
range as that obtained in comparable studies (Baldaro et al.,
2001; Gomez et al., 2005; Harrison et al., 2000; Palomba et
al., 2000; Vögele et al., 2003), it may not have been high
enough to show significant differences. We must remember
that our stimuli, while depicting relevant aspects of breast
cancer, were not designed to generate an anxious state. In-
deed, care was taken to design messages that, while dealing
with threatening information, were sensitive enough to be
used as a promotional communications that could be di-
rected to the general population. Consequently, increasing
the magnitude of the threat to obtain higher differences on
autonomic response would not be a coherent option, nor
would it be considered ethical for this case. Stimuli dealing
with a less sensitive issue, allowing for more intense threat-
ening information and greater message differences without
compromising its nature and objectives (like car accidents or
drug use), could be capable of generating distinct responses
more easily.
Nevertheless, what is more important is that psycho-
physiological responses to the messages did appear to be rel-
evant at modulating the subsequent behavioral response. In-
dependently of the kind of message that were exposed to,
subjects showed different psychophysiological response pat-
terns that could be associated with posterior behavior. It is
likely that individual characteristics or differences in stress
load interact with message conditions in order to produce
differential responses (Brownley, Hurwitz, & Schneiderman,
2000). Thus, it is the response, not the message itself what
could be more directly associated to message behavioural ef-
fects. In concordance with previous results, an autonomic
pattern of response consisting of a heart rate decrease ac-
companied by an increase in skin conductance was related to
a greater likelihood of following the instructions contained in
the message (Ordoñana et al., 2009). Alternatively, we found
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral responses to health promotion messages 421
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
that those women who did not follow the instructions in the
message, and anticipated to request a mammogram by them-
selves, before scheduled, were more likely to show a defen-
sive response pattern (i.e., concomitant increases in HR and
SC).
A decrease in HR in the face of aversive stimulation has
been associated with the facilitation of stimulus perception
(Lang et al., 1997; Palomba et al., 2000). It has been inter-
preted in terms of perceptive-attentional requirements of
emotional stimuli, and is related to the orienting response.
Thus, a sustained HR decrease has been considered as an in-
dex of continuous attention towards aversive stimuli (Cook
& Turpin, 1997; Gomez et al., 2005; Palomba et al., 2000).
However, while HR deceleration is associated to an orienting
response, acceleration relates to defensive responses
(Verschuere et al., 2004).
The defence cascade model (Lang et al., 1997) proposed
that the difference between OR and DR is not dichotomous
but directly related to stimulus aversiveness. This aversive-
ness depends on the quality of the stimulus, but also on con-
textual situation, personal experience and individual charac-
teristics. When the aversive level of the stimulus is low, at-
tention is directed towards novelty or significant information
rather than to known or neutral stimuli. In this case, sus-
tained cardiac deceleration is indicative of continued atten-
tion to an aversive stimulus and occurs when the defensive
system is moderately activated but action is not imminent
(Öhman, Hamm, & Hugdahl, 2000). This would be reflected
in a classical OR (SC increase and HR decrease). However,
when the aversive level of the stimulus is higher, orienting
arousal turns to defensive activation to prepare an organism
for basic flight-or-fight reactions, with a pronounced re-
sponse involving HR acceleration.
That is, as expected, it seems that a pattern of psycho-
physiological response indicative of stimulus perception and
attention is associated with adherence to message recom-
mendations. This could imply a relationship between the de-
gree of attention to and processing of the information con-
tained in the stimulus and the later behavior (Ordoñana et
al., 2009). Thus, it would seem that the information devoted
to elicit a scared response, actually could generate attention
to the message in some subjects.
However, other subjects showed a defensive autonomic
pattern, which is the kind of response associated to an emo-
tional reaction to aversive stimuli, like fear. These subjects
also were compliant on taking a preventive mammogram,
but their behavior was not exactly the same. They were more
likely to anticipate and request the MS before they could be
scheduled. This could be explained as an answer to a higher
degree of anxiety that should be resolved as soon as possible.
The fact that these women had also higher scores on trait-
anxiety and neuroticism points to a similar conclusion.
