Home > Protection Motivation Theory and Prevention of AIDS: A Literature Review

© Lisa C. Wallis, Health Behavior: Theoretical Perspectives, Fall 1997

Introduction
Though both deaths and the incidence of AIDS declined from 1995 to 1996 for the first time in the history of the disease (Centers for Disease Control and Prevention, 1997), a large number of people in the United States are still affected by AIDS. According to the Centers for Disease Control and Prevention (CDC), approximately 235,470 people in the U.S. have been diagnosed with AIDS and are still living with the disease (CDC, 1997). No longer affecting only the typical high-risk groups, 10,110 of the newly diagnosed cases of AIDS in 1996 were acquired through male to female or female to male sexual contact (CDC, 1997), making it a problem that cannot be dismissed as a problem of "others." While any number of factors can increase the likelihood of acquiring the HIV virus that causes AIDS, these factors have one thing in common. They are all somehow linked to individual behavior and the choices one makes regarding his or her actions. Whether it be engaging in male homosexual contact without a condom, using intravenous drugs, or having unprotected heterosexual intercourse, behaviors are the root of the spread of AIDS. This indicates that the spread of AIDS can be prevented. Without the availability of an HIV vaccine, "continued emphasis on behavioral risk reduction and other prevention strategies…is the most effective way to reduce HIV infections" (CDC, 1997, p. 866).

Behavioral theories serve as a means of developing interventions to reduce harm to individuals by analyzing and integrating concepts from psychology, sociology, and other behavior-related fields. By providing a framework for development, theories synthesize ideas into workable plans of action. With such a large, widespread problem as AIDS in the United States, such a framework is essential. It can be assumed that AIDS is something most people would wish to avoid, with its unpleasant opportunistic infections and its guaranteed—though now occasionally delayed—death outcome. How can people be convinced to take actions that will reduce their chances of getting AIDS? Use of Protection Motivation Theory is one option.

Protection Motivation Theory (PMT), like the Health Belief Model and the Theory of Reasoned Action, "assumes that anticipation of a negative health outcome and the desire to avoid this outcome or reduce its impact creates motivation for self-protection" (Weinstein, 1993, p. 324). The motivation to protect is generated by essentially four processes, including severity of the outcome, personal vulnerability to the outcome, availability of an effective means of protection, and the perceived ability to complete the needed protective action. An advantage of the Protection Motivation Theory is that it allows development of hypotheses which may be proved or disproved (Rogers, 1975). Therefore, it is easily tested, and in the case of AIDS prevention, it would not be necessary to spend a great deal of time to apply the theory to interventions and evaluate their outcomes. Protection Motivation Theory is simple in that it is derived from prior theories and is common-sensical rather than revolutionary (Rogers, 1975). While it cannot predict the amount of behavior change that will occur following an intervention, Protection Motivation Theory can predict whether some groups more than others will benefit from interventions based on the theory (Weinstein, 1993). Such identification of target populations would allow health educators to develop personally appropriate interventions. A solution is needed now, and Protection Motivation Theory-based interventions may be a means of reducing the spread of the HIV virus.

Approach to Literature Review
This literature review will explore the history of the Protection Motivation Theory, from its roots in fear appeals research through its development into a useful model of prevention, explanation, and intervention development. The basic concepts of Protection Motivation Theory will be examined and revisions to the theory will be described in detail. Lastly, its multiple applications to general health behavior will be reviewed, followed by a more specific application within AIDS-related research endeavors.

Historical Aspects of Protection Motivation Theory
Fear is a human emotion experienced by all sometime in their lifetimes. The emotion of fear is not inherent, but it is learned through previous experience or observation. That is, fear develops after one witnesses or experiences a negative outcome in a formerly neutral situation (Rogers, 1983). It is a reaction to a sense of imminent danger, whether real or imagined. Fear can protect one from harm, draw one away from a dangerous situation, or serve as motivation to escape an unpleasant situation (Rogers, 1975), so it does appear to serve a useful purpose. In health-related behavioral research, fear is invoked by persuasive communications which describe potentially harmful consequences that may occur if recommended guidelines are not followed (Rogers, 1975). These communications are known as fear appeals. Fear appeals are made up of any combination of a number of factors which, when manipulated, produce varying levels of fear. These factors include the type of negative outcome, the likelihood of occurrence, visual depictions of negative outcomes, and the degree of emphasis on negative aspects of the outcomes (Rogers, 1983). The goal of fear appeals is "to eliminate response patterns that might produce aversive consequences or establish response patterns that might prevent the occurrence of noxious events" (Rogers, 1975, p. 83). Rogers’ Protection Motivation Theory is an attempt to link fear appeals and response patterns, or behavior change.

It was for a while believed that the emotion of fear led directly to behavior change, which influenced Janis to adopt the fear-as-acquired-drive model of motivation and attitude change. Janis (1967) hypothesized that rather than being driven to change by the desire to avoid negative outcomes, people are driven to change to reduce the level of fear they are experiencing. The reduction of fear then leads to attitude change. Further studies disputed the model when they neglected to find a direct link between drive and attitude change (Rogers, 1983). Next, Leventhal (1970) developed a model which distinguished between emotional reactions and coping strategies and hypothesized that behavior change is a result of attempts to control the imminent danger, not to reduce fear. He assumed that emotional and cognitive responses to a fear appeal happen concurrently but do not affect each other. This model greatly influenced Rogers’ (1975) development of the Protection Motivation Theory.

