Although public health emergencies can require exceptional interventions, the behavioural science community has a duty to remain level-headed, follow the science, and call out unethical practice. This article argues that the use of intense fear messaging by the government is inadvisable: it is likely damaging mental health while being of questionable practical value.
Specifically, it is likely to be:
Ineffective, since fear levels are already high and efficacy-focused messaging would be more effective, the effectiveness of fear messaging is often based on questionable evidence, the messaging will likely activate mortality salience, and, altogether, fear messaging may ‘backfire’ by producing psychologically defensive responses.
Unhealthy, since fear messaging induces anxiety and stress which has negative effects on mental and physical wellbeing (and, ironically, the immune system).
Unethical, since fear messaging is inherently designed to distress people, it takes away their free will, the negatives likely outweigh the positives, it exacerbates social inequalities, and there are more ethical alternatives available.
If you’re a behavioural scientist who would like to protest the government’s use of fear messaging, please pass this article on to other behavioural scientists; if you would consider signing an letter to the government’s behavioural scientists (at the SPI-B and the BIT), please get in touch with Patrick at pf@patrickfagan.co.uk.
Since early 2020, the UK has been plunged into a health emergency without modern precedent. COVID-19 has been recorded on the death certificates of 2.65m people worldwide to-date, including 125k in the UK (WHO, 2021). The disease can be unpleasant and debilitating, and can produce long-term health outcomes like fatigue, ‘brain fog’, insomnia, shortness of breath, and dizziness (NHS, 2021). Ultimately, there is little doubt that this is a serious disease that requires a serious response.
Accordingly, the British government has taken an evidence-led approach to combating COVID-19, largely following the recommendations of scientific transnational NGOs like the World Health Organisation (WHO), as well as the Cabinet Office’s Scientific Advisory Group on Emergencies (SAGE) and its behavioural science subsidiary, the Scientific Pandemic Insights Group on Behaviours (SPI-B). Thus, the government has mandated many interventions (typically behavioural) aimed at reducing the transmission of the virus.
One such intervention has been the use of fear messaging - that is, messages designed to scare people into compliance by threatening them with otherwise negative consequences (Witte, 1992). An SPI-B release on the 22nd March 2020 (pp. 1-2) recommended that “the perceived level of personal threat needs to be increased among those who are complacent, using hard-hitting emotional messaging”. A clear manifestation of this was the hard-hitting “Look Them in the Eyes” campaign which, according to sources close to the government, was aimed at increasing the perceived risk and threat of the disease (Campaign, 2021).
Fear, as horror author HP Lovecraft once noted (1927), is “the oldest and strongest emotion”. Indeed, a meta-analysis of brain imaging research suggests that fearful stimuli are those most likely to activate the brain’s ‘emotion centre’, the amygdala (Costafreda et al., 2008). Accordingly, it is little surprise that the use of fear in messaging both grabs attention (LoBue & DeLoache, 2008) and motivates behaviour (Witte & Allen, 2000); and likewise, a meta-analysis of 127 papers concluded that fear appeals have a significant impact on attitudes, intentions and behaviours (d=0.29; Tannenbaum et al., 2015). A recent paper found that, even considering perceived risk and political and moral attitudes, the only predictor of behavioural change (e.g., social distancing) was fear of the virus (Harper et al., 2020).
On the face of it, fear appears to be an important tool for changing behaviours, and therefore limiting the spread of coronavirus. However the relationship between fear and behaviour change is nuanced, the negative psychological impact of fear needs to be accounted for and there are troubling ethical questions that must be answered.
With the following considerations in mind, can such intense fear messaging as we have seen recently ever be justified?
1. Ineffective
Although the aforementioned meta-analysis (Tennenbaum et al., 2015) did find that fear has a small effect on outcomes, it also noted that effectiveness was moderated by a number of variables including the target audience, the frequency of the desired behaviour and perceived behavioural control over the outcomes. Indeed, theories of fear messaging such as the Health Belief Model, Protection Motivation Theory, and the Extended Parallel Process Model suggest that focusing on threat alone is rarely enough to change behaviour (see Norman et al., 2015; Salazar et al., 2013; Skinner, Tiro & Champion, 2015). In addition, the quality of evidence supporting fear appeals is often poor (see Hastings, Stead & Webb, 2004).
Ultimately, a more recent meta-analysis (Kok et al., 2018, p.111) concluded, “…[the empirical evidence] does not support positive effects of fear appeals. Nonetheless, their use persists and is even promoted by health psychology researchers, causing scientific insights to be ignored or misinterpreted.”
The first point to consider is that the relationship between fear messaging and behavioural change is nuanced: it is not always a case of more fear producing more effects, and several theories have been proposed by way of explanation.
Early research was guided by Drive Theory, which held that fear is an acquired drive that motivates a response; importantly, it held that the relationship between fear and response followed an inverted-U-shaped function, where too-low levels of fear do not motivate behaviour, but too-high levels motivate defence mechanisms instead of compliance and thus become counterproductive (Hovland, Janis, & Kelley, 1953; Janis, 1967; Janis & Feshbach, 1953; Quinn, Meenaghan, & Brannick, 1992). However, substantial empirical evidence contradicts this hypothesis and suggests that the model is linear – the more fear, the more persuasion (Beck & Frankel, 1981; Boster & Mongeau, 1984; Witte & Allen, 2000).
Alternatively, several studies suggest that the effectiveness of fear appeals is moderated by self-efficacy - that is, the (perceived) ability to carry out the behaviour advocated in the message (e.g., Anderson, 2000; Girandola, 2000; Ruiter, Abraham & Kok, 2001; Smith, 1997; Snipes, LaTour & Bliss, 1999). Namely, Protection Motivation Theory suggests that the behavioural response depends on both perceived threat (i.e., the risk and severity of negative outcomes) and perceived efficacy (i.e., the ability of oneself to carry out the behaviour, and the ability of the behaviour to reduce negative outcomes; Block & Keller, 1998; LaTour & Zahra, 1989; Pechmann, Zhao, Goldberg, & Reibling, 2003; Rogers, 1983; Tanner, Hunt & Eppright, 1991). There has been good empirical support for this model (e.g., Kleinot & Rogers, 1982; Maddux & Rogers, 1983; Mulilis & Lippa, 1990).
