Reducing Health-Information Avoidance Through Contemplation

Abstract

Despite the importance of learning about one’s health, people sometimes opt to remain ignorant. In three studies, we investigated whether prompting people to contemplate their reasons for seeking or avoiding information would reduce avoidance of personal health information. In Study 1, people were more likely to opt to learn their risk for type 2 diabetes if they had completed a motives questionnaire prior to making their decision than if they had not. In Study 2, people were more likely to opt to learn their risk for cardiovascular disease if they had first listed and rated reasons for seeking or avoiding the information than if they had not. Study 3 replicated Study 2 but also showed that contemplating reasons for avoiding versus seeking reduced avoidance of personal-risk information only when the risk condition was treatable.

Keywords

information avoidance contemplation decision making health cognition(s)

Between 2006 and 2009, an average of 50,000 people per year were diagnosed with HIV in the United States (Prejean et al., 2011). Knowledge of one’s HIV status is important in preventing both the transmission of the disease (Hall et al., 2010) and the development of AIDS (Centers for Disease Control and Prevention, 2011). Nevertheless, as many as 55% of people tested for HIV fail to return to the test site to receive their results (Hightow et al., 2003; Molitor, Bell, Truax, Ruiz, & Sun, 1999). Although many factors may contribute to this failure to return, it is likely that a portion of people do not return because they do not wish to learn the results (Grusky, Johnston, & Swanson, 2007).

Avoidance of one’s health status is not unique to HIV testing. Research on avoidance of health information has suggested that people sometimes intentionally opt not to learn information, such as their risk for a disease (Howell & Shepperd, 2012, 2013; Howell, Shepperd, & Logan, 2012). Theorizing on defensive avoidance suggests that people avoid learning such information when it might threaten a cherished belief, produce unwanted affect, or obligate undesired behavior (Sweeny, Melnyk, Miller, & Shepperd, 2010). Presumably, interventions that reduce the importance of these threats should reduce information avoidance (Howell & Shepperd, 2012).

One way to reduce the importance of the threats associated with information is to prompt people to contemplate their motives for avoiding information, which should shift focus from the immediate threat associated with the information to the long-term meaning or consequences of learning the information early. The transtheoretical model of behavior change suggests that the act of contemplation, which involves considering the pros and cons of one’s desired actions, is essential to promoting health-behavior change (Prochaska & DiClemente, 2005). Here, we refer to contemplation as deliberation about the reasons why one would or would not want the information. Research on metacognition has suggested that thinking about one’s own thoughts activates regions of the brain associated with mental self-control and allows people to regulate their thinking just as they regulate their behaviors (Shimamura, 2000). When prompted to consider their own cognitive processes, people can switch from intuitive to analytical decision making (Alter, Oppenheimer, Epley, & Eyre, 2007), which allows them to override their gut feelings in favor of quantifiably superior decisions (Batha & Carroll, 2007).

Researchers have long argued that people have two systems for information processing and decision making: (a) the hot system, which is based on emotion and intuition, and (b) the cold system, which is based on logic (Abelson, 1963). The hot system is quicker and involves areas of the brain associated with emotion. The cold system is slower and involves areas of the brain associated with memory (Goel & Dolan, 2003; Smith & DeCoster, 2000). These two systems can produce different outcomes (Denes-Raj & Epstein, 1994). For instance, people engaging in hot-system processing are more persuaded by peripheral message cues, such as the emotional appeal of a message or the attractiveness of the message source. People engaging in cold-system processing are more persuaded by logical arguments and careful thinking (Petty & Cacioppo, 1986). Moreover, when people are emotional, they sometimes become unable to make decisions that they would consider rationally superior (Keltner & Lerner, 2010).

Research has suggested that people respond to health threats using processes that mirror these two systems of decision making (Witte, 1992, 1994). Specifically, people can direct efforts toward reducing negative emotions associated with the threat (i.e., fear control) or toward reducing their personal risk for the threat (i.e., danger control). Fear control, like hot-system processing, is emotionally driven. When engaging in fear control, people respond defensively (McQueen, Vernon, & Swank, 2012). Danger control, like cool-system processing, is cognitively driven. When engaging in danger control, people respond to health threats with health-promoting behaviors (Witte, 1994). Because metacognition induces people to switch from the hot to the cool system of processing (Fletcher & Carruthers, 2012), we expected that it would also move people from defensive processing and behaviors (i.e., processes driven by emotional concerns) to more health-promoting processing and behaviors (i.e., processes driven by more deliberative cognitions).