Expanding upon Leventhal’s ideas, Rogers hoped to develop a model that would create a precise means of measuring and comparing fear appeals (Rogers, 1983). In addition to fear appeals research, Protection Motivation Theory also drew from general expectancy-value theories. These theories assume that "the tendency to act in a particular fashion is…a function of the expectancy that the given act will be followed by some consequence and the value of the consequence" (Rogers, 1975, pp. 96-97). In early development stages of Protection Motivation Theory, Rogers combined the influences of fear appeals and expectancy-value research. He stated that there are three essential parts to a fear appeal. These are the level of an event’s aversive qualities (the value), and the likelihood the event will occur if no action is taken and the availability of an effective means of avoiding the event (the expectancies) (Rogers, 1983). Over time this original structure has been expanded into the Protection Motivation Theory in use today.

Tenets of Protection Motivation Theory
According to Protection Motivation Theory, attitude or behavior change occurs when great protection motivation is aroused, not when a person in simply fearful (Rogers, 1983). Studies have shown that is possible to arouse fear in a person by chemical means when no fear-inducing environmental cues are present. In these situations, people attribute feelings of fear to cues that otherwise would not cause fear in these people. These instances do not lead to attitude or behavior change, therefore fear appeal and physiological response are unrelated (Rogers, 1983). Instead, fear appeals create a sense of motivation to protect one’s self. This protection motivation, in turn, leads to either reduction or cessation of a harmful behavior or instigation of a healthful behavior (Rogers, 1983).

Unlike fear appeal theories, which deal with fear as an emotional response, Protection Motivation Theory emphasizes the cognitive processes of avoiding adverse outcomes. In the original explanation of the theory, Rogers described these processes as the degree of noxiousness of a depicted event, the probability of that event happening and the availability and effectiveness of a preventive measure (Rogers, 1975). If a person does not view an outcome as severe, likely to happen, and preventable by any means, no protection motivation would be aroused. Thus, the variables act as mediators between a fear appeal and behavior change. Each variable is equally likely to motivate someone to change behavior, and as the degree of each variable increases, the intent to change behavior increases (Rogers, 1975). It was believed in the original formulation of Protection Motivation Theory that if any one of the variables were left out of the model, protection motivation would not be aroused. This is described as a multiplicative relationship among the variables and was later refuted in the research (Maddux & Rogers, 1983).

The revised theory of protection motivation is much more detailed than the original version, yet it remains fairly easy to comprehend. To the original three constructs Rogers added self-efficacy. This is an individual’s belief in her ability to successfully complete a specific task within a specific situation (Bandura, 1977). In relation to Protection Motivation Theory, "self-efficacy determines if coping behavior will be initiated, which behavior(s) will be chosen, how much effort will be expended, and how long it will persist" (Rogers, 1983, p. 169), with greater self-efficacy leading to greater intent to adopt behavior recommendations. In fact, Godin and Shephard (1990) report that at least for exercise behavior, any results appearing to support Protection Motivation Theory are largely a result of self-efficacy rather than the other theory variables.

Rogers restructured the theory into three components that included the original concepts but presented them in a different format. These components are sources of information, cognitive mediating processes, and coping modes. Sources of information may be either environmental or intrapersonal. These would include fear appeals, observation, personality, and past experience (Rogers, 1983). The sources, in turn, lead to cognitive mediating processes.

The cognitive processes incorporate the original three concepts as well as self-efficacy, and they are the core of Protection Motivation Theory (Rogers, 1983). Severity, vulnerability, response efficacy, and self-efficacy are believed to be independent of one another, yet combined they influence the level of protection motivation aroused. Unlike fear appeals, protection motivation moves a person to make long-term changes and even repeat actions as needed, although the state of fear has typically vanished. That is, the environment is changed, and emotional responses are not necessary to invoke a protective response (Rogers, 1975). Therefore while fear does aid when an immediate danger exists, it does not provide the necessary motivation to induce lasting behavior change (Rogers, 1983). Protection motivation is a direct result of a cognitive appraisal of threats and coping strategies.

Threat appraisals evaluate the results of maladaptive behavior. They consider the intrinsic or extrinsic rewards of maladaptive behavior and weigh them against the severity of and vulnerability to an undesired outcome. If the rewards of acting in an unhealthy manner exceed a person’s perception of the severity of an outcome or the likelihood of its occurrence, the person will choose to act in a maladaptive fashion. Coping appraisals, on the other hand, analyze adaptive behavior. Costs of making a change are evaluated and compared to level of self-efficacy for behavior change and the availability of an effective response to the threat. If a person believes that the response available to avoid the outcome is effective and that she can perform the response, she will modify her behavior in a favorable way if the costs of making the change are less strong than the efficacy beliefs (Rogers, 1983).

The decision to change behavior to avoid a negative outcome leads to coping modes. These can be single or multiple acts done only once or repeated any number of times (Rogers, 1983). It would seem that behaviors requiring less effort over a shorter span of time would be more easily changed. Regardless, Protection Motivation Theory assumes that the cognitive processes determine whether a person elects an adaptive or maladaptive coping mode, not time or effort factors directly.

