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Reducing Information Avoidance Through Self-Affirmation

Permanent Link: http://ufdc.ufl.edu/UFE0043045/00001

Material Information

Title: Reducing Information Avoidance Through Self-Affirmation
Physical Description: 1 online resource (56 p.)
Language: english
Creator: HOWELL,JENNIFER L
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011

Subjects

Subjects / Keywords: AFFIRMATION -- HEALTH -- INFORMATION -- SOCIAL
Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Although recent medical advances allow people to identify and address medical conditions early, many people forego medical screening and thereby remain ignorant of their health status. One explanation for this avoidance is that people feel threatened by possible bad news. One way to reduce the threat associated with bad news is to affirm a person?s overall sense well-being (Steele, 1988). When affirmed, people focus on their overall integrity, rather than the part of their self that is threatened by the bad news, and thus, the area under threat is subjectively less important. Study 1 tested whether self-affirmation reduces avoidance of health information. Participants wrote an essay about the characteristic they considered most important to their self-concept. In the Affirmation condition, participants described a time they personally demonstrated the characteristic. In the No-Affirmation condition participants described a time that a friend demonstrated the characteristic. Next, participants watched a video about a fictitious disease, TAA deficiency, described as affecting one in five college-age students and as having severe negative health-consequences. The video emphasized the importance of early detection. After completing a risk calculator for TAA deficiency, participants chose either to learn or to decline learning their risk for TAA deficiency. As predicted, fewer participants avoided learning their risk in the affirmation condition (16%) than in the no-affirmation condition (55%). Study 2 examined whether self-affirmation reduces information avoidance that occurs when learning the information obligates the person to undertake some undesired behavior. Participants who either were or were not affirmed learned that testing at high risk for a disease either would or would not obligate them to undergo a follow-up physical exam at a hospital. As predicted, although the obligation manipulation increased avoidance among non-affirmed participants, it had no effect on avoidance among affirmed participants. Study 3 extended the findings of Studies 1 and 2 by examining whether self-affirmation reduces information avoidance typically seen when a disease is portrayed as uncontrollable rather than controllable. As expected, non-affirmed participants were more likely to avoid learning their risk for TAA deficiency when it was described as uncontrollable. However, affirmed participants were unaffected by disease controllability. Taken together, these three studies show that self-affirmation diminishes information avoidance and is an effective remedy to situational factors that typically increase avoidance.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by JENNIFER L HOWELL.
Thesis: Thesis (M.S.)--University of Florida, 2011.
Local: Adviser: Shepperd, James A.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2011
System ID: UFE0043045:00001

Permanent Link: http://ufdc.ufl.edu/UFE0043045/00001

Material Information

Title: Reducing Information Avoidance Through Self-Affirmation
Physical Description: 1 online resource (56 p.)
Language: english
Creator: HOWELL,JENNIFER L
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011

Subjects

Subjects / Keywords: AFFIRMATION -- HEALTH -- INFORMATION -- SOCIAL
Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Although recent medical advances allow people to identify and address medical conditions early, many people forego medical screening and thereby remain ignorant of their health status. One explanation for this avoidance is that people feel threatened by possible bad news. One way to reduce the threat associated with bad news is to affirm a person?s overall sense well-being (Steele, 1988). When affirmed, people focus on their overall integrity, rather than the part of their self that is threatened by the bad news, and thus, the area under threat is subjectively less important. Study 1 tested whether self-affirmation reduces avoidance of health information. Participants wrote an essay about the characteristic they considered most important to their self-concept. In the Affirmation condition, participants described a time they personally demonstrated the characteristic. In the No-Affirmation condition participants described a time that a friend demonstrated the characteristic. Next, participants watched a video about a fictitious disease, TAA deficiency, described as affecting one in five college-age students and as having severe negative health-consequences. The video emphasized the importance of early detection. After completing a risk calculator for TAA deficiency, participants chose either to learn or to decline learning their risk for TAA deficiency. As predicted, fewer participants avoided learning their risk in the affirmation condition (16%) than in the no-affirmation condition (55%). Study 2 examined whether self-affirmation reduces information avoidance that occurs when learning the information obligates the person to undertake some undesired behavior. Participants who either were or were not affirmed learned that testing at high risk for a disease either would or would not obligate them to undergo a follow-up physical exam at a hospital. As predicted, although the obligation manipulation increased avoidance among non-affirmed participants, it had no effect on avoidance among affirmed participants. Study 3 extended the findings of Studies 1 and 2 by examining whether self-affirmation reduces information avoidance typically seen when a disease is portrayed as uncontrollable rather than controllable. As expected, non-affirmed participants were more likely to avoid learning their risk for TAA deficiency when it was described as uncontrollable. However, affirmed participants were unaffected by disease controllability. Taken together, these three studies show that self-affirmation diminishes information avoidance and is an effective remedy to situational factors that typically increase avoidance.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by JENNIFER L HOWELL.
Thesis: Thesis (M.S.)--University of Florida, 2011.
Local: Adviser: Shepperd, James A.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2011
System ID: UFE0043045:00001