Because information avoidance is a form of defensive responding (Howell & Shepperd, 2012), we suspected that it is driven by the hot, fear-based system (McQueen et al., 2012)—that is, people respond to an intuitive desire to protect their current cognitions, behavior, and affect without fully considering the long-term importance of learning the information. However, inducing people to contemplate their cognitions surrounding avoidance should interfere with this automatic, defensive processing and encourage consideration of the value of learning the information. We hypothesized that in these cases, contemplation would tend to reduce information avoidance, but that it would not always do so. Because contemplation induces deliberative processing, it should reduce avoidance only when the benefits of learning the information clearly exceed the costs (i.e., when avoiding the information appears analytically inferior). However, in instances in which learning information has little benefit to the self, contemplation should not influence avoidance.

It is important to note that contemplation does not always result in better outcomes. For instance, when deciding between alternatives, people induced to contemplate their reasons for a decision are often less satisfied with their choice (Wilson et al., 1993). Furthermore, acting based on intuition and feelings often prompts less risk taking (e.g., reduced monetary gambling) than does acting based on logic and cognition (see Loewenstein, Weber, Hsee, & Welch, 2001, for a review). In short, intuitive reactions can sometimes produce better (e.g., more satisfactory and less risky) outcomes than can thoughtful reactions (Kahneman, 2011). We suspected that, although contemplation may not always produce health-promoting behaviors, it could reduce avoidance of health information when avoidance is the rationally inferior option.

Theoretical Contributions

The present research is theoretically important in at least two ways. First, unlike prior accounts, such as those found in the selective-exposure literature (see Smith, Fabrigar, & Norris, 2008), which focuses almost exclusively on the choice between information that is consistent versus inconsistent with personal attitudes, our conceptualization distinguishes between receiving and not receiving information. Furthermore, researchers have typically conceptualized selective-exposure findings in terms of cognitive dissonance (Hart et al., 2009), yet our hypotheses about the role of contemplation do not lend themselves to a dissonance explanation.

Second, this investigation is only the second aimed at reducing information avoidance. The first showed that self-affirmation, or focusing on one’s overall integrity, reduces information avoidance (Howell & Shepperd, 2012). However, affirmation can be ineffective when people are aware of its presumed effects (Sherman et al., 2009), suggesting that affirmation may not always succeed in reducing information avoidance. Our current intervention entails making people aware of their cognitions.

The Present Research

We investigated whether inducing people to contemplate their reasons for seeking and avoiding information reduces avoidance. Participants chose whether to learn their risk for type 2 diabetes (Study 1), cardiovascular disease (CVD; Study 2), or an enzyme deficiency (Study 3) based on their responses to an online risk calculator. In Study 1, participants answered a series of questions about potential motives for seeking and avoiding their risk either before (contemplation condition) or after (no-contemplation condition) making their decision. In Study 2, participants either listed and rated the strength of their reasons for seeking or avoiding information (contemplation condition) or listed facts about CVD (no-contemplation condition) prior to making their decision. In Study 3, participants learned that an enzyme deficiency was either treatable or untreatable and then completed the reason-listing task used in Study 2.

Because contemplation encourages more deliberative processing (Fletcher & Carruthers, 2012), we expected that it would reduce information avoidance when information seeking appeared to be the analytically superior choice. Thus, in Studies 1 and 2, we hypothesized that people would more often choose to learn risk information in the contemplation conditions compared with the no-contemplation conditions. However, in Study 3, we hypothesized that information seeking was the superior choice when the disease was treatable but not when it was untreatable. Because contemplation presumably makes people process more deliberatively, cognitively assessing the value of each option, we hypothesized that contemplation would reduce avoidance of information about one’s risk for a treatable disease but would have little effect on avoidance of information about one’s risk for an untreatable disease.

Study 1

Method

Participants

Participants were 146 undergraduates (96 women, 50 men; mean age = 19.0 years, SD = 2.5) who participated in return for the partial fulfillment of a research-participation requirement.

Design and procedure

An experimenter dressed in medical scrubs greeted participants, escorted them to work stations, and told them that they were participating in a study about type 2 diabetes that was being conducted in collaboration with the university hospital. The experimenter then left the room, and participants watched an informational video about diabetes. The video included a series of health images (e.g., doctors, patients, figures from medical pamphlets) and a recorded voice explaining the causes and symptoms of type 2 diabetes and the typical treatment of the disease. After watching the video, participants sat at computers, where they completed a diabetes risk calculator (University of Maryland Medical System, 2009) and then read a message on the screen stating that the computer had calculated their risk for type 2 diabetes. Participants next read that they could learn their results and could select one of two options: “Yes, please give my risk estimate for Type-II diabetes” or “No, I do not want to learn my risk for Type-II diabetes right now.” The primary dependent measure was whether participants chose to learn their diabetes risk.