The acceptable measure of protection motivation arousal may perhaps be viewed as one of the theory’s shortcomings. Rather than evaluating behavior change, protection motivation is best measured by assessing the intent to change behavior. The intentions are believed to be accurate means of predicting behavior if "(1) the behavior, object, situation, and time are measured at the same level of specificity, and (2) the measure of intention reflects intention at the time the behavior is measured" (Rogers, 1983, p. 172). Generally it is assumed that intentions are a true indication of behavior, and past research has supported this assumption (Rogers, Deckner, & Mewborn, 1978).

Typically, as any one of the four cognitive mediating variables increases in strength, greater protection motivation is aroused, which leads to greater intent to change behavior. Also, weak variable levels are assumed to have the opposite effect. Once the multiplicative relationship among the variables was rejected, researchers began to consider the additive rule. According to this rule, the combination of four high strength variables would produce the maximum intent. However, this is not always the case. Maddux and Rogers (1983), in one of the earliest studies incorporating the revised Protection Motivation Theory, encountered two unexpected results in cases where the highest intent was generated. Intending to test the revised Protection Motivation Theory, which included self-efficacy as the fourth component, the researchers studied the effects of a smoking intervention on undergraduate smoking habits. The first unusual result they termed a precaution strategy. This occurred when low vulnerability combined with high response efficacy and high self-efficacy to persuade the subjects to protect themselves even when they clearly were not at risk. Subjects figured there was no reason to take a chance. The other strategy, hyperdefensiveness, occurred when high vulnerability was combined with either high response efficacy or high self-efficacy, but not both. The subjects felt they had nothing to lost by attempting to avoid danger. It appears that the additive rule may apply, but only to a certain degree (Maddux & Rogers, 1983).

Another unusual effect, which Rogers (1983) refers to as a boomerang effect, occurs when people feel completely unable to protect themselves from a threat. This is a result of no perceived response efficacy or low self-efficacy, and the person will not attempt to cope at all. If an available coping response is viewed ineffective, the higher the vulnerability component, the less likely he is to attempt to cope. Thus in the absence of an effective means of coping, a fear appeal may cause more harm than good by increasing anxiety without providing a means for release (Rogers, 1983).

Protection Motivation Theory is a means for predicting intent to change behavior as well as explain why some people are more affected by fear appeals than other people. Sources of information, like fear appeals, trigger two cognitive processes—threat and coping appraisals—within which people evaluate the pluses and minuses of behavior change. Severity, vulnerability, response efficacy, self-efficacy, intrinsic and extrinsic rewards of maladaptive behavior, and costs of adaptive behavior are all variables a person considers in the decision-making process. Intent to change behavior is generated only when the benefits outweigh the costs associated with making the change. This theory of behavior change has been applied to a number of health-related behaviors. These studies have examined not only the Protection Motivation Theory variables alone, but many have incorporated other individual variables to determine what characteristics may influence whether or not one behaves according to Rogers’ (1983) Protection Motivation Theory.

General Application of Protection Motivation Theory
Since its earlier use in cigarette smoking research (Maddux & Rogers, 1983), Protection Motivation Theory has been applied to a variety of health-related behaviors. These include exercise, substance use and abuse, workplace health protection, self-diagnosis, parental protection of children, and treatment of health problems. This section will review many of these studies, indicating whether or not they have proven to support Protection Motivation Theory as proposed by Rogers (1983).

Exercise. Wurtele and Maddux (1987) attempted to test the generality of Protection Motivation Theory beyond fear arousal by using the model to design an intervention promoting exercise among college-age women. One hundred sixty subjects, who were classified as non-exercisers, were presented with written materials describing the four PMT components as either present or absent with regard to exercise. For example, a woman may have been assigned to a group where severity and vulnerability variables were present and response efficacy and self-efficacy variables were absent. Subjects were asked to rate degree of agreement with statements reflecting the four constructs. In addition, the subjects reported their intention to exercise following the intervention. This study attempted to improve upon other studies by also following up with the subjects two weeks later to see if their intentions matched actual performance (Wurtele & Maddux, 1987).

Self-efficacy beliefs and vulnerability were the two significant predictors of the women’s intentions to exercise. An interaction effect among vulnerability, response efficacy, and self-efficacy was also observed. Intentions and actual behavior proved to be significantly related, but the correlation was low. Only intention scores, and not the PMT constructs, were significant predictors of exercise two weeks following the intervention. The researchers hypothesized that the low correlation between intent and behavior was due to the way exercise was referred to in a general sense rather than in specific terms (Wurtele & Maddux, 1987). Like Maddux and Rogers (1983), these researchers also observed a precaution strategy among their subjects. That is, as long as subjects felt they had the ability to start and maintain and exercise program, they did so regardless of response efficacy or vulnerability variable exposure (Wurtele & Maddux, 1987).