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1 REDUCING INFORMATION AVOIDANCE THROUGH SELF AFFIRMATION By JENNIFER HOWELL A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SC IENCE UNIVERSITY OF FLORIDA 2011

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2 2011 Jennifer Howell

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3 For my family

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4 ACKNOWLEDGMENTS I thank Dr. James Shepperd both for his guidance on this project and for his encouragement, enthusiasm, and dedication as a mentor. James is an exc eptional researcher and I feel tremendously privileged to work alongside such a talented and motivated individual. I also thank Dr. Traci Giuliano, of Southwestern University, for both her helpful comments on this manuscript and her continued support of my personal and professional development. Additionally, I thank Drs. Gregory Webster and Martin Heesacker for offering their insight while serving as committee members. Finally, I thank all of my research assistants for their hard work and enthusiasm, and fo r tolerating my often excessive requests.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Information Avoidance and Self Affirmation ................................ ............................ 13 Behavioral Obligation and Controllability ................................ ................................ 15 Overview and Hypotheses ................................ ................................ ...................... 17 2 STUDY 1 ................................ ................................ ................................ ................. 20 Method ................................ ................................ ................................ .................... 20 Participants ................................ ................................ ................................ ....... 20 Design and Procedure ................................ ................................ ...................... 20 Measures ................................ ................................ ................................ .......... 21 Primary dependent measure: avoidance. ................................ .................. 21 Process and individual difference measures. ................................ ............. 22 Results and Discussion ................................ ................................ ........................... 23 Analyses ................................ ................................ ................................ ........... 23 Information Avoidance and Affirmation ................................ ............................. 24 Additional Variance ................................ ................................ .......................... 24 S tep 1: Dispositional health avoidance. ................................ ..................... 24 Step 2: Anticipated negative affect and anticipated regret. ........................ 24 Overall Model ................................ ................................ ................................ ... 25 Positive and Negative Affect ................................ ................................ ............. 25 Summary ................................ ................................ ................................ .......... 25 3 STUDY 2 ................................ ................................ ................................ ................. 28 Method ................................ ................................ ................................ .................... 28 Participants ................................ ................................ ................................ ....... 28 Design and Procedure ................................ ................................ ...................... 28 Results and Discussion ................................ ................................ ........................... 28 Analyses ................................ ................................ ................................ ........... 28 Information Avoidance and Affirmation ................................ ............................. 29 Additional Variance ................................ ................................ .......................... 29 Step 1: Dispositional health avoidance. ................................ ..................... 30