As part of the contemplation manipulation, participants completed an 18-item survey either before (contemplation condition, n = 89) or after (no-contemplation condition, n = 57) they made their choice. These items prompted reflection on the cognitive, affective, and behavioral consequences of learning that one is at high risk for type 2 diabetes; perceptions of personal coping abilities; and general thoughts about type 2 diabetes. The survey included items such as “Learning that I am at high risk for diabetes would be distressing” and “I would regret not learning my risk for diabetes,” to which participants responded using scales ranging from 1 (strongly disagree) to 7 (strongly agree). We did not design these items to tap a single construct but, rather, to prompt in-depth contemplation about cognitions surrounding avoidance. A full list of the survey items appears in the appendix.

In addition to completing these survey items, participants estimated, after choosing whether to learn their risk results, their personal likelihood of developing diabetes, using a scale from 1 (not at all likely) to 7 (very likely). We included this item to determine whether the effects of contemplation were limited to participants who estimated that they were at low risk for developing diabetes. The experimenter then debriefed participants and thanked them for their participation. The institutional review board approved all study procedures.

Results and discussion

As predicted, fewer participants avoided learning their diabetes risk in the contemplation condition (25%) than in the no-contemplation condition (44%), χ²(1, N = 146) = 5.57, p < .02, Φ = .20. These results suggest that prompting people to contemplate the possible consequences of learning information can reduce information avoidance. This effect was not qualified by an interaction with personal likelihood of developing the disease, b = −0.05, SE = 0.07, Wald = 0.56, n.s. Moreover, participants in the contemplation (M = 3.3, SD = 1.6) and no-contemplation (M = 3.3, SD = 1.3) conditions did not differ in their risk estimates for diabetes, t(132.3) = 0.26, n.s., d = 0.05.

An examination of responses to the items composing our contemplation manipulation showed that, although participants in the contemplation and no-contemplation conditions differed on some items, none of these items consistently predicted information avoidance. This finding suggests that no specific item was responsible for the effect of contemplation on avoidance. Rather, it was completing (or not completing) the items as a whole that influenced avoidance.

Study 2

Study 1 had three limitations. First, compared with participants in the no-contemplation condition, participants in the contemplation condition had more time between learning that they could receive their risk feedback and making their decision. Thus, it may have been the passage of time, rather than contemplation, that diminished avoidance. Second, simply reading the items may have decreased avoidance without actually prompting people to process their own cognitions deliberatively. Third, we did not know whether our findings would generalize to different populations or to other diseases.

To address these concerns, we designed Study 2 differently from Study 1 in four ways. First, before making their decision, the no-contemplation group in Study 2 completed a task matched in duration to the contemplation group’s task. Second, we included a different and more direct manipulation of contemplation (i.e., a cost-benefit analysis). Finally, we made two changes to ensure generality of our findings: (a) We included noncollege participants, and (b) we used a different health condition—CVD.

Method

Participants

Participants were 130 adults (83 women, 47 men; mean age = 35.4 years, SD = 16.3), recruited online via e-mail and social-networking Web sites, who participated anonymously, voluntarily, and without compensation.

Design and procedure

After consenting, participants sat at computers, where they completed an online CVD risk calculator (Mayo Clinic, 2010) and learned that the computer would calculate their lifetime risk while they completed a brief task. In the contemplation condition (n = 72), participants generated four reasons to seek and four reasons to avoid their CVD-risk feedback. They then rated the importance of each reason in their determination of whether they would learn their risk, using scales from 1 (not at all important) to 7 (very important). In the no-contemplation condition (n = 58), participants listed eight facts they knew about CVD and rated the importance of each fact in their knowledge about CVD. Next, participants chose whether to learn their risk. Once again, participants estimated their personal likelihood of developing CVD, using a scale from 1 (not at all likely) to 7 (very likely). After completing the survey, participants read a written debriefing and were thanked for their time.

Results and discussion

Fewer participants avoided learning their CVD risk in the contemplation condition (28%) than in the no-contemplation condition (55%), χ²(1, N = 130) = 10.05, p < .01, Φ = .28. This effect was not qualified by an interaction with personal likelihood of developing CVD, b = −0.06, SE = 0.08, Wald = 0.54, n.s. Once again, participants in the contemplation (M = 3.5, SD = 1.5) and no-contemplation (M = 3.0, SD = 1.5) conditions did not differ in their risk estimates, t(120) = 1.83, n.s., d = 0.34.