A third model, Terror Management Theory, argues that awareness of one’s own mortality can, since death is ultimately unavoidable, produce paralysing anxiety; this is buffered by cultural worldviews (e.g., religions) which increase self-esteem and reduce the fear of death – such that being reminded of one’s mortality causes people to vigorously defend their worldviews (Greenberg et al., 1986; Hayes et al., 2010; Pyszczynski et al., 1996; Rosenblatt et al., 1989; Schmeichel et al., 2009). This model has been applied to fear-based health messaging, suggesting that subconscious thoughts of death can undermine the message by directing behaviour towards protecting the psychological self rather than the physical self (Goldenberg & Arndt, 2008).
What Protection Motivation Theory and Terror Management Theory have in common, is the requirement for efficacy in combination with fear: people need to feel that they have some sort of control over the risk as well as their own mortality. High fear is only effective when the proposed coping behaviour is seen as efficacious and feasible (Blumberg, 2000; de Turck et al., 1992; Donovan, 1991; Snipes, LaTour & Bliss, 1999; Witte et al., 1998). In a meta-analysis of experimental studies, Sheeran, Harris and Epton (2014, p. 511) concluded that “risk appraisals had larger effects on outcomes when response efficacy and self-efficacy were enhanced”. In fact, two earlier meta-analyses both found that efficacy was a stronger predictor than threat when it came to changing behaviours (Floyd, Prentice-Dunn & Rogers, 2000; Milne, Sheeran & Orbell, 2000).
Failing to consider efficacy is potentially a major flaw in extant fear messaging research. Kok and colleagues’ meta-analysis (2018), found that, out of all the studies published up until 2012, only six varied both threat and efficacy in randomised behavioural trials. The authors concluded that “fear appeals are only effective in case of high self-efficacy; a situation that is quite rare in health promotion practice” (p. 121) - and in fact, threat messaging in situations of low efficacy may actually have counterproductive effects, as illustrated in their diagram below.
Effect size for presence of threat, by low versus high efficacy (Kok et al., 2018)
Indeed, the literature is replete with examples of fear messaging producing counterproductive, maladaptive responses, which reduce unpleasant feelings of fear rather than mitigating the risk itself, such as avoiding or tuning out the message, rejecting the relevance of the message to oneself, or counter-arguing with the message and doubting its credibility (see Blumberg, 2000; Sego & Stout, 1994; Keller, 1999). Over half a century ago, Janis and Feshbach (1953) suggested that anxiety-arousing messages could produce negative reactions, such as inattentiveness, aggressiveness and defensive avoidance. As an illustration, research using electroencephalographic measures of brain activity (EEG) found that smokers, shown scary pictures and videos, responded in a defensive way by ignoring the information (Kessels, Ruiter & Jansma, 2010; Kessels et al., 2014). In qualitative terms, Bayer and Fairchild (2016, p. 395) concluded that “fear-arousing efforts may provoke political resistance that could cast a shadow of arrogance and contempt, substantially distracting from the substance and warrant for critically important public health campaigns”.
With respect to pandemics specifically, denial was observed among Liberians during the 2014-16 Ebola outbreak due to fear of the disease and its fatal effects (Omidian, Tehoungue & Monger, 2014); Cheung (2015, p. 71) summarised that “while a reasonable level of fear may help people to cope with disaster, overwhelming fear can be paralysing”.
It’s also important to note that fear messaging can have ironic consequences by provoking a need for soothing which is gratified by maladaptive behaviours (Henley, 2002). For example, some research with anti-smoking campaigns has found that smokers report the adverts make them feel so anxious they need to smoke (e.g., Eadie & Smith, 1995; MacAskill et al., 1993). It is therefore perhaps not unreasonable to infer that fear messaging would cause people to maladaptively seek social contact during the COVID-19 pandemic, given that social contact is well known to reduce stress (e.g., Kikusui, Winslow & Mori, 2006).
Finally, the reported effectiveness of fear appeals must be considered in light of the quality of its data. Firstly, fear messaging research tends to take place in experimental conditions which differ to the real world, where people can ignore or discount messaging they do not like (Kitchen, 1986; Pechmann, 2001). Secondly, many studies use self-reported measures, which are biased by respondents giving logical explanations for what are largely emotional responses (Hackley & Kitchen, 1999; Wertz, 1998). Many studies similarly rely on respondents’ perceptions of effectiveness rather than observed behavioural effects (Biener & Taylor, 2002; Biener et al., 2000) and the two do not correlate well (Austin, Pinkleton, & Fujioka, 1999); indeed, fear appeals sometimes do well in surveys but fail to actually change behaviour (e.g., DeJong & Wallack, 1999).
Crucially, only a few studies have researched fear messaging in ‘the real world’. These have found that such campaigns are effective in raising awareness and changing attitudes (Biener et al., 2000; Donovan, Jalleh, & Henley, 1999; Grey et al., 2000; Hill, Chapman & Donovan, 1998) but only sometimes effective in changing behaviour (Baker, 1995; Transport Accident Commission, 2002).
Hastings, Stead and Webb (2004, p. 978) concluded: “The case for using fear appeals may be tentatively proven in the laboratory, but, in the real world, marketing questions about the use of fear remain unanswered (and often unexplored).”
With respect to COVID-19, therefore, the use of fear messaging may be ill-advised. While the SPI-B likely relied on empirical evidence on the effectiveness of fear, there are many methodological issues with this evidence that may reduce its in-vivo applicability. Furthermore, COVID-19 fear appeals are likely to evoke mortality salience, resulting in counterproductive behaviours; and, appeals to coping and efficacy are likely to be more effective. This is particularly true in cases such as this where background levels of fear are already extremely high (Muthusamy, Levine & Weber, 2009).
2. Unhealthy
Fear messaging does, by definition, increase feelings of anxiety and tension (e.g., Boster & Mongeau, 1984; Putwain & Best, 2011; von der Embse, Schultz & Draughn, 2015). The government’s widespread and sustained use of fear messaging must therefore be weighed against the consistent finding that negative affect is a negative predictor of both mental and physical wellbeing (e.g., Diener & Chan, 2011; Krueger & Chang, 2008; Lahey, 2009; Puente-Martínez et al., 2018; Xu & Roberts, 2010); in short, scaring people could be making them ill.