These results can be integrated into the theoretical struc-
ture of the EPPM opening some new perspectives and high-
lighting at least three specific points. Firstly, as suggested be-
fore, a strong emotional response would not be always nec-
essary for threat to be perceived on a sufficient level. Threat-
ening information does not always produce fear, and not in
every subject. Whether it elicits an attentional or an emo-
tional response would depend on the message, the contextu-
al clues, and the personal experience and characteristics of
the subject. Attention is more likely to be directed to stimuli
with a motivational significance for the individual (Lang et
al., 1997). Hence in the context of a classical health preven-
tion message, focusing on severity and susceptibility may
trigger attention, and motivate the further processing of the
message, but there would be no need to actually elicit
fear. A cognitive appraisal evaluating a possible, but non-
imminent, risk may suffice as a motivational factor to con-
tinue processing the message. Secondly, our data supports
the EPPM proposition regarding the behavioral outcomes.
According to this model, when people experience fear they
are motivated to reduce that fear by engaging in either dan-
ger or fear control processes, as determined by the efficacy
appraisal. Women in our sample that showed a defensive
pattern of response were more likely to show an intermedi-
ate response: they took the mammogram, but they did not
follow the instructions in the message to get it. Apparently,
they were too anxious to wait for a scheduled appointment
and needed to resolve as soon as possible. In this case, the
behavior displayed was correct (in terms of getting the
mammogram), but they did not follow correctly the instruc-
tions of the message. It could be said that they engaged in
fear control processes but displaying an adaptive behavior.
This fact could be related to suboptimal responses of the
public (theoretically adequate but excessive and inefficient)
in front of health threats that can generate also dysfunctional
situations. Overreactions to health threats provoking prob-
lems in health care services (e.g., excessive demands), social
environments (e.g., isolation requests) or even markets (e.g.,
generalization of refusal to unaffected food products due to
a food alert), are common and relatively frequent examples
of this. Thirdly, our results do not support the notion that
measuring subjective fear can be an adequate substitute for
psychophysiological responses. We have not been able to
find significant correlations between psychophysiological
and subjective fear responses, and the same result was ob-
tained in a previous report (Ordoñana et al., 2009). Classical
theory in the psychophysiology of emotions assumes that the
three systems that define emotion (subjective reports, physi-
ological responses, and overt behavior) do not necessary
show high correlations (Lacey & Lacey, 1970) and, actually,
the reports of affective experience and physiology are as-
sumed to show discordance (Bradley & Lang, 2007). Hence,
the analysis of psychophysiological responses can offer, by
itself, relevant and unique information to interpret the ef-
fects of this kind of stimuli.
There are several limitations of the present study that
warrant discussion and point to future directions for re-
search. Firstly, the objective itself of the study and, as noted
before, the nature of the topic of breast cancer, did not allow
us to introduce extreme differences between messages. This
422 Francisca González-Javier et al.
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
lack of dissimilarity could have contributed to the absence
of clearly significant differences in the psychophysiological
responses to the stimuli. Secondly, low relilability of some of
the self-report sub-scales (i.e., perceived severity, self-
efficacy and defensive avoidance) may have affected part of
the results of the analysis involving self-reports.
Finally, although sample size was similar to that used by
other studies (Christie & Friedman, 2004; Gomez et al.,
2005; Harrison et al., 2000; Palomba et al., 2000), and in
spite of its ecological validity, sample amplification might
have led to more meaningful results.
In summary, this study presents a psychophysiological
approach to the analysis of behavioral effects of messages
used in health promotion campaigns. We report specific rela-
tionships between autonomic responses and outcome varia-
bles that may help to understand how people react to mes-
sages conveying relevant information. Our conclusions may
be integrated within current theoretical models, such as
EPPM, supporting it and opening some new perspectives.
Future research is required to extend these findings, and to
explore the relationship between psychophysiological and
subjective response patterns to real stimuli, as well as the ef-
fect of these factors on behavioral variables.
Acknowledgements.- The authors are grateful to Dr. Julio
Sánchez-Meca for his assistance during data analysis as well as to
the Breast Cancer Prevention Program in Murcia (Spain) and the
Public Health Authorities in Murcia (Spain) for their assistance in
this project.