Rather than simply presenting information on the negative effects of not exercising, Robberson and Rogers (1988) used both positive and negative messages to persuade their subjects to begin and exercise program. They intended "to compare appeals to physical danger (health) to appeals to psychological/social danger (self-esteem)" (Robberson & Rogers, 1988, p. 278). Hypothesizing that both positive and negative appeals would produce better outcomes than no message at all, the researchers presented female, non-exercising college students with essays emphasizing either the positive effects of exercise on health or psychological state, the negative effects of exercise, or both. A control group was included for comparison. Like Wurtele and Maddux (1987), the subjects rated agreement with statements representing the four PMT components and also indicated their intentions to exercise (Robberson & Rogers, 1988).

Positive self-esteem messages produced significantly higher intentions to exercise than negative self-esteem messages. The combined messages also produced higher intentions than negative messages alone. Both positive self-esteem and combined self-esteem messages resulted in higher intention scores than the control messages. Among health messages, negative and combined message subjects scored significantly higher on intentions than the control group. The researchers concluded that when making appeals to change for the sake of health alone, negative messages work. Nevertheless, people can be convinced to engage in healthy behavior for reasons other than physical well-being (Robberson & Rogers, 1988).

Attempting to expand the application of Protection Motivation Theory to adolescents, Fruin, Pratt, and Owen (1991) went beyond the main four components of the theory to include response costs and to assess proneness to adaptive or maladaptive coping strategies. Not only because they had not been studied before, adolescents were selected for an exercise-related intervention because they have been shown to be potentially at risk for cardiovascular disease (Fruin, Pratt, & Owen, 1991). The researchers presented Australian ninth and tenth graders with written essays regarding response efficacy, self-efficacy, and response costs. The assessment tool addressed those three variables as well as adaptive coping modes and maladaptive coping modes and intention to exercise. The researchers believed that high response efficacy, high self-efficacy and low response cost messages would positively impact adaptive coping strategies; the opposite messages would endorse maladaptive coping strategies.

Independently, the three variables produced the strongest statement agreement when their corresponding messages were high. Only self-efficacy significantly impacted intention to exercise. Overall, the subjects strongly endorsed the adaptive coping strategies regardless of which essays they read, although already active teens tended to endorse adaptive coping strategies more strongly than non-exercisers. The researchers suggested that practitioners should focus their efforts on strengthening adolescents’ adaptive coping responses.

Substance use and abuse. Focusing specifically on alcoholism, Runge, Prentice-Dunn, and Scogin (1993) incorporated Protection Motivation Theory in a study that compared hospitalized elderly substance abusers to elderly community members living at home. No intervention was designed, instead the researchers simply compared the groups’ attitudes toward alcohol use and abuse. It was found that the hospitalized substance abusers felt more vulnerable to the effects of alcohol abuse, reported higher response costs of even moderate drinking, and reported lower levels of response efficacy than the community members. The researchers conclusion was that various groups who differ in behavior will differ in response to health threats (Runge, Prentice-Dunn, & Scogin, 1993).

Again applying the theory to adolescents, Wallerstein and Sanchez-Merki (1994) incorporated protection motivation within a complex, multi-faceted alcohol and substance abuse prevention program called the Adolescent Social Action Program (ASAP). This program is currently used in a number of middle schools, though the original research occurred in the southwestern United States. The goal of the program was "to reduce excess morbidity/mortality among youth who live in high-risk environments, to encourage them to make healthier choices in their own lives, and to empower them to play active political and social roles in their communities and society for positive change" (Wallerstein & Sanchez-Merki, 1994, p. 105). It was believed that if high-risk youth were taught to view themselves as part of a larger society, they would feel an increased responsibility and would not make choices which would let themselves and others down. The study placed them in an active role, rather than the passive role usually reserved for subjects in research studies (Wallerstein & Sanchez-Merki, 1994). These subjects participated in listening-dialogue-action situations where they interviewed and interacted with substance abuse patients and jail residents.

Unlike a typical fear appeal, the ASAP program required teens to think critically and analyze why things are as they are. Over time, the researchers discovered that the interviews and following group discussions had a pronounced impact on the subjects. Severity and vulnerability beliefs increased, as the adolescents realized that they, too, were only one choice away from hospitalization or jail--both believed to be serious consequences. In addition, self-efficacy beliefs increased as the subjects began to believe that they could help prevent some of these problems be speaking up to family members or friends. Rather than ending the study after observing the changes, the ASAP program uses the effects to help the communities. Students who have completed the program successfully are trained as peer educators (Wallerstein & Sanchez-Merki, 1994).

In a more traditional study design, Sturges and Rogers (1996) attempted to extend Protection Motivation Theory to children by focusing on tobacco use, a behavior often begun during youth. Their study compared children to adolescents and young adults, with the belief that children would respond differently to smoking messages since children tend to live in the present and may have difficulty thinking of long-term consequences of behavior. All three groups were exposed to audio messages in which the researchers manipulated the threat, coping and immediacy of health problems due to tobacco use (Sturges & Rogers, 1996).

The results indicated that adolescents young adults responded best when the threat and coping messages were consistent; that is, either when both were high or both were low. Coping alone was the most important factor for children. Regardless of level of threat, children in the high coping group scored high for intent to avoid tobacco. Perhaps surprisingly, distancing the effects of tobacco use from the present time did not devalue their threat among children. The further in time the consequences of tobacco use, the greater was children’s intent to avoid using it. Sturges and Rogers (1996) concluded that even though children are incapable of understanding why tobacco is bad for them, they are able to understand what actions are appropriate and desirable. Therefore, if they are presented with means of avoiding a health problem, they are likely to attempt to do so.