While there does not appear to be any direct evidence on the negative well-being effects of fear messaging, research suggests that a relationship is likely - that often, the only thing we have to fear is fear itself. For example, using public data in New Zealand, Pearson and Breetzke (2014) found that, even after adjusting for confounding variables, an increased fear of crime predicted lower mental and physical wellbeing, while no such effect was observed for neighbourhood crime rates. In other words, crime did not impact wellbeing, but the fear of crime did.
Research into news exposure suggests something similar. The number of television viewing hours for a negative event has been shown to increase psychological distress (Schlenger et al. 2002; Silver et al. 2002), and, in specific terms, scholars have shown that greater media exposure to traumatic events, like the OKC bombing (Pfefferbaum et al., 1999), Boston Marathon bombing (Thompson et al. 2019), and 9/11 (Silver et al. 2013) has a negative effect on mental health. More broadly, Boukes and Vliegenthart (2017) applied latent growth curve modelling to a sample of 2,767 people and found that the consumption of ‘hard’ news television programs has a negative effect on the development of mental wellbeing.
Regarding COVID-19 specifically, greater COVID-19 media consumption has been linked to greater psychological distress, and approximately two thirds of this effect were explained by increased perceptions of threat (Stainback, Hearne & Trieu, 2020). Similarly, Satici et al. (2020) found that fear of COVID-19 had a negative relationship with mental wellbeing; and Shevlin and colleagues (2020) showed that anxiety related to COVID-19 uniquely contributed to somatic symptoms, particularly gastrointestinal and fatigue symptoms, over and above factors like pre-existing health conditions and generalised anxiety disorder.
Though none of the aforementioned results are necessarily causal, they do draw attention to the potential for fear messaging to reduce wellbeing. Indeed, Garfin, Silver and Holman (2020, p. 355) stated that “paradoxically, while journalists and public health officials worked to communicate critical information globally regarding risk assessments and recommendations, a related threat emerged - psychological distress resulting from repeated media exposure to the outbreak.”
This psychological distress can ironically disrupt a person’s ability to cope with COVID-19 and the life changes necessitated by it, such as reducing the number of social interactions, being productive at work, and caregiving for oneself and others (e.g., Kowaleski-Jones & Christie-Mizell, 2010; Ramchandani & Psychogiou, 2009). In the most extreme cases, it has been reported that individuals scared of COVID-19 have committed suicide because they thought they were infected even though they were not (Goyal et al., 2020; Mamun & Griffiths, 2020).
As an aside, this raises concerns about the government’s “Act Like You’ve Got It” campaign, which implored people to act as though they had been infected with COVID-19 (BBC, 2021). Countless priming experiments have demonstrated that behaviours can impact emotions and cognitions accordingly, in a process known as embodied persuasion (see Van Rompay, 2014), and indeed a Health Psychology study found that priming people to think about illness had a deleterious impact on their cognitions and behaviours (Orbell & Henderson, 2016). In short, there is reason to suspect that encouraging healthy members of the public to act like they are ill might, at least psychologically, cause harm.
Furthermore, as Espinola and colleagues (2016, p. 102) stated in their analysis of the Ebola outbreak in West Africa, “fear-related behaviours may exacerbate harm, leading to severe and sometimes deadly consequences”. The authors explain, for example, that increased levels of fear resulted in: family members of Ebola patients caring for loved ones at home (due to fear of hospitals), where protective equipment and proper care procedures were lacking; patients consequently dying at home and cadavers being cleansed and prepared by family members, hastening viral transmission; groups of people fleeing high-infection areas, spreading the disease elsewhere; people avoiding emergency treatment units out of fear of catching Ebola there, resulting in increased deaths from Ebola as well as non-Ebola conditions; and healthcare workers and Ebola patients suffering the effects of stigma, discrimination, and even physical attacks from the community at large. Additionally, Cheung (2015) also noted that maladaptive rumours escalated in Monrovia, including the theories that the disease was brought in by foreign aid workers, that patients were having their organs harvested and cannibalised, and that the outbreak was a hoax orchestrated by the government; indeed, fear and paranoia are natural bedfellows (e.g., Cromby & Harper, 2009). It is therefore possible that elevated fear from government messaging will only increase the already considerable levels of conspiracy ideation (e.g., Romer & Jamieson, 2020) and non-COVID-related deaths due to missed diagnoses (e.g., Maringe et al., 2020).
Finally, the government’s use of fear messaging must be considered in context. The pandemic has already seen extremely high levels of stress and anxiety among the public, as well as a burgeoning mental health crisis (e.g., Cullen, Gulati & Kelly, 2020; Fancourt, Steptoe & Bu, 2020; Garfin, Silver & Holman, 2020; Kumar & Nayar, 2020; Pfefferbaum & North, 2020; Shevlin et al., 2020). The use of confinement and social isolation is also likely to have resulted in many psychopathological outcomes among the public - such as fatigue, sleep disorders, cognitive impairment, delusions, anxiety, depression, hostility, loss of self-esteem, and lower wellbeing - as well as, ironically, a compromised immune system (Abad, Fearday & Safdar, 2010; Cacioppo & Cacioppo, 2014; Cacioppo et al., 2015; Gammon, 1998; Gunderson, 1974; Kellerman, Rigler & Siegel, 1977; Pagel & Chouker, 2016; Sapolsky, Alberts & Altmann, 1997; Zuckerman et al., 1968). The use of fear messaging must thus be carefully weighed against the already substantial burdens of mental and physical health under the current conditions.
3. Unethical
The use of fear in advertising is typically held to very high ethical standards. The Advertising Standards Authority (ASA, 2013, p. 1), for example, states that “marketing communications must not cause fear or distress without justifiable reason; if it can be justified, the fear or distress should not be excessive”. In a review of the literature, Hastings, Stead and Webb (2004) conclude by calling on social campaigns to re-examine their fondness for fear appeals and to make sure one does not breach the Hippocratic principle of, “First, do no harm.”