References
Baldaro, B., Mazzetti, M., Codispoti, M., Tuozzi, G., Bolzani, R., & Trom-
bini, G. (2001). Autonomic reactivity during viewing of an unpleasant
film. Perceptual. & Motor Skills, 93, 797-805.
https://doi.org/10.2466%2Fpms.2001.93.3.797
Bradley, M. M., & Lang, P. J. (2007). Emotion and Motivation. In J. T.
Cacioppo, L. G. Tassinary, & G. G. Berntson (Eds.), Handbook of Psy-
chophysiology (3rd ed.) (pp.581-607). Cambridge University Press.
Bradley, M. M, & Lang, P. J. (2000). Measuring emotion: behavior, feeling,
and physiology. In R. D. Lane, L. Nadel (Eds.), Cognitive Neuroscience of
Emotion (pp. 242– 276). Oxford University Press.
Bradley, M. M., Codispoti, M., Cuthbert, B. N., & Lang, P. J. (2001). Emo-
tion and motivation I: defensive and appetitive reactions in picture pro-
cessing. Emotion 1, 3, 276-298. https://doi.org/10.1037/1528-
3542.1.3.276
Brownley, K. A., Hurwitz, B. E., & Schneiderman, N. (2000). Cardiovascu-
lar psychophysiology. In J. T. Cacioppo, L. G. Tassinary, G. G. Bern-
tson (Eds.), Handbook of Psychophysiology (2nd ed.)(pp. 224-264), Cam-
bridge University Press.
Carey, R. N., McDermott, D. T., & Sarma, K. M. (2013). The Impact of
Threat Appeals on Fear Arousal and Driver Behavior: A Meta-Analysis
of Experimental Research 1990-2011. PloS ONE, 8(5), e62821.
https://doi.org/10.1371/journal.pone.0062821
Carrera, P., Muñoz, D., & Caballero, A. (2010). Mixed emotional appeals in
emotional and danger control processes. Health Communication, 25, 726-
736. https://doi.org/10.1080/10410236.2010.521914
Chadwick, A. E., Zoccola, P. M., Figueroa, W. S., & Rabideau, E. M. (2016).
Communication and stress: Effects of hope evocation and rumination
messages on heart rate, anxiety, and emotions after a stressor. Health
Communication, 31(12), 1447-1459.
https://doi.org/10.1080/10410236.2015.1079759
Chen, L., Yang, X., Fu, L., Liu, X., & Yuan, C. (2019). Using the Extended
Parallel Process Model to examine the nature and impact of breast can-
cer prevention information on mobile-based social media: Content
analysis. JMRI mHealth and uHealth, 7(6), e13987.
https://doi.org/10.2196/13987
Christie, I. C., & Friedman, B. H. (2004). Autonomic specificity of discrete
emotion and dimensions of affective space: a multivariate approach. In-
ternational Journal of Psychophysiology, 51, 143-153.
https://doi.org/10.1016/j.ijpsycho.2003.08.002
Cook, E. W., & Turpin, G. (1997). Differentiating orienting, startle, and de-
fense responses: The role of affect and its implications for psycho-
pathology. In P. J. Lang, R. F. Simons & M. Balaban (Eds.), Attention
and orienting: Sensory and motivational processes (pp.137-164). Lawrence Erl-
baum Associates.
Davydov, D. M., Zech, E., & Luminet, O. (2011). Affective Context of
Sadness and Physiological Response Patterns. Journal of Psychophysiology,
25, 67-80. https://doi.org/10.1027/0269-8803/a000031
Dillard, J. P. (1994). Rethinkin the study of fear appeals: An emotional per-
spective. Communication Theory, 4(4), 295-323.
https://doi.org/10.1111/j.1468-2885.1994.tb00094.x
Dillard, J. P., & Nabi, R. L. (2006). The persuasive influence of emotion in
cancer prevention and detection messages. Journal of Communication,
56(1), 123–139. https://doi.org/10.1111/j.1460-2466.2006.00286.x
Doyore, F., Birhanu, Z., Kebede, Y., Dejene, T., & Jara, D. (2013). Are
people controlling the danger or fear for condom use as HIV/AIDS
preventive message? An evaluative type of study based on extended
parallel process model. Journal of AIDS & Clinical Research, 4 (12), 264.
https://doi.org/10.4172/2155-6113.1000264
Eysenck, H. J., & Eysenck, S. B. G. (1975). Manual of the Eysenck Personality
Questionnaire Junior and Adult. Hodder and Stoughton.