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6 Step 2: Ant icipated negative affect and anticipated regret. ........................ 30 Overall Model ................................ ................................ ................................ ... 30 Positive and Negative Affect ................................ ................................ ............. 31 Summary ................................ ................................ ................................ .......... 31 4 STUDY 3 ................................ ................................ ................................ ................. 33 Method ................................ ................................ ................................ .................... 33 Participants ................................ ................................ ................................ ....... 33 Design and Procedure ................................ ................................ ...................... 33 Results and Discussion ................................ ................................ ........................... 33 Analyses ................................ ................................ ................................ ........... 33 Information Avoidance ................................ ................................ ...................... 33 Additional Variance ................................ ................................ .......................... 34 Step 1: Dispositional health avoidance. ................................ ..................... 34 Step 2: Anticipated negative affect and anticipated regret. ........................ 34 Overall Model ................................ ................................ ................................ ... 35 Positive and Negative Affect ................................ ................................ ............. 35 Summary ................................ ................................ ................................ .......... 35 5 GENERAL DISCUSSION ................................ ................................ ....................... 38 Summary ................................ ................................ ................................ ................ 38 The Importance of Situational Factors ................................ ................................ .... 38 Limitatio ns and Future Directions ................................ ................................ ........... 39 The Process of Affirmation ................................ ................................ ...................... 40 Implications ................................ ................................ ................................ ............. 42 Conclusions ................................ ................................ ................................ ............ 43 APPENDIX A AFFIRMATION MANIPULATION ................................ ................................ ............ 44 B TAA DEFICIENCY RISK CALCULATOR ................................ ................................ 45 C TESTING DECISION ................................ ................................ .............................. 48 D THOUGHTS QUESTIONNAIRE ................................ ................................ ............. 49 E SHORT PANAS ................................ ................................ ................................ ...... 52 LIST OF REFERENCES ................................ ................................ ............................... 53 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 56

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7 LIST OF TABLES Table page 2 1 Scale Reliabilities ................................ ................................ ............................... 26

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8 LIST OF FIGURES Figure page 2 1 Percentage of participants avoiding their risk feedback in the affirmation and no affirmation conditions in Study 1. ................................ ................................ ... 27 3 1 Percentage of participants avoiding their risk feedback as a function of affirmation and behavioral obligat ion. ................................ ................................ 32 4 1 Percentage of participants avoiding their risk feedback as a function of affirmation and disease controllability. ................................ ................................ 37

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9 Abstract of Thesis P resented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science REDUCING INFORMATION AVOIDANCE THROUGH SELF AFFIRMATION By Jennifer Howell May 2011 Chair: James A. Shepperd Major: Psychology Although recent medical advances allow people to identify and address medical conditions early, many people forego medical screening and thereby remain ignorant of their health status. One explanation for this avoidance is t hat people feel threatened by possible bad news. One way to reduce the threat associated with bad news is to affirm being (Steele, 1988). When affirmed, people focus on their overall integrity, rather than the part of their se lf that is threatened by the bad news, and thus, the area under threat is subjectively less important. Study 1 tested whether self affirmation reduces avoidance of health information. Participants wrote an essay about the characteristic they considered most important to their self concept. In the Affirmation condition, participants described a time they personally demonstrated the characteristic. In the No Affirmation condition participants described a time that a friend demonstrated the characteristic. Next, participants watched a video about a fictitious disease, TAA deficiency, described as affecting one in five college age students and as having severe negative health consequences. The video emphasized the importance of early detection. After complet ing a risk calculator for TAA deficiency, participants chose either to learn or to decline learning their risk for

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10 TAA deficiency. As predicted, fewer participants avoided learning their risk in the affirmation condition (16%) than in the no affirmation co ndition (55%). Study 2 examined whether self affirmation reduces information avoidance that occurs when learning the information obligates the person to undertake some undesired behavior. Participants who either were or were not affirmed learned that te sting at high risk for a disease either would or would not obligate them to undergo a follow up physical exam at a hospital. As predicted, although the obligation manipulation increased avoidance among non affirmed participants, it had no effect on avoidan ce among affirmed participants. Study 3 extended the findings of Studies 1 and 2 by examining whether self affirmation reduces information avoidance typically seen when a disease is portrayed as uncontrollable rather than controllable. As expected, non aff irmed participants were more likely to avoid learning their risk for TAA deficiency when it was described as uncontrollable. However, affirmed participants were unaffected by disease controllability. Taken together, these three studies show that self affir mation diminishes information avoidance and is an effective remedy to situational factors that typically increase avoidance.