Indeed, social marketers appear to have been cooling off fear appeals in recent history, as Bayer and Fairchild (2016) note. For example, in the mid-1980s, fear campaigns to combat the emerging HIV epidemic caused indignation among target communities, and the advertisements were seen as immoral; the messaging backfired and imposed unfair psychological and social burdens. Within three decades, AIDS-focused interventions wanted specifically to avoid shocking, scaring and judging the people they were talking to (White, 2015). COVID-19 killed fewer British people than, say, heart disease last year (ONS, 2020), and yet politicians and the public would likely be aghast at fearful, shaming campaigns aimed at encouraging people to improve their diet and exercise more - why should ethics change for coronavirus?
Ethically speaking, deontological theory - which concerns the inherent morality and humaneness of an action - would outright reject the use of fear appeals, since it is wrong to make people distressed whatever the benefits might be (Duke et al., 1993; Smith & Quelch, 1992; Snipes et al., 1999). Fear appeals intrude on people’s private lives and expose them against their will to harmful or offensive messages and may create unnecessary anxiety (Benet, Pitts & LaTour, 1993; Hyman & Tansey, 1990; LaTour & Zahra, 1989). Henthorne and colleagues (1993) argue that any level of fear which is not “psychologically comfortable” may be unethical. Similarly, Beauchamp (1988) raises the point of free will, arguing that manipulative advertising which exerts emotional pressure raises moral questions if it compromises the recipient’s ability to make a rational and free choice.
On the other hand, utilitarian theory concerns the consequences of an action and holds that it is ethical if it produces a net benefit; this approach supports the use of fear messaging as long as the outcome is beneficial to society and other approaches are less effective (see Hastings, Stead & Webb, 2004). However, as discussed, fear messaging is unlikely to be effective and it likely has negative mental health consequences, making it unethical in the utilitarian sense. While a campaign may be implemented with the best of intentions, it can ultimately backfire and have disastrous societal consequences - such as China’s eradication of sparrows as pests during the Great Leap Forward, which ultimately allowed locusts to thrive and resulted in wide-scale starvation (Steinfeld, 2018).
Indeed, there may be unintended socio-political consequences of fear messaging at a macro level. It is known that fear induces a desire for authoritarian control (e.g., Asbrock & Fritsche, 2013; Feldman & Stenner, 1997; Judges, 1999), and safety and security have been the rationalisations for totalitarian regimes throughout history – as H. L. Mencken (1918) once said, “The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary”. In the current ‘authoritarianism pandemic’ of increased surveillance and a diminished right of assembly and protest (Thompson & Ip, 2020), it is important to query whether fear messaging might be helping to set the emotional conditions in which political authoritarianism can take root.
Furthermore, the role of efficacy in the effectiveness of fear messaging suggests it has the potential to increase social inequality. As discussed previously, several studies have found that threatening messages only work when people feel they have efficacy to control the outcome (see Kok et al., 2018). This means that fear-arousing campaigns are most persuasive among people who are already equipped (socially and psychologically) to act on the message - while those who are less able to act on the message are more likely to respond maladaptively (e.g., by rejecting the message), which makes them even more vulnerable to the risk. In other words, they can cause less efficacious segments in society to lag even further behind (Arblaster et al., 1996; Hastings et al., 1998). This inequality violates the ethical principle of equal justice for everyone.
Bearing in mind all of the above - that fear appeals engender distress against people’s will, that they have negative unintended consequences and that they can further inequalities - the ethical case for fear appeals is weak, and their use verges on indefensible when considering that there are alternatives which may be equally as effective, if not more so. For example, anti-smoking campaigns using humour, irony, supportive messages, empathy, positive role models, empowerment, and self-affirmation have all produced favourable attitudinal and behavioural changes (e.g., Belch et al., 1995; Biener & Taylor, 2002; de Turck et al., 1994; Falk et al., 2015; Mintz, Hazel & Schoales, 1999; Pechmann 2001; Reichert, Heckler, & Jackson, 2001). In fact, Shen (2011) directly compared empathy versus fear in anti-smoking PSAs, and found empathy arousing messages to be more effective than fear-arousing ones.
Ultimately, it is critical that behavioural scientists pay attention to the ethical implications of their work. Psychologists generally have a bad track record in which they have simply ‘followed the science’ without concern for ethics - from Harry Harlow’s cruel experiments on monkeys to John Money’s violating research into gender identity among children, and many other examples in-between, familiar even to undergraduate psychology students. There is a disturbing tendency for psychologists to see human beings as a set of discrete behaviours to manipulate - as ‘nudge units’ - without considering individual subjectivity and quality of life. As Holocaust survivor Elie Wiesel once said, “We must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph” (Annas & Utley, 1992, p. ix).
Psychologists must learn from the mistakes of the past, and consider that just because an intervention works, does not mean it is right; even if an intervention saves humans, we must not lose our humanity.
In conclusion, while public health emergencies like COVID-19 can require exceptional interventions to reduce the cost to human life, these should not come at the cost of ethical principles, wellbeing nor quality of life. Furthermore, it is imperative to act on the basis of the best available scientific evidence.
Therefore, the use of fear messaging by Her Majesty’s Government is inadvisable. The government’s behavioural scientists must truly ‘follow the science’ regarding fear messaging, consider crucial ethical implications, and mitigate the catastrophic impact of their recommendations on the mental wellbeing of the country.
If you are a behavioural scientist concerned by the government’s use of fear, please pass this article on. If you would consider signing a letter about it to the SPI-B and the BIT, please email Patrick at pf@patrickfagan.co.uk.
References
Abad, C., Fearday, A., & Safdar, N. (2010). Adverse effects of isolation in hospitalised patients: a systematic review. Journal of hospital infection, 76(2), 97-102.
Anderson, R. B. (2000).Vicarious and persuasive influences on efficacy expectations and intentions to perform breast self-examination. Public Relations Review, 26, 97–114.
Annas, E. R., & Utley, G. J. (1992). The Nazi doctors and the Nuremberg Code: human rights in human experimentation: human rights in human experimentation. Oxford University Press, USA.