Worksite health protection. A few applications of Protection Motivation Theory have attempted to use the theory to stress of the importance of following safety rules within the workplace. The earliest of these studies, which was published just prior to Rogers (1983) revision of the theory, examined information seeking behaviors among safety and health managers employed by the U.S. Department of Agriculture (Beck & Feldman, 1983). It was an unique study in that it addressed the issue of taking protective action for the safety of others. The researchers examined whether increasing the factors of severity, vulnerability, response efficacy, and self-efficacy would motivate the managers to seek safety information on behalf of their employees, even when their own health was not at risk (Beck & Feldman, 1983). For the purpose of this study, information seeking was regarded as a type of protective behavior.

None of the managers’ beliefs about workplace hazards, such as the severity of them or co-worker likelihood of exposure, predicted information-seeking behavior. However, they were all correlated with information seeking behavior. When beliefs about information seeking were assessed, however, the seriousness of needing information, the likelihood of needing information, and the perceived usefulness of additional information were significant predictors of seeking behavior. Beliefs managers held about their ability to protect themselves was significantly related to information seeking for their co-workers. The researchers concluded that the study was overall supporting of Rogers (1983) revised Protection Motivation Theory, with the latter-most finding providing supporting the addition of self-efficacy (Beck & Feldman, 1983).

Sinclair, Gershon, Murphy, and Goldenhar (1996) developed a series of videotapes that were intended to train hospital nurses how to avoid bloodborne pathogens in the workplace. The videotapes incorporated the four main components of Protection Motivation Theory--probability of occurrence, magnitude of noxiousness, response efficacy, and self-efficacy. Slightly modifying Rogers’ (1983) version of the theory, Sinclair and his colleagues examined the role of affect as a mediator between persuasive messages and cognitive processes. Affect is a measure of the consistency between a person’s expectations and goals, and its reactions include not only fear, but also guilt, empathy, or anger. The researchers report that among the target audience of health care workers, the videotapes were successful in generating negative affect (Sinclair, et al., 1996). Results regarding the effectiveness of the videotapes in protecting the workers from bloodborne pathogens is not yet available.

Another recent study combined PMT variables with an annoyance factor to explain the use of hearing protection devices (HPDs) among manufacturing workers (Melamed, Rabinowitz, Feiner, Weisberg, & Ribak, 1996). Convincing people to wear HPDs is a difficult thing to do, because they are often uncomfortable and make communication difficult. To compound the difficulty, loss of hearing is gradual and not immediately sensed as a problem (Melamed et al., 1996). Only 42% of the subjects in the study used HPDs regularly, which the researchers indicated was evidence of the problem of ensuring use of health protection devices in the workplace. Nevertheless, the researchers attempted to determine whether Protection Motivation Theory variables could account for variance in HPD use, beyond what can be attributed to annoyance with the noise produced at the jobsite.

The results were mixed. Self-efficacy and vulnerability, in that order, were the two PMT variables which demonstrated predictive relationships with HPD use. Noise annoyance was also a significant predictor of use. On the other hand response efficacy and perceived severity results were not significant, even among those who had begun to lose their hearing. Surprisingly, even actual hearing loss was not a significant motivator to HPD use, as only 28.8% of subjects suffering from mild to severe hearing loss used HPDs regularly. The researchers encouraged health protection workers to focus their efforts on increasing self-efficacy beliefs, since this was the most powerful variable from the PMT (Melamed et al., 1996).

Self-diagnosis. Many diseases, like workplace health conditions, are preventable if an individual wishes to take action to protect her health. Others, while not completely preventable, can be identified early during a stage in which the disease is more easily treated. These types of diseases appear to lend themselves well to study of Protection Motivation Theory.

Rippetoe and Rogers (1987) used Protection Motivation Theory as a framework for studying why people choose to adapt adaptively or maladaptively when faced with the threat of breast cancer. The researchers refer to maladaptive behavior in the sense that it is the avoidance of "dealing with the reality of the situation" (Rippetoe & Rogers, 1987, p. 598). They do acknowledge, however, that such reactions may actually be adaptive if they reduce a person’s anxiety or if there is no available effective response. Nevertheless, for the purposes of their study, avoidance of the situation was viewed as maladaptive. Combining the PMT variables of severity and vulnerability into a stronger variable—threat—Rippetoe and Rogers manipulated that variable and self-efficacy and response efficacy within essays presented to female psychology undergraduates. They predicted that each variable would have an independent effect on intentions to perform breast self-examinations (BSEs). In addition, they believed the subjects would respond in an adaptive fashion when self- and response efficacies were high in a high-threat situation.

The results fully supported their hypotheses. The higher the individual variables of threat, self-efficacy, and response efficacy, the greater the intentions to perform BSEs. In addition, under high-threat conditions, high self- and response efficacies increased adaptive coping. Alternatively, low self- and response efficacies increase maladaptive coping strategies, specifically fatalism, religious faith, and hopelessness. Under low-threat conditions, these same results did not surface. Thus, Rippetoe and Rogers (1987) concluded that analysis of both threat and coping appraisals is necessary to predict how individuals will elect to cope with a health threat.