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11 CHAPTER 1 INTRODUCTION Each year, the American Cancer Society reports the incidence and prevalence of cancer in the United States As part of their report, they offer guidelines for how often a person should be screened, and emphasize the life saving importance of adhering to these guidelines. Despite these recommendations, millions of Americans choose not to undergo regular screeni ngs for various types of cancer (American Cancer Society, 2009). People fail to undergo cancer screening for a variety of reasons, including lack of resources, ignorance of screening opportunities, and perceptions of low risk (e.g., Donavan & Syngal, 1998 ). Important to the present study, people sometimes forego screening for cancer because they do not want to know their test results (e.g., Ajekigbe, 1991; Weitzman, Zapka, Estabrook, & Valentine Goins, 2001). This active and intentional choice to avoid scr eening represents one illustration of how people avoid learning about themselves and the world around them. In other domains, people wish choose not to learn the sex of their unb orn child (Shipp, Shipp, Bromley, Sheahan, Cohen, Lieberman, & Benacerraf, 2004), and, depending on the study, as many as 55% of people who undergo HIV testing fail to return to receive their results ( Hightow, Miller, Leone, Wohl, Smurzynski, & Kaplan, 200 3; Mullitor, Bell & Traux, 1999). Why do people avoid learning information? Research on selective exposure posits that people prefer to receive information consistent with their attitudes and opinions ( see Smith, Fabrigar & Norris, 2008, for a review ). Fo r example, people prefer to read internet based messages that are consistent with their political views rather than

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12 messages that are inconsistent with those views (Knobloch Westerwick & Meng, 2009). By choosing to expose themselves only to attitude consis tent information, people can avoid the discomfort associated with a challenge to their way of thinking. The selective exposure literature argues that people choose belief consistent information over belief inconsistent information to avoid dissonance asso ciated with holding conflicting opinions simultaneously ( Hart, Albarracin, Eagly, Brechan, Lindberg, & Merrill, 2009). However, because participants receive a choice between one of two messages, the selective exposure literature fails to account for situat ions in which people avoid information altogether (e.g., a person declining testing for a genetic disease). Thus, researchers coined the broader term Information Avoidance to describe any behavior designed to prevent or delay the acquisition of available but potentially al. (2010) propose that people avoid information to the extent that they believe that the information might cause them an undesired emotion, a change in a che rished belief, or an unwanted change in behavior. Information avoidance can occur in a variety of contexts (Sweeny et al., 2010) but is of particular concern when it comes to health. For example, although regular screenings for colorectal cancer can signi ficantly reduce mortality (Walsh & Terdiman, 2009), many people choose never to be screened for colorectal cancer (Donavan & Syngal, 1998; Weitzman, et al., 2001). Similarly, although regular screening for cervical cancer reduces the likelihood of mortalit y, a representative sample of over 1000 at risk U.S. women revealed that close to 20% failed to undergo regular cervical cancer screenings.

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13 Importantly, not all failures to seek information represent information avoidance. For example, a person may lack t he financial resources to undergo screening or may simply not care. Thus, information avoidance refers only to the conscious decision to avoid information. Information Avoidance and Self Affirmation People may avoid information for many reasons. Of import ance to the present study, to the extent that people find a piece of information threatening, they should be more likely to avoid it. Information can be threatening in a variety of ways. For example, if people feel that information will cause a change in a cherished belief, obligate an undesired behavior, or produce some negative emotion, they will be more likely to avoid that information (Sweeny et al., 2010). Each of these motives for avoidance can be thought of as representing a type of threat. For insta nce, information that results in a worldview, and their self views. Information that obligates an undesired behavior can ey), as well as their perceptions of personal control. Finally, information that produces negative emotions might threaten being, their mood, and their coping ability. If people avoid information because it is threatening, the n diminishing the threat associated with information should reduce avoidance of the information. One way to decrease the subjective threat of information is through self affirmation (see Sherman & Cohen, 2006, for a review). Self affirmation involves bolst ering one's overall self integrity in response to a threat to self worth (Sherman & Cohen, 2006; Steele, 1988). worth, the threat becomes less menacing, making coping with that threat easier. For example, rece iving a low grade on an exam

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1 4 concept if she considers herself to be a good student. However, if she focuses on other areas that are central to her self concept (e.g., her ability as a musician, how many friends she has), the low grade on the exam becomes subjectively less threatening (i.e., because it threatens only a small part of her overall self worth rather than the entirety of a domain specific self worth). Research confirms that self affirmation reduces feelings of threat (Sherman & Cohen, 2002), increases acceptance of health information (Sherman, Nelson, & Steele, 2000), and can increase the likelihood of healthy behaviors (Epton & Harris, 2008). Self affirmation allows people to reframe threatening information in ways that are less threatening. In one study, female coffee drinkers considered their ability to demonstrate a characteristic that was either important (affirmation) or unimportant (no affirmation) to them. They then read a message linking caffeine consum ption to breast cancer. Whereas affirmed participants reported being more accepting of the message and intended to change their coffee consumption, non affirmed participants derogated the message and reported lower intentions to change their coffee consump tion (Sherman et al., 2000). Similar effects occur for a variety of health messages (e.g., Harris & Napper, 2005). Sherman and his colleagues argue that affirmed participants are more accepting of threatening messages because they focus on a broader self v iew rather than on the specific aspect of themselves that is under threat. In addition to influencing intentions, self affirmation can produce positive changes in health behavior. For example, participants in one study answered questions about their past k indness (affirmation condition) or about preferences on neutral topics (e.g., favorite vacation spots ; no affirmation condition). Participants then read a message that