Arblaster, L., Lambert, M., Entwistle, V., Forster, M., Fullerton, D., Sheldon, T., & Watt, I. (1996). A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health. Journal of Health Services Research & Policy, 1(2), 93-103.
ASA (2013, November 8th). Fear and distress: Advice Online [web page]. Retrieved from: https://www.asa.org.uk/advice-online/fear-and-distress.html
Asbrock, F., & Fritsche, I. (2013). Authoritarian reactions to terrorist threat: Who is being threatened, the Me or the We?. International journal of psychology, 48(1), 35-49.
Austin, E. W., Pinkleton, B., & Fujioka, Y. (1999). Assessing prosocial message effectiveness: Effects of message quality, production quality, and persuasiveness. Journal of health communication, 4(3), 195-210.
Baker, C. (1995). Advertising Works 8: Papers from the IPA Advertising Effectiveness Awards 1994. In Health Education Board for Scotland— Smoking: sticks and carrots (Chap. 18). Henley-on-Thames, England: NTC Publications.
Bayer, R., & Fairchild, A. L. (2016). Means, ends and the ethics of fear-based public health campaigns. Journal of medical ethics, 42(6), 391-396.
BBC (2021, January 9th). Covid-19: Act like you've got the virus, government urges [news article]. Retrieved from: https://www.bbc.com/news/uk-55598918
Beauchamp, T. L. (1988). Manipulative advertising. In Beauchamp, T. L., & Bowie, N. E. (Eds.), Ethical theory and business (3rd ed.). Englewood Cliffs, NJ: Prentice-Hall.
Beck, K. H., & Frankel, A. (1981). A conceptualization of threat communications and protective health behavior. Social Psychology Quarterly, 204-217.
Belch, G. E., Belch, M. A., & Jones, M. A. (1995). An exploratory investigation of teenagers’ attitudes toward anti-drug appeals. European Advances in Consumer Research, 2, 329–336.
Benet, S., Pitts, R. E., & LaTour, M. (1993). The appropriateness of fear appeal use for health care marketing to the elderly: Is it OK to scare granny?. Journal of Business Ethics, 12(1), 45-55.
Biener, L., McCallum-Keller, G., & Nyman, A. L. (2000). Adults’ response to Massachusetts anti-tobacco television advertisements: Impact of viewer and advertisement characteristics. Tobacco Control, 9, 401–407.
Biener, L., & Taylor, T. M. (2002). The continuing importance of emotion in tobacco control media campaigns: a response to Hastings and MacFadyen. Tobacco Control, 11(1), 75-77.
Block, L. G., & Keller, P. A. (1998). Beyond protection motivation: An integrative theory of health appeals. Journal of applied social psychology, 28(17), 1584-1608.
Blumberg, S. J. (2000). Guarding against threatening HIV prevention messages: An information-processing model. Health Education and Behavior, 27, 780–795.
Boster, F. J., & Mongeau, P. (1984). Fear-arousing persuasive messages. Annals of the International communication Association, 8(1), 330-375.
Boukes, M., & Vliegenthart, R. (2017). News consumption and its unpleasant side effect. Journal of Media Psychology.
Cacioppo, J. T., & Cacioppo, S. (2014). Social relationships and health: The toxic effects of perceived social isolation. Social and personality psychology compass, 8(2), 58-72.
Cacioppo, J. T., Cacioppo, S., Capitanio, J. P., & Cole, S. W. (2015). The neuroendocrinology of social isolation. Annual review of psychology, 66, 733-767.
Campaign (2021, January 27th). Will the government’s new emotive Covid ad make people obey the rules? [article]. Retrieved from: https://www.campaignlive.co.uk/article/will-governments-new-emotive-covid-ad-people-obey-rules/1705634
Cheung, E. (2015). An outbreak of fear, rumours and stigma: psychosocial support for the Ebola virus disease outbreak in West Africa. Intervention, 13(1), 70-6.
Costafreda, S. G., Brammer, M. J., David, A. S., & Fu, C. H. (2008). Predictors of amygdala activation during the processing of emotional stimuli: a meta-analysis of 385 PET and fMRI studies. Brain research reviews, 58(1), 57-70.
Cromby, J., & Harper, D. J. (2009). Paranoia: A social account. Theory & Psychology, 19(3), 335-361.
Cullen, W., Gulati, G., & Kelly, B. D. (2020). Mental health in the Covid-19 pandemic. QJM: An International Journal of Medicine, 113(5), 311-312.
de Turck, M. A., Goldhaber, G. M., Richetto, G. M., & Young, M. J. (1992). Effects of fear-arousing warning messages. J. PROD. LIABIL., 14(2), 217-223.
deTurck, M. A., Rachlin, R. A., & Young, M. J. (1994). Effects of a role model and fear in warning label on perceptions of safety and safety behavior. ACR North American Advances.
Diener, E., & Chan, M. Y. (2011). Happy people live longer: Subjective well‐being contributes to health and longevity. Applied Psychology: Health and Well‐Being, 3(1), 1-43.
Donovan, R. J., Jalleh, G., & Henley, N. (1999). Executing effective road safety advertising: are big production budgets necessary?. Accident Analysis & Prevention, 31(3), 243-252.
Duke, C. R., Pickett, G. M., Carlson, L., & Grove, S. J. (1993). A method for evaluating the ethics of fear appeals. Journal of Public Policy & Marketing, 12(1), 120-129.
Eadie, D., & Smith, C. (1995). The role of applied research in public health advertising: some comparisons with commercial marketing. Health Education Journal, 54(3), 367-380.
Espinola, M., Shultz, J. M., Espinel, Z., Althouse, B. M., Cooper, J. L., Baingana, F., ... & Rechkemmer, A. (2016). Fear-related behaviors in situations of mass threat. Disaster health, 3(4), 102-111.
Falk, E. B., O’Donnell, M. B., Cascio, C. N., Tinney, F., Kang, Y., Lieberman, M. D., ... & Strecher, V. J. (2015). Self-affirmation alters the brain’s response to health messages and subsequent behavior change. Proceedings of the National Academy of Sciences, 112(7), 1977-1982.