Fishbein, M., & Ajzen, I. (2010). Predicting and changing behaviour: The reasoned
action approach. Psychology Press.
Fowles, D. C., Christie, M. J., Edelberg, R., Grings, W. W., Lykken, D. L., &
Venables, P. H. (1981). Publication recommendations for electrodermal
measurements. Psychophysiology, 18(3), 232-239.
https://doi.org/10.1111/j.1469-8986.1981.tb03024.x
Gore, T., & Campanella, C. (2005). Testing the theoretical design of a health
risk message: reexamining the major tenets of the Extended Parallel
Process Model. Health Education & Behavior, 32(1), 27-41.
https://doi.org/10.1177/1090198104266901
Green, E. C., & Witte, K. (2006). Can fear arousal in public health cam-
paigns contribute to the decline of HIV prevalence? Journal of Health
Communication, 11(3), 245–259.
https://doi.org/10.1080/10810730600613807
Gomez, P., Zimmermann, P., Guttormsen-Schär, S., & Danuser, B. (2005).
Respiratory responses associated with affective processing of film stim-
uli. Biological Psychology, 68, 223-235.
https://doi.org/10.1016/j.biopsycho.2004.06.003
Gross, J. J., Sutton, S. K., & Ketelaar, T., 1998. Relations between affect and
personality: Support for the affect-level and affective-reactivity views.
Personality and Social Psychology Bulletin, 24, 279-288.
https://doi.org/10.1177%2F0146167298243005
Hagenaars, M. A., Roelofs, K., & Stins, J. F. (2014). Human freezing in re-
sponse to affective films. Anxiety, Stress & Coping: An International Jour-
nal, 27(1), 27-37. https://doi.org//10.1080/10615806.2013.809420
Hale, J. L., & Dillard, J. P. (1995). Fear appeals in health promotion cam-
paigns: too much, too little, or just right?. In E. Maibach, R. L. E. Par-
rot (Eds.), Designing Health Messages. Approaches from Communication Theory
and Public Health Practice (pp.65-80). Sage Publications.
Harrison, L. K., Carroll, D., Burns, V. E., Corkill, A. R., Harrison, C. M.,
Ring, C., & Drayson, M. (2000). Cardiovascular and secretory immuno-
globulin: A reactions to humorous, exciting and didactic film presenta-
tions. Biological Psychology, 52(2), 113-126.
https://doi.org/10.1016/s0301-0511(99)00033-2
A psychophysiological approach to fear appeals. Autonomic, subjective and behavioral responses to health promotion messages 423
anales de psicología / annals of psychology, 2021, vol. 37, nº 3 (october)
Keller, S. N., Graham-Austin, C., & McNeill, V. (2017). A theater interven-
tion to promote communication and disclosure of suicidal ideation.
Journal of Applied Communication Research, 45(3), 294-312.
https://doi.org/10.1080/00909882.2017.1320569
Kessels, L. T. E., Ruiter, R. A. C., & Jansma, B. M. (2010). Increased atten-
tion but more efficient disengagement: Neuroscientific evidence for de-
fensive processing of threatening health information. Health Psychology,
29(4), 346-354. https://doi.org/10.1037/a0019372
Kreibig, S. D., Wilhelm, F. H., Roth, W. T., & Gross, J. J. (2007). Cardio-
vascular, electrodermal, and respiratory response patterns to fear –and
sadness- inducing films. Psychophysiology, 44(5), 787-806.
https://doi.org/10.1111/j.1469-8986.2007.00550.x
Kreibig, S. D. (2010). Autonomic nervous system activity in emotion: A re-
view. Biological Psychology, 84, 394-421.
https://doi.org/10.1016/j.biopsycho.2010.03.010
Lacey, J.I, & Lacey, B.C. (1970). Some autonomic-central nervous system
interrelationship. In P. Black (Ed.), Physiological Correlates of Emotion (pp.