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15 encouraged eating fruits and vegetables. In the following week, affirmed participants at e an average of six more servings of fruits and vegetables than did non affirmed participants (Epton & Harris, 2008). In summary, research shows that affirming people can make them more accepting of threatening health messages (Sherman et al., 2000), can increase intentions to reduce risky behavior (Sherman et al., 2000), and can increase health behaviors (Epton & Harris, 2008). Importantly, research suggests that these effects occur primarily because of a reduction in the threat associated with a message. That is, because people perceive the information as less threatening, they respond less defensively and therefore are more likely to accept that information ( Critcher Dunning, & Armor, 2010) If self ssociated with information, then people who are self affirmed should be less likely than non affirmed participants to avoid information. Behavioral Obligation and Controllability People sometimes avoid learning information when they believe it might indu ce them to take some undesired behavior. For example, in a survey of expectant parents who had previously given birth to a child with a genetic defect, several declined genetic testing of their fetus because they feared that the results would prompt them t o abort the pregnancy (Kelly, 2009). Similarly, a study of Belgian immigrants revealed that many who were waiting for citizenship chose to avoid HIV testing despite a history of risky sexual behavior. Their reason: they were obligated to report all illness to the government and believed that testing HIV positive would jeopardize their citizenship application (Mairakunda et al., 2009). Other research shows that South African sex workers avoid HIV screening because positive test results would endanger their

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16 l ivelihood (Vargas, 2011), and that the primary reason Nigerian women gave for delaying a visit to their physician about a suspicious lump in their breast was a fear that they would have to have a mastectomy (Ajekigbe, 1991). In addition to this self repo rt evidence, studies from our lab reveal that an obligation to take action can increase information avoidance (Howell & Shepperd, 2011). In one study, participants learned that being at high risk for a disease would require them to undergo an unpleasant an d invasive physical examination (High Obligation condition) or a non invasive examination (Low Obligation condition). As expected, more participants in the High Obligation condition than the Low Obligation condition opted to avoided screening for the disea se. In the present project, I evaluated whether affirmation reduces information avoidance even when the information obligates undesired behavior. Because affirmation reduces the threat associated with information (Sherman & Cohen, 2006), the threat posed by obligation should seem less menacing to affirmed individuals and, as a result, they should be less likely to avoid information. A second situational factor that can increase avoidance is the controllability of an outcome (Melnyk & Shepperd, 2011). Spe cifically, people are more likely to avoid information when learning that information will not allow them to assert control over their situation. For instance, participants reported that they would more inclined to avoid genetic testing for an untreatable disease than a treatable disease ( Yaniv, Benador, & Sagi, 2004). Additionally, women were more likely to avoid learning their breast cancer risk after reading about the uncontrollable predictors of breast cancer than after reading about controllable predic tors of breast cancer (Melnyk & Shepperd, 2011). In another

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17 study, participants were more likely to avoid information about their risk for a genetic disease, alopecia, when it was described as being treatable rather than untreatable ( Dawson, Savitsky, & Du nning, 2006) Taken together, these studies suggest that people should be more likely to avoid learning their risk for an uncontrollable disease compared to a controllable disease. In the present project, I evaluated whether affirmation could remedy avoid ance of information pertinent to uncontrollable events. If affirmation reduces the threat associated with information (Sherman & Cohen, 2006), then fewer affirmed participants than non affirmed participants should avoid risk feedback. In a similar vein, no n affirmed obligation leads to greater avoidance. By contrast, affirmed participants should avoid less than non affirmed participants regardless of obligation. Finally, alt hough non affirmed participants should avoid risk feedback for uncontrollable diseases more than controllable diseases, affirmed participants should avoid less than non affirmed participants, regardless of controllability. Overview and Hypotheses Hypothesi s 1: In general, I expected that self perceptions of information as threatening, would reduce information avoidance. Specifically, I anticipated that more affirmed participants than non affirmed would avoid information a bout their risk for a disease. Hypothesis 2: I predicted that affirming participants would eliminate avoidance typically seen when undesired behavior is obligated (Hypothesis 2) Hypothesis 3: Finally, I anticipate that affirming participants will diminis h the avoidance typically seen when a disease is uncontrollable (Hypothesis 3).