A similar study was conducted among males, but instead it assessed intentions to perform testicular self-examinations (TSEs), and it attempted to account for knowledge about the method. (Steffen, 1990). Half of the subjects read a brochure about TSE, and all subjects were asked whether they had prior knowledge of it. Only prior knowledge was significantly correlated with any of the PMT variables; the subjects lacking prior knowledge viewed testicle cancer as more severe. In addition, the results showed that among men without prior knowledge of testicular self-examinations, only perceived vulnerability was a significant predictor of intent to perform TSE. Furthermore, among men with prior knowledge, no Protection Motivation Theory variables were significant predictors of intention. Steffen (1990) suggested that future campaigns promoting TSEs should be targeted separately to groups with and without prior knowledge of the procedure.

An eclectic study by Brouwers and Sorrentino (1993) attempted to control of prior knowledge completely by presenting subjects with information on a fabricated disease for which a home-diagnosis test was available. Like Beck and Feldman’s (1983) study of information seeking among health and safety managers, this study measured interest in more information rather than intent to change behavior. Furthermore, it attempted to combine Protection Motivation Theory with Uncertainty Theory. According to that theory, people are either certainty-oriented or uncertainty-oriented. Uncertainty-oriented people are comfortable with and will address uncertainty, while certainty-oriented people are more motivated in situations where issues of self and environment are clear. The researchers predicted that uncertainty-oriented subjects would be more likely to seek information that will help them self-diagnose than certainty-oriented subjects, especially when threat, self- and response efficacy is high (Brouwers & Sorrentino, 1993).

The results supported the integration of PMT and Uncertainty Theory. Protection Motivation Theory variables predicted whether or not more information on the disease was desired, and uncertainty orientation variables mediated the relationship. High threat and high self- and response efficacies increased the desire for more information among uncertainty-oriented subjects. Alternatively, certainty-oriented individuals sought information more often when either threat or response efficacy was high. Results also indicated that certainty-oriented subjects were more likely to use maladaptive coping strategies, such as those demonstrated by Rippetoe and Rogers (1987). The researchers did not believe one study combining the theories was sufficient to formulate intervention strategies; however, they did point out that highly threatening and highly efficacious information can be quite effective among uncertainty-oriented individuals. For certainty-oriented individuals it may be overwhelming and anxiety provoking (Brouwers & Sorrentino, 1993).

Parental protection of children. Though few studies apply Protection Motivation Theory to situations where motivation is aroused for other-than-self protection, such studies do exist (Beck & Feldman, 1983; Campis, Prentice-Dunn, & Lyman, 1989; Strobino, Keane, Holt, Hughart, & Guyer, 1996). A couple of these studies assess parental protection of their children and it is affected by PMT variables. Campis and her colleagues (1989), focusing solely on coping appraisal, assessed its impact on whether or not parents informed their elementary-school-aged children about sexual abuse. Response cost, which may include difficulty or unpleasantness, was singled out in this study as it never had been before. The researchers hypothesized that as response efficacy and self-efficacy were increased, parents would indicate a greater intent to inform their children about sexual abuse. On the other hand, response cost was believed to be inversely related to intent (Campis et al., 1989).

Indeed, increasing the coping information available to parents increased the likelihood that they would talk to their children about sexual abuse. Self-efficacy results indicated it was a greater influence on intent than response efficacy. The researchers suggested that response efficacy was pre-established prior to the study due to widespread coverage of the topic in the media. The successful application of PMT in this circumstance offers valuable suggestions for increasing dialogue between parents and children about this topic (Campis et al., 1989). If parents are instructed how to tell their children about sexual abuse, they will be more likely to do so.

A second study examined parental attitudes and knowledge about immunization and the impact these beliefs had on their children’s immunization status (Strobino et al., 1996). The study assumed there were no rewards related to a child contracting a preventable disease, so the variable of maladaptive rewards was omitted from the PMT framework. Severity, vulnerability, response and self-efficacies and response costs were evaluated. The researchers also included external variables including demographic characteristics, social support, and health care access. Strobino and her colleagues (1996) predicted that all PMT and external variables would significantly affect immunization rates.

Surprisingly they found that parents’ protection motivation attitudes do not explain their children’s immunization status. Most believed that the preventable diseases were severe, that their children were vulnerable, that they were capable of getting their children vaccinated, and that vaccines are effective. Nevertheless, only 54% of children had been vaccinated up to the appropriate age standards. Instead, issues of demographics, medical care access, and social support variables were much better predictors of immunization status. The researchers suggest that rather than focusing attention on educating parents on the importance of immunizations, intervention programs must address the social issues that are keeping parents from having their children immunized (Strobino et al., 1996).

Treatment of health problems. Studies’ use of Protection Motivation Theory to analyze prevention-focused interventions is well-established in the literature. Less common are studies that apply the theory within the context of a medical care setting, where a patient is already suffering from a disease or health problem. On one hand, such studies could be described as prevention-focused in that they intend to prevent worsening of the condition. Alternatively, the studies’ results may differ dramatically due to the existent condition of the subjects and the attitudes and behaviors exhibited by them.