205-227). New York, NY: Academic Press.
Lang, P.J., Bradley, M.M., & Cuthbert, B.N. (1997). Motivated attention: af-
fect, activation, and action. In P. J. Lang, R. F. Simons, M. T. Balaban
(Eds.), Attention and Orienting: Sensory and Motivational Processes (pp. 97-
136). Lawrence Erlbaum Associates.
Lang, P. J., Davis, M., & Öhman, A. (2000). Fear and anxiety: Animal mod-
els and human cognitive psychophysiology. Journal of Affective Disorders,
61(3), 137- 159. https://doi.org/10.1016/s0165-0327(00)00343-8
Lang, P. J., Greenwald, M. K., Bradley, M. M., & Hamm, A. O. (1993).
Looking at pictures: affective, facial, visceral, and behavior reactions.
Psychophysiology, 30(3), 261-273. https://doi.org/10.1111/j.1469-
8986.1993.tb03352.x
Maloney, E. K., Lapinski, M. K., & Witte, K. (2011). Fear Appeals and Per-
suasion: A Review and Update of the Extended Parallel Process Model.
Social and Personality Psychology Compass, 5(4), 206-219.
https://doi.org/10.1111%2Fj.1751- 9004.2011.00341.x
Marett, K., Vedadi, A., & Durcikova, A. (2019). A quantitative textual analy-
sis of three types of threat communication and subsequent maladaptive
responses. Computers & Security, 80, 25-35.
https://doi.org/10.1016/j.cose.2018.09.004
McKay, D. L., Berkowitz, J. M., Blumberg, J. B., & Goldberg, J. P. (2004).
Communicating cardiovascular disease risk due to elevated homocyste-
ine levels: Using the EPPM to develop print materials. Health Education
& Behavior, 31(3), 355-371.
https://doi.org/10.1177/1090198104263353
Mewborn, C. R., & Rogers, R. W. (1979). Effects of threatening and reas-
suring components of fear appeals on physiological and verbal
measures of emotion and attitudes. Journal of Experimental Social Psycholo-
gy, 15(3), 242-253. https://doi.org/10.1016/0022-1031(79)90035-0
Öhman, A., Hamm, A., & Hugdahl, K. (2000). Cognition and the autonom-
ic nervous system. In T. T. Cacioppo, L. G. Tassinary, G. G. Berntson
(Eds.), Handbook of Psychophysiology (2nd ed.) (pp. 533-571). Cambridge
University Press.
Ooms, J. A., Jansen, C. J. M., Hommes, S., & Hoeks, J. C. J. (2017). “Don´t
make my mistake”: on the processing of narrative fears appeals. Interna-
tional Journal of Communication, 11, 4924-4945.
Ordoñana, J. R., González-Javier, F., Espín-López, L., & Gómez-Amor, J.
(2009). Self- report and Psychophysiological Responses to Fear Ap-
peals. Human Communication Research, 35, 195-220.
https://doi.org/10.1111/j.1468-2958.2009.01344.x
Palomba, D., Sarlo, M., Angrilli, A., Mini, A., & Stegagno, L. (2000). Cardiac
responses associated with affective processing of unpleasant film stimu-
li. International Journal of Psychophysiology, 27, 55-67.
https://doi.org/10.1016/s0167-8760(99)00099-9
Peters, G-J. Y., Ruiter, R. A. C., & Kok, G. (2013). Threatening communi-
cation: a critical re-analysis and a revised meta-analytic test of fear ap-
peal theory. Health Pschology Review, 7(1), 8-31.
https://doi.org/10.1080/17437199.2012.703527
Popova, L. (2011). The Extended Parallel Process Model: Illuminating the
Gaps in Research. Health Education & Behavior, 39(4), 455-473.
https://doi.org/10.1177/1090198111418108
Ruiter, R. A. C., Abraham, C., & Kok, G. (2001). Scary warnings and ration-
al precautions: A review of the psychology of fear appeals. Psychology and
Health, 16, 613-630. https://doi.org/10.1080/08870440108405863
Ruiter, R. A. C., Verplanken, B., Kok, G., & Werrij, M. Q. (2003). The role
of coping appraisal in reactions to fear appeals: Do we need threat in-
formation? Journal of Health Psychology, 8, 465-474.