Fancourt, D., Steptoe, A., & Bu, F. (2020). Trajectories of depression and anxiety during enforced isolation due to COVID-19: longitudinal analyses of 59,318 adults in the UK with and without diagnosed mental illness. medRxiv.
Feldman, S., & Stenner, K. (1997). Perceived threat and authoritarianism. Political Psychology, 18(4), 741-770.
Floyd, D. L., Prentice‐Dunn, S., & Rogers, R. W. (2000). A meta‐analysis of research on protection motivation theory. Journal of applied social psychology, 30(2), 407-429.
Gammon, J. (1998). Analysis of the stressful effects of hospitalisation and source isolation on coping and psychological constructs. International journal of nursing practice, 4(2), 84-96.
Garfin, D. R., Silver, R. C., & Holman, E. A. (2020). The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure. Health psychology, 39(5), 355-357.
Girandola, F. (2000). Peur et persuasion: présentations des recherches (1953-1998) et d'une nouvelle lecture. L'année Psychologique, 100(2), 333-376.
Goldenberg, J. L., & Arndt, J. (2008). The implications of death for health: a terror management health model for behavioral health promotion. Psychological review, 115(4), 1032.
Goyal, K., Chauhan, P., Chhikara, K., Gupta, P., & Singh, M. P. (2020). Fear of COVID 2019: First suicidal case in India!. Asian journal of psychiatry, 49, 101989.
Greenberg, J., Pyszczynski, T., & Solomon, S. (1986). The causes and consequences of a need for self-esteem: A terror management theory. In Public self and private self (pp. 189-212). Springer, New York, NY.
Grey, A., Owen, L., & Bolling, K (2000). A breath of fresh air: Tackling smoking through the media. London: Health Development Agency
Gunderson, E. E. (1974). Psychological studies in Antarctica. Human Adaptability in Antarctic conditions (Antarctic Research Series, Vol. 22, pp. 115–131) (Washington, DC: American Geophysical Union, 1974).
Hackley, C. E., & Kitchen, P. J. (1999). Ethical perspectives on the postmodern communications Leviathan. Journal of Business Ethics, 20(1), 15-26.
Harper, C. A., Satchell, L. P., Fido, D., & Latzman, R. D. (2020). Functional fear predicts public health compliance in the COVID-19 pandemic. International journal of mental health and addiction, 1-14.
Hastings, G. B., Stead, M., Margaret, W., Lowry, R., MacFadyen, L., McVey, D., ... & Tones, K. (1998). Using the media to tackle the health divide: future directions. Social Marketing Quarterly, 4(3), 42-67.
Hastings, G. B., Stead, M., & Webb, J. (2004). Fear appeals in social marketing: Strategic and ethical reasons for concern. Psychology & marketing, 21(11), 961-986.
Hayes, J., Schimel, J., Arndt, J., & Faucher, E. H. (2010). A theoretical and empirical review of the death-thought accessibility concept in terror management research. Psychological bulletin, 136(5), 699.
Henley, N. (2002). You will die! Mass media invocations of existential dread. M/C Journal, 5(1).
Henthorne, T. L., LaTour, M. S., & Nataraajan, R. (1993). Fear appeals in print advertising: An analysis of arousal and ad response. Journal of advertising, 22(2), 59-69.
Hill, D., Chapman, S., & Donovan, R. (1998). The return of scare tactics. Tobacco Control, 7(1), 5-8.
Hovland, C. I., Janis, I. L., & Kelley, H. H. (1953). Communication and persuasion. Yale University Press.
Hyman, M. R., & Tansey, R. (1990). The ethics of psychoactive ads. Journal of Business Ethics, 9(2), 105-114.
Janis, I. L. (1967). Effects of fear arousal on attitude change: Recent developments in theory and experimental research. Advances in experimental social psychology, 3, 166-224.
Janis, I. L., & Feshbach, S. (1953). Effects of fear-arousing communications. The Journal of Abnormal and Social Psychology, 48(1), 78.
Judges, D. P. (1999). Scared to death: Capital punishment as authoritarian terror management. UC Davis L. Rev., 33, 155.
Keller, P. A. (1999). Converting the unconverted: The effect of inclination and opportunity to discount health-related fear appeals. Journal of Applied Psychology, 84(3), 403.
Kellerman, J., Rigler, D., & Siegel, S. E. (1977). The psychological effects of isolation in protected environments. The American journal of psychiatry, 134(5), 563–565
Kessels, L. T., Ruiter, R. A., & Jansma, B. M. (2010). Increased attention but more efficient disengagement: neuroscientific evidence for defensive processing of threatening health information. Health Psychology, 29(4), 346.
Kessels, L. T., Ruiter, R. A., Wouters, L., & Jansma, B. M. (2014). Neuroscientific evidence for defensive avoidance of fear appeals. International Journal of Psychology, 49(2), 80-88.
Kikusui, T., Winslow, J. T., & Mori, Y. (2006). Social buffering: relief from stress and anxiety. Philosophical Transactions of the Royal Society B: Biological Sciences, 361(1476), 2215-2228.
Kitchen, P. J. (1986). Zipping, zapping and nipping. International Journal of Advertising, 5(4), 343-352.
Kleinot, M. C., & Rogers, R. W. (1982). Identifying effective components of alcohol misuse prevention programs. Journal of Studies on Alcohol, 43(7), 802-811.
Kok, G., Peters, G. J. Y., Kessels, L. T., Ten Hoor, G. A., & Ruiter, R. A. (2018). Ignoring theory and misinterpreting evidence: the false belief in fear appeals. Health Psychology Review, 12(2), 111-125.
Kowaleski-Jones, L., & Christie-Mizell, C. A. (2010). Depressed mood and body weight: Exploring race differences in adolescence. Youth & Society, 41(4), 503-518.
Krueger, P. M., & Chang, V. W. (2008). Being poor and coping with stress: health behaviors and the risk of death. American journal of public health, 98(5), 889-896.
Kumar, A., & Nayar, K. R. (2020). COVID 19 and its mental health consequences. Journal of Mental Health, 180(6), 817-8.
Lahey, B. B. (2009). Public health significance of neuroticism. American Psychologist, 64(4), 241.