Flynn, Lyman and Prentice-Dunn’s (1995) study, like those mentioned in the previous section, attempted to measure parental health beliefs and the impact they had on their children. The parents in this study had children previously diagnosed with muscular dystrophy, a disease for which treatment can be time-consuming and painful, though it is an effective means of increasing mobility and reducing discomfort. The researchers attempted to be the first to examine all six parts of Protection Motivation Theory within a single study. Attitudes regarding severity, vulnerability, response efficacy, self-efficacy, adaptive costs, and maladaptive benefits were assessed and intentions and self-report behaviors were evaluated. In addition, the researchers believed they were the first to examine PMT and compliance with medical treatment regimens (Flynn, Lyman, & Prentice-Dunn, 1995).

Unlike the study Strobino and her colleagues (1996), this study found support for the idea that PMT variables may be applicable beyond self-protective behavior. Response efficacy elicited the strongest level of protection motivation, followed closely by self-efficacy, though the latter results were not statistically significant. Conversely, self-efficacy was a significant predictor of intentions and behavior, but response efficacy was not. Threat appraisal variables—severity, vulnerability, and maladaptive benefits—showed no significant relationships, but the researchers felt that was because it was the children who were ill but the parents attitudes that were measured. Apparently, "threat appraisal appears to operate differently for people experiencing an illness than for those at risk for illness" (Flynn, Lyman, & Prentice-Dunn, 1995, p. 61).

Conflicting results were found by Taylor and May (1996) in their study of compliance to treatment regimens among injured athletes. They hoped to identify what factors could make athletes comply with injury rehabilitation guidelines and to use Protection Motivation Theory variables to predict compliance with home-based programs. Two types of compliance were identified for this study’s purposes: compliance with rest recommendations and compliance with treatment. This distinction made a difference. Severity proved to be the strongest predictor of compliance to treatment, while susceptibility was the strongest predictor of compliance to rest. Self-efficacy and response efficacy were important factors, as well. Separating the subjects into compliers and non-compliers, the researchers found that people in high efficacy intervention groups were more likely to comply with their treatment guidelines. A suggestion to add outcome value to the PMT was made, as all compliers valued their health more than non-compliers (Taylor & May, 1996).

Summary of General Applications
The Protection Motivation Theory has been applied to a wide variety of health behaviors with mixed results. Across nearly all studies, self-efficacy emerges as the strongest predictor of intent to change behavior. This provides overwhelming support for the inclusion of that variable within Protection Motivation Theory as revised by Rogers (1983). Nevertheless, all PMT components were significantly linked to intent in at least one study, indicating that successful application of Protection Motivation Theory is heavily influenced by the type of behavior being examined, the age or developmental stage of the study population, and the presence or absence of external factors which contribute to behavior change.

AIDS-Related Applications of Protection Motivation Theory
Perhaps the greatest amount of research regarding Protection Motivation Theory to date has been related to protection from the HIV virus that causes AIDS (Aspinwall, Kemeny, Taylor, Schneider, & Dudley, 1991; Eppright, Tanner, & Hunt, 1994; Rhodes, Wolitski, & Thornton-Johnson, 1992; Stanton, Black, Kaljee, & Ricardo, 1993; Van der Velde & Van der Pligt, 1991; Vanwesenbeeck, de Graaf, van Zessen, Straver, & Visser, 1993). For the most part, these studies have addressed the issue of condom use as a means of protecting one’s self from the virus. This indicates that sexual transmission is still viewed as the most common means of transmitting the disease, a view that is supported by research (CDC, 1997).

Stanton, Black, Kaljee, and Ricardo (1993) focused their research on urban early adolescents, a group presumed to be at high risk for HIV infection. They intended to incorporate a number of disciplines into the study, explaining that attitudes and behavior are a result of more than just one single perspective of environment or biology, for example. Using the Protection Motivation Theory as a guide, the study examined the relative importance of sexual activity in the culture and attempted to create a culturally-relevant intervention for promotion of safe sex. Focus groups were conducted to assess how the youths viewed sexual behavior. Although AIDS was regarded as severe by all, perhaps most frightening was the result that perceived vulnerability to HIV was completely lacking among the teens. In addition, although self-efficacy for condom use was high among the teens, no one spontaneously associated condom use with protection from HIV. The focus group design limited the number of issues addressed by the study, so it is not generalizable to all teens by any means (Stanton et al., 1993).

An adapted model of protection motivation, called the Ordered Protection Motivation Model was proposed by Eppright, Tanner, and Hunt (1994). The main difference between the models was the addition of two AIDS knowledge variables, experiential and generalized problem. Subjects were university students from four universities around the country. Sixteen separate hypotheses were generated based on previous studies, and the results were mixed. In general, experiential knowledge increased the likelihood of engaging in maladaptive (unsafe) sex behaviors; however, it was not possible to assess the degree of experience to find why this was the case. Similarly, perceived vulnerability to AIDS also increased the likelihood of engaging in maladaptive behavior. At the same time, vulnerability and self-efficacy increased the likelihood of engaging in adaptive behavior. The researchers attempted to explain the apparent inconsistency of these data by predicting that adaptive or maladaptive behavior is highly a function of the level of past experience (Eppright, Tanner, & Hunt, 1994).