Participants in the contemplation condition rated their reasons for seeking (M = 5.9, SD = 1.1) to be more important than their reasons for avoiding (M = 4.3, SD = 1.8), t(71) = 6.39 p < .001, d = 0.76, which suggests that contemplation participants considered avoidance the inferior option.¹ We computed a difference score by subtracting participants’ ratings of their reasons for avoiding information from their ratings of reasons for seeking information and examined the association between this difference and avoidance. The more that participants’ reasons for seeking outweighed their reasons for avoiding, the less likely they were to avoid receiving their feedback, r(72) = −.29, p < .02. In sum, participants were less likely to avoid information when they contemplated their motives and regarded avoidance to be an inferior option.

Study 3

The results of Studies 1 and 2 suggested that contemplation is an effective method for reducing information avoidance. However, there are at least four possible alternative explanations. First, participants may have simply responded to demand characteristics. When we asked them to consider why they might seek or avoid information, participants may have surmised that we were interested in avoidance behavior and, therefore, chosen the response they believed we preferred (i.e., information seeking). Second, research has shown that people may infer their attitudes based on the ease with which they can generate attitude-related thoughts (Schwarz et al., 1991). Participants in the no-contemplation condition in Study 2, who had a difficult time generating facts about CVD, may have simply assumed that they did not care about their CVD risk and responded with less information seeking. Third, it is possible that participants in the contemplation condition in both studies engaged in more in-depth thinking about their decision but did not perceive seeking as the superior option (i.e., they did not actually consider their motives). In this case, simply thinking more about the decision may have biased participants toward seeking without actually prompting contemplation of motives.

Fourth, contemplation may have prompted behavior consistent with cultural norms rather than greater deliberation. Research has shown that when asked to generate reasons for their behavior, people generate reasons that are easy to articulate, culturally valued, and readily available in memory (Wilson et al., 1993). Although we know of no evidence that reasons for seeking are more likely to have these characteristics than reasons for avoiding, it could be that contemplation moves people toward seeking without actually prompting them to consider their own cognitions.

Study 3 tested these alternative explanations. If contemplation reduces avoidance by prompting deliberative processing (rather than by creating demand characteristics, inducing personal-attitude inferences, prompting deeper thought, or making cultural norms salient), then contemplation should reduce information avoidance only when avoiding is the inferior option.

Although learning one’s risk can be important for preventative care or treatment, for some conditions (e.g., Huntington’s disease, Creutzfeldt-Jakob disease, and type 1 diabetes), preventative care or treatment is unavailable or ineffective—that is, sometimes learning one’s risk or being diagnosed early does not allow one to prevent the onset of the disease or treat the symptoms after diagnosis. Researchers have argued that in such cases, the pragmatic value of learning information is reduced (Melnyk & Shepperd, 2012), which makes people more inclined to avoid learning their risk. For example, more women avoided learning their risk for breast cancer after reading about uncontrollable predictors of breast cancer than after reading about controllable predictors of breast cancer (Melnyk & Shepperd, 2012). Other research has shown that more participants opt to avoid learning personal-risk information about an untreatable disease than a treatable disease (Dawson, Savitsky, & Dunning, 2006; Yaniv, Benador, & Sagi, 2004).

We argued that these effects occur because when diseases are controllable, the long-term benefits of learning about personal risk more clearly outweigh the short-term costs. However, when diseases are uncontrollable, the benefits of learning are less clear. If contemplation truly initiates more deliberative processing, then it should reduce avoidance more for a controllable or treatable disease (because learning the information provides clear benefits) than for an uncontrollable or untreatable disease (because learning the information is not as clearly beneficial).

Method

Participants

Participants were 166 undergraduates (78 women, 88 men; mean age = 18.6 years, SD = 0.96) who participated in return for the partial fulfillment of a research requirement.

Design and procedure

The procedure was identical to that of Study 1 except that instead of watching a video about diabetes, participants watched a video about a fictitious disease called thioamine acetlyase (TAA) deficiency (Jemmott, Ditto, & Croyle, 1986). As in Study 1, the video included health images and a recorded voice (ostensibly that of a physician at the university hospital). The video explained that 20% of college students have TAA deficiency and that it could create severe medical complications despite an absence of early symptoms. Participants in the treatable condition (n = 82) learned that TAA deficiency could be treated by taking a daily pill. Participants in the untreatable condition (n = 84) learned that there was no treatment for TAA deficiency (Howell & Shepperd, 2012). As in Study 2, we assigned participants to either a contemplation condition (n = 83), in which they generated and rated reasons for seeking and avoiding the information, or a no-contemplation condition (n = 83), in which they listed eights facts they had learned about TAA deficiency from the video. As in Studies 1 and 2, participants estimated their personal likelihood of developing TAA deficiency. However, in Study 3, they gave their personal likelihood as a percentage (0%–100%).