https://doi.org/10.1177/13591053030084006
Sánchez-Navarro, J. P., Martínez-Selva, J. M., & Román, F. (2006). Uncov-
ering the relationship between defence and orienting in emotion: Cardi-
ac reactivity to unpleasant pictures. International Journal of Psychophysiology,
61, 34-46. https://doi.org/10.1016/j.ijpsycho.2005.10.023
Sánchez-Navarro, J. P., Martínez-Selva, J. M., Torrente, & Román, F.
(2008). Psychophysiological, behavioral, and cognitive indices of the
emotional response: A factor-analytic study. The Spanish Journal of Psy-
chology, 11(1), 16-25. https://doi.org/10.1017/s1138741600004078
Sánchez-Navarro, J. P., Martínez-Selva, J. M., Torrente, G., Pineda, S., Mur-
cia-Liarte, J. B. & Carrillo-Verdejo, E. (2012). Preattentive processing
of feared stimuli in blood–injection–injury fearful subjects. International
Journal of Psychophysiology, 84, 95-101.
https://doi.org/10.1016/j.ijpsycho.2012.01.016
Seligowski, A.V., Lebois, L.A.M., Hill, S.B., Kahhale, I., Jovanovic, T., Win-
ternitz, S.R., Kaufman, M.L. & Ressler, K.L. (2019). Autonomic re-
sponses to fear conditioning among women with PTSD and dissocia-
tion. Depression and Anxiety, 36(7), 625-634.
https://doi.org/10.1002/da.22903
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the
State-Trait Anxiety Inventory. Consulting Psychologist Press.
Verschuere, B., Crombez, G., De Clercq, A., & Koster, E. H. W. (2004).
Autonomic and behavioral responding to concealed information: dif-
ferentiating orienting and defensive responses. Psychophysiology, 41, 461-
466. https://doi.org/10.1111/j.1469- 8986.00167.x
Vögele, C., Coles, J., Wardle, J., & Steptoe, A. (2003). Psychophysiologic ef-
fects of applied tension on the emotional fainting response to blood
and injury. Behavior Research and Therapy, 41(2), 139-155.
https://doi.org/10.1016/S0005-7967(01)00133-4
Watson, M., Pettingale, K.W., & Goldstein, D. (1983). Effects of a fear ap-
peal on arousal, self-reported anxiety, and attitude towards smoking.
Psychological Reports, 52(1), 139-146.
https://doi.org/10.2466%2Fpr0.1983.52.1.139
Witte, K. (1992a). Putting the fear back into fear appeals: the extended par-
allel process model. Communication Monographs, 59, 329-349.
https://doi.org/10.1080/03637759209376276
Witte, K. (1992b). The role of threat and efficacy in AIDS prevention. Inter-
national Quarterly of Community Health Education, 12, 225-249.
https://doi.org/10.2190%2FU43P- 9QLX-HJ5P-U2J5
Witte, K. (1994). Fear control and danger control: a test of the Extended
Parallel Process Model EPPM. Communication Monographs, 612, 113-134.
https://doi.org/10.1080/03637759409376328
Witte, K. (1998). Fear as motivator, fear as inhibitor: Using the extended
parallel process model to explain fear appeal successes and failures.
In P. A. Andersen & L. K. Guerrero (Eds.), The Hand-Book of Communi-
cation and Emotion: Research, theory, application and context (pp. 423-450).
San Diego, CA: Academic Press.
Witte, K., & Allen, M. (2000). A meta–analysis of fear appeals: implications
for effective public health campaigns. Health Education & Behavior, 275,
591-615. https://doi.org/10.1177%2F109019810002700506
Zonouzy, V. T., Niknami, S., Ghofranipour, F., & Montazeri, A. (2019). An
educational intervention based on the extended parallel process model
to improve attitude, behavioral intention, and early breast cancer diag-
nosis: a randomized trial. International Journal of Women´s Health, 11, 1-10.
https://doi.org/10.2147/IJWH.S182146