A similar link between vulnerability and risk-reduction behavior was found by Aspinwall and her colleagues (1991) in a study of gay men. That is, as perception of vulnerability to AIDS increased, engaging in sexual activity increased. The researchers hypothesized that high vulnerability may create such anxiety among gay men that they surrender to unsafe behaviors in order to reduce that anxiety. A complex study, it attempted to examine not only PMT variables and sexual behavior, but also the variable of the Health Belief Model, Self-Efficacy Theory, and effects of having a steady partner and HIV status. The researchers believed that by incorporating the predictor variables from all three theories, a better level of understanding of AIDS-related behavior among gay men would be reached. The results suggested a number of ways gay men could be targeted to encourage safe-sex behavior. Among these, the PMT variable of vulnerability should be addressed by attempting to reduce the anxiety associated with it, and self- and response efficacies need to be increased in order to assist gay men to reduce risky behaviors (Aspinwall et al., 1991).

Van der Velde and Van der Pligt (1991) applied PMT constructs to behavioral intentions of heterosexual and homosexual adults in Amsterdam. Among the homosexual subjects, again vulnerability was significantly and inversely related to intention to adopt safe sex techniques. The severity, self- and response efficacies were all significantly and positively related to intention. Heterosexual subjects scores for response efficacy and self-efficacy were the only two significantly related to intention, perhaps because they falsely assumed they were safe from the AIDS virus. Overall, the researchers believed the heterosexual data fit better with Protection Motivation Theory, so they emphasized that different intervention strategies are needed for different groups (Van der Velde & Van der Pligt, 1991).

Rather than focusing efforts on high-risk injection-drug users (IDUs), one study evaluated the effectiveness of a program for female partners of IDUs (Rhodes, Wolitski, & Thornton-Johnson, 1992). Incorporating five related models, the researchers created an intervention that attempted to reduce the risk of HIV among these women through a variety of means including counseling, medical care, and free condoms and bleach. Educational sessions taught the women about HIV transmission, use of condoms, and negotiating skills. While PMT variables were not independently examined, some general results showed improvement among the women. Ninety-one percent of the women indicated they had taken steps to reduce their chances of getting AIDS. Perhaps response and self-efficacy portions of the program played a role in this empowerment by giving the women tools to take control of their sexual behavior (Rhodes, Wolitski, and Thornton-Johnson, 1992).

The last study again limited its efforts to a specific population—this time male clients of female prostitutes in Amsterdam (Vanwesenbeeck et al., 1993). Only costs and benefits of condom use were assessed, so it is not a true application of the Protection Motivation Theory proposed by Rogers (1983). The researchers felt it was important to limit their research to those factors, since one limit of PMT is that people’s perceptions of costs and benefits differ and therefore the model cannot be applied uniformly. In general, condom users have a more positive view (response benefit) of commercial sex and condoms, so it follows that the response costs of commercial sex and condoms are greater for non-users (Vanwesenbeeck et al., 1993).

Summary of AIDS-Related Applications
Clearly, Protection Motivation Theory fails to be applied consistently among the AIDS-related studies described. Thus it is difficult to assess the effectiveness of the theory in explaining safe sex behavior by comparing the results. Some trends, however, did emerge. Among homosexual subjects, for example, perceived vulnerability plays a crucial role in determining the likelihood of engaging in safe-sex behavior. Due to the prolonged societal portrayal as the primary victims of AIDS, many homosexuals have elected to surrender to the virus and elect not to use condoms during sexual contact. Heterosexuals, on the other hand, appear to be negatively affected by their lack of perceived vulnerability. That is, though they believe they have the means of protecting themselves from the virus, they are less likely to believe they will be infected with it and therefore do not always cognitively link condom use and protection from AIDS.

Conclusion
Except in a few rare instances, AIDS is a disease of behavioral choices. The Protection Motivation Theory attempts to explain why behavioral choices are made. Nevertheless, it does not appear to be a comprehensive enough approach for dealing with AIDS protection behavior. Among suggestions made to expand PMT for AIDS-related research were inclusion of past behavior, HIV-status, presence of a primary partner, and general and experiential knowledge of AIDS (Aspinwall et al., 1991; Eppright, Tanner, & Hunt, 1994; Van der Velde & Van der Pligt, 1991). Such a diverse population is now affected by HIV and AIDS, so future studies must address the needs and issues of segments of the population.

In general as well, the Protection Motivation Theory is an incomplete model for explaining and predicting health behavior change as a result of desire to protect one’s self or others. A number of other factors, including past knowledge or experience with a health problem, are not considered within the theory, limiting its usefulness. This is not to say it should be dismissed entirely. The body of research described in this paper can be useful for designing interventions for specific targeted groups by appealing to the PMT variables which influence them most.

By focusing strictly on perceived severity, vulnerability, response efficacy, and self-efficacy, studies incorporating the Protection Motivation Theory as proposed by Rogers (1983) will be limiting themselves. It appears to be critical that the population being studied and the type of behavior change being proposed be considered, and that necessary adjustments to the theory be made. If studies neglect the impact of the environment, previous exposure to or knowledge of the problem, and individual health values, results will be inconclusive and useless. In addition, intention cannot always be assumed to lead to prolonged behavior change. Long-term follow-up of subjects is needed to determine whether intentions are a true reflection of behavior.

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