Results and discussion

As is evident from the results shown in Figure 1, when we described TAA deficiency as treatable, fewer participants avoided learning their TAA risk in the contemplation condition (20%) than in the no-contemplation condition (53%), χ²(1, N = 78) = 9.02, p = .003, Φ = .34. However, when we described TAA deficiency as untreatable, we observed no difference in avoidance between the contemplation (40%) and no-contemplation (55%) conditions, χ²(1, N = 80) = 1.75, p = .19, Φ = .14. All interactions with personal likelihood were nonsignificant (bs < 0.02, SEs < 0.03, Walds < 0.56, n.s.). Once again, participants in the contemplation (M = 24.8, SD = 13.9) and no-contemplation (M = 24.1, SD = 13.6) conditions did not differ in their risk estimates for TAA deficiency, t(161) = 0.29, n.s., d = 0.05.

Fig. 1.

Results from Study 3: percentage of participants who avoided learning about their risk for a health condition as a function of treatability of the condition and contemplation of reasons for seeking and avoiding the information.

As Figure 2 shows, controllability influenced the discrepancy between reasons for seeking and reasons for avoiding, F(1, 81) = 8.95, p = .004, η = .29. As in Study 2, participants rated their reasons for seeking the information (M = 5.6, SD = 1.06) as more important than their reasons for avoiding it (M = 4.2, SD = 1.86) when we described the disease as treatable, t(41) = 4.59, p < .001, d = 0.71. By contrast, participants rated their reasons for seeking (M = 5.1, SD = 1.05) and avoiding (M = 4.8, SD = 1.33) as equally important when we described the disease as untreatable, t(42) = 1.14, p = .26, d = 0.17. Interestingly, unlike in Study 2, the discrepancy between reasons for seeking and reasons for avoiding was unrelated to avoidance, r(82) = .08, n.s.

Fig. 2.

Results from Study 3: importance of reasons for seeking versus avoiding information about personal risk for a health condition as a function of treatability of the condition and type of reasons. Higher scores indicate greater importance.

General Discussion

Results from three studies confirmed that contemplation can reduce information avoidance when avoidance appears to be the analytically inferior option. In Study 1, participants who completed a questionnaire assessing their motives prior to making a decision to seek or avoid risk information were less likely to avoid learning their risk for type 2 diabetes than were participants who completed the questionnaire after making their decision. Study 2 replicated this effect and provided initial evidence of the process underlying this effect. Participants who listed and rated reasons for seeking or avoiding information about their risk were less inclined to avoid learning their risk for CVD than were participants who simply listed facts about CVD.

Study 3 demonstrated that contemplation reduces information avoidance only when information seeking is the superior option. Specifically, when we described TAA deficiency as treatable, participants induced to contemplate their reasons for seeking or avoiding information considered seeking the superior option and showed less avoidance. By contrast, when we described TAA deficiency as untreatable, contemplation had no effect. This result ruled out alternative explanations for the results of Studies 1 and 2 (i.e., that contemplation created demand characteristics, induced personal attitude inferences, prompted deeper thought, or made cultural norms salient) and suggests that contemplation directs people toward rational decision making.

Although our results are the first to suggest that contemplation can reduce problematic avoidance of health information, more research is needed. First, our studies examined participants’ decision to learn the results of an online risk calculator. We do not know whether the results of our studies would generalize, for example, to patients’ returning to a physician’s office following an abnormal mammogram. Second, we do not know whether contemplation can reduce information avoidance in nonhealth domains (e.g., avoidance of information about one’s relationship partner).

Finally, we return to an observation we made at the outset of this article. Despite the importance of early detection, many people who are tested for HIV fail to return to the test site for their results. Our research suggests that simply asking people to contemplate why they make such decisions can reduce avoidance of health information, particularly when it is more rational to learn the information. This strategy may reduce the public-health burden of disease by offering a new, theory-based intervention to reduce problematic information avoidance.

Footnotes

Appendix

Acknowledgements

The authors thank Ken Savitsky for his comments on an earlier draft of this manuscript.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.

Funding

This article was supported by a National Science Foundation Graduate Research Fellowship awarded to J. L. Howell under Grant DGE-0802270; by an Intergovernmental Personnel Assignment Agreement between J. A. Shepperd and the National Cancer Institute; and by National Institute of Dental and Craniofacial Research Grant U54DE019261-0, funded through the Southeast Center for Research to Reduce Disparities in Oral Health, to J. A. Shepperd.

Notes

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