LaTour, M. S., & Zahra, S. A. (1989). Fear appeals as advertising strategy: should they be used?. Journal of Consumer Marketing, 6(2).
LoBue, V., & DeLoache, J. S. (2008). Detecting the snake in the grass: Attention to fear-relevant stimuli by adults and young children. Psychological science, 19(3), 284-289.
Lovecraft, H. P. (1927). Supernatural horror in literature. The Palingenesis Project (Wermod and Wermod Publishing Group).
MacAskill, S., Will, V., Hughes, K., & Eadie, D. (1993). The Health Education Board for Scotland’s 1992 anti-smoking initiative. Glasgow, Scotland: University of Strathclyde, Centre for Social Marketing.
Maddux, J. E., & Rogers, R. W. (1983). Protection motivation and self-efficacy: A revised theory of fear appeals and attitude change. Journal of experimental social psychology, 19(5), 469-479.
Mamun, M. A., & Griffiths, M. D. (2020). First COVID-19 suicide case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies. Asian journal of psychiatry, 51, 102073.
Maringe, C., Spicer, J., Morris, M., Purushotham, A., Nolte, E., Sullivan, R., ... & Aggarwal, A. (2020). The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. The lancet oncology, 21(8), 1023-1034.
Mencken, H. L. (1918). Damn. Рипол Классик.
Milne, S., Sheeran, P., & Orbell, S. (2000). Prediction and intervention in health‐related behavior: A meta‐analytic review of protection motivation theory. Journal of applied social psychology, 30(1), 106-143.
Mintz, J. H., Hazel, J., & Schoales, T. (1999). Challenge to youth: a health Canada anti-tobacco campaign. Social Marketing Quarterly, 5(3), 99-102.
Mulilis, J. P., & Lippa, R. (1990). Behavioral change in earthquake preparedness due to negative threat appeals: A test of protection motivation theory. Journal of applied social psychology, 20(8), 619-638.
Muthusamy, N., Levine, T. R., & Weber, R. (2009). Scaring the already scared: Some problems with HIV/AIDS fear appeals in Namibia. Journal of Communication, 59(2), 317-344.
NHS (2021, March 18th). Long-term effects of coronavirus (long COVID) [webpage]. Retrieved from: https://www.nhs.uk/conditions/coronavirus-covid-19/long-term-effects-of-coronavirus-long-covid/
Norman, P., Boer, H., Seydel, E. R., & Mullan, B. (2015). Protection motivation theory. In Conner, M. & Norman, P. (Eds.), Predicting and changing health behavior; research and practice with social cognition models (3rd ed., pp. 70–106). New York: Open University Press.
Omidian, P., Tehoungue, K., & Monger, J. (2014). Medical anthropology study of the Ebola virus disease (EVD) outbreak in Liberia/West Africa. WHO Field Report. Monrovia Liberia.
Orbell, S., & Henderson, C. J. (2016). Automatic effects of illness schema activation on behavioral manifestations of illness. Health Psychology, 35(10), 1144.
Pagel, J. I., & Choukèr, A. (2016). Effects of isolation and confinement on humans-implications for manned space explorations. Journal of Applied Physiology.
Pearson, A. L., & Breetzke, G. D. (2014). The association between the fear of crime, and mental and physical wellbeing in New Zealand. Social Indicators Research, 119(1), 281-294.
Pechmann, C. (2001). Changing adolescent smoking prevalence: Impact of advertising interventions. Changing adolescent smoking prevalence, 171-81.
Pechmann, C., Zhao, G., Goldberg, M. E., & Reibling, E. T. (2003). What to convey in antismoking advertisements for adolescents: The use of protection motivation theory to identify effective message themes. Journal of marketing, 67(2), 1-18.
Pfefferbaum, B., & North, C. S. (2020). Mental health and the Covid-19 pandemic. New England Journal of Medicine, 383(6), 510-512.
Pfefferbaum, B., Seale, T. W., McDonald, N. B., Brandt Jr, E. N., Rainwater, S. M., Maynard, B. T., ... & Miller, P. D. (2000). Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry, 63(4), 358-370.
Puente-Martínez, A., Páez, D., Ubillos-Landa, S., & Costa-Dutra, D. (2018). Examining the structure of negative affect regulation and its association with hedonic and psychological wellbeing. Frontiers in psychology, 9, 1592.
Putwain, D. W., & Best, N. (2011). Fear appeals in the primary classroom: Effects on test anxiety and test grade. Learning and Individual Differences, 21(5), 580-584.
Pyszczynski, T., Wicklund, R. A., Floresku, S., Koch, H., Gauch, G., Solomon, S., & Greenberg, J. (1996). Whistling in the dark: Exaggerated consensus estimates in response to incidental reminders of mortality. Psychological Science, 7(6), 332-336.
Quinn, V., Meenaghan, T., & Brannick, T. (1992). Fear appeals: Segmentation is the way to go. International Journal of Advertising, 11(4), 355-366.
Ramchandani, P., & Psychogiou, L. (2009). Paternal psychiatric disorders and children's psychosocial development. The Lancet, 374(9690), 646-653.
Reichert, T., Heckler, S. E., & Jackson, S. (2001). The effects of sexual social marketing appeals on cognitive processing and persuasion. Journal of advertising, 30(1), 13-27.
Rogers, R. W. (1985). Attitude change and information integration in fear appeals. Psychological reports, 56(1), 179-182.
Romer, D., & Jamieson, K. H. (2020). Conspiracy theories as barriers to controlling the spread of COVID-19 in the US. Social Science & Medicine, 263, 113356.
Rosenblatt, A., Greenberg, J., Solomon, S., Pyszczynski, T., & Lyon, D. (1989). Evidence for terror management theory: I. The effects of mortality salience on reactions to those who violate or uphold cultural values. Journal of personality and social psychology, 57(4), 681.
Ruiter, R. A., Abraham, C., & Kok, G. (2001). Scary warnings and rational precautions: A review of the psychology of fear appeals. Psychology and health, 16(6), 613-630.
Salazar, L. F., Crosby, R. A., Noar, S. M., Walker, J. H., & DiClemente, R. (2013). Models based on perceived threat and fear appeals. Health behavior theory for public health principles, foundations, and applications. America: Jones & Bartlett Learning, 83-104.
Sapolsky, R. M., Alberts, S. C., & Altmann, J. (1997). Hypercortisolism associated with social subordinance or social isolation among wild baboons. Archives of general psychiatry, 54(12), 1137-1143.
Satici, B., Saricali, M., Satici, S. A., & Griffiths, M. D. (2020). Intolerance of uncertainty and mental wellbeing: serial mediation by rumination and fear of COVID-19. International Journal of Mental Health and Addiction, 1-12.
Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., ... & Kulka, R. A. (2002). Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. Jama, 288(5), 581-588.
Schmeichel, B. J., Gailliot, M. T., Filardo, E. A., McGregor, I., Gitter, S., & Baumeister, R. F. (2009). Terror management theory and self-esteem revisited: the roles of implicit and explicit self-esteem in mortality salience effects. Journal of personality and social psychology, 96(5), 1077.
Sego, T., & Stout, P. A. (1994). Anxiety associated with social issues: The development of a scale to measure an antecedent construct. ACR North American Advances.
Sheeran, P., Harris, P. R., & Epton, T. (2014). Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies. Psychological bulletin, 140(2), 511.
Shen, L. (2011). The effectiveness of empathy-versus fear-arousing antismoking PSAs. Health communication, 26(5), 404-415.
Shevlin, M., Nolan, E., Owczarek, M., McBride, O., Murphy, J., Gibson Miller, J., ... & Bentall, R. P. (2020). COVID‐19‐related anxiety predicts somatic symptoms in the UK population. British Journal of Health Psychology, 25(4), 875-882.
Silver, R. C., Holman, E. A., Andersen, J. P., Poulin, M., McIntosh, D. N., & Gil-Rivas, V. (2013). Mental-and physical-health effects of acute exposure to media images of the September 11, 2001, attacks and the Iraq War. Psychological science, 24(9), 1623-1634.
Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, M., & Gil-Rivas, V. (2002). Nationwide longitudinal study of psychological responses to September 11. Jama, 288(10), 1235-1244.
Skinner, C. S., Tiro, J., & Champion, V. L. (2015). Background on the health belief model. Health behavior: Theory, research, and practice, 75, 1-34.
Smith, S. L. (1997). The effective use of fear appeals in persuasive immunization: An analysis of national immunization intervention messages. Journal of Applied Communication Research, 25, 264–292.
Smith, N.C., & Quelch, J. A. (1992). Ethical issues in researching and targeting consumers. In Smith, N. C., & Quelch, J. A. (Eds.), Ethics in marketing. Boston: Irwin.
Snipes, R. L., LaTour, M. S., & Bliss, S. J. (1999). A model of the effects of self-efficacy on the perceived ethicality and performance of fear appeals in advertising. Journal of Business Ethics, 19, 273–285.
SPI-B (2020, March 22nd). Options for increasing adherence to social distancing measures [report]. Retrieved from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/882722/25-options-for-increasing-adherence-to-social-distancing-measures-22032020.pdf
Stainback, K., Hearne, B. N., & Trieu, M. M. (2020). COVID-19 and the 24/7 News Cycle: Does COVID-19 News Exposure Affect Mental Health?. Socius, 6, 2378023120969339.
Steinfeld, J. (2018). China’s deadly science lesson: How an ill-conceived campaign against sparrows contributed to one of the worst famines in history. Index on Censorship, 47(3), 49-49.
Tannenbaum, M. B., Hepler, J., Zimmerman, R. S., Saul, L., Jacobs, S., Wilson, K., & Albarracín, D. (2015). Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological bulletin, 141(6), 1178.
Tanner Jr, J. F., Hunt, J. B., & Eppright, D. R. (1991). The protection motivation model: A normative model of fear appeals. Journal of marketing, 55(3), 36-45.
Thompson, R. R., Jones, N. M., Holman, E. A., & Silver, R. C. (2019). Media exposure to mass violence events can fuel a cycle of distress. Science advances, 5(4), eaav3502.
Thomson, S., & Ip, E. C. (2020). COVID-19 emergency measures and the impending authoritarian pandemic. Journal of Law and the Biosciences.
Transport Accident Commission (2002). The TAC’s road safety campaign. Victoria, Australia.
Van Rompay, T. J. (2014, May). Embodied persuasion. In International Conference on Persuasive Technology (pp. 247-252). Springer, Cham.
von der Embse, N. P., Schultz, B. K., & Draughn, J. D. (2015). Readying students to test: The influence of fear and efficacy appeals on anxiety and test performance. School Psychology International, 36(6), 620-637.
Wallack, W. D. L. (1999). A Critical Perspective on the Drug Czar's Antidrug Media Campaign. Journal of Health Communication, 4(2), 155-160.
Wertz, S. (1998). Significance of emotion [report]. Retrieved from: http://www.ciadvertising.org/studies/student/98_fall/theory/weirtz/Significance.htm
White M. C. (2015, December 28th). H.I.V. Education That Aims to Empower, Not Shame [article]. Retrieved from: http://www.nytimes.com/2015/12/28/business/media/hiv-education-that-aims-toempower-not-shame.html
WHO (2021, March 22nd). WHO Coronavirus (COVID-19) Dashboard [webpage]. Retrieved from: https://covid19.who.int/
Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communications Monographs, 59(4), 329-349
Witte, K., & Allen, M. (2000). A meta-analysis of fear appeals: Implications for effective public health campaigns. Health education & behavior, 27(5), 591-615.
Witte, K., Berkowitz, J. M., Cameron, K. A., & McKeon, J. K. (1998). Preventing the spread of genital warts: Using fear appeals to promote self-protective behaviors. Health Education & Behavior, 25(5), 571-585.
Xu, J., & Roberts, R. E. (2010). The power of positive emotions: It’sa matter of life or death—Subjective well-being and longevity over 28 years in a general population. Health Psychology, 29(1), 9.
Zuckerman, M., Persky, H., Link, K. E., & Basu, G. K. (1968). Experimental and subject factors determining responses to sensory deprivation, social isolation, and confinement. Journal of Abnormal Psychology, 73(3p1), 183.