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18 I tested these hypotheses in three studies. In Study 1, I randomly assigned participants to either an affirmation or a no affirmation condition, and assessed differences in av oidance of risk feedback. In Study 2, I randomly assigned participants to one of four conditions in a 2 (Affirmation: Affirmed or Not Affirmed) x 2 (Obligation: High or Low) between subjects design. In Study 3, I randomly assigned participants to one of fo ur conditions in a 2 (Affirmation: Affirmed or Not Affirmed) x 2 (Disease Controllability: Controllable or Uncontrollable) between subjects design. In addition to examining the effects of affirmation on avoidance, I measured other factors associated with avoidance. By doing so, I examined potential suppressor effects and explained additional variance in information avoidance. P revious information avoidance studies reveal three predictors to be particularly important in accounting for avoidance. First, ou r lab has developed a measure that assesses individual differences in the tendency to avoid health information (i.e., the Dispositional Health Avoidance Scale). We find that people who score higher on our measure are more likely to avoid specific informati on about their health. For example, in a recent study, people who scored higher on our measure were more likely to avoid learning their feedback for a fictitious disease, TAA Deficiency (Howell & Shepperd, 2011). I anticipate that s baseline tendency to avoid health information will clarify the effects of affirmation on avoidance. A second factor that predicts information avoidance is anticipated negative affect associated with a diagnosis (Sweeny et al., 2010). In a recent study, participants were more likely to avoid their risk for diabetes to the extent that they expected that being diagnosed with the disease would make them feel bad (Howell & Shepperd, 2009).

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19 Third, greater anticipated regret about avoiding the information predi cts less information avoidance (Melnyk & Shepperd, 2011). For example, participants in one study were significantly less likely to avoid their risk for cardiovascular disease if they believed they would regret that decision (Howell & Shepperd, 2010). Impor tantly because anticipated negative affect and anticipated regret should be unaffected by affirmation, they should both predict beyond affirmation alone. To maximize the amount of variance explained by the model, I entered each of these factors (Appendix D) into a logistic regression. By doing so, I sought to better understand the unique effect of self affirmation on information avoidance and to explore whether dispositional health avoidance, anticipated negative affect, and anticipated regret would predic t avoidance beyond affirmation.

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20 CHAPTER 2 STUDY 1 Study 1 examined whether affirmation reduces avoidance of screening feedback. Method Participants Participants were 40 undergraduates (26 women) who participated in partial fulfillment of an experimen tal participation requirement. Design and Procedure When participants arrived for the experiment, an experimenter dressed in medical scrubs escorted them to individual work stations and told them that they would complete two unrelated surveys: a paper and pencil survey for the psychology department assessing values, and an online survey from the university hospital assessing risk for a disease called TAA Deficiency. The psychology survey (Appendix A) introduced the affirmation manipulation ( Sherman, et al ., 2000 ). The instructions guided participants to list traits that were central to their self concept, to identify the trait that they considered most important, and to write a short essay about a time that they successfully demonstrated the trait (Affirma tion condition) or about a time that a friend successfully demonstrated the trait (No Affirmation condition). In prior self affirmation studies, the No Affirmation condition typically involves writing about innocuous events such as preferences (e.g., Epton & Harris, 2008). By having participants write about a friend successfully demonstrating the trait, I eliminated the possibility that any effect that emerged was due to writing about a positive or successful experience rather than due to affirmation

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21 Next participants completed the hospital survey, which involved completing a demographic questionnaire and viewing a video about a (fictitious) disease called Tiomene Acetlyace (TAA) deficiency, which ostensibly produces a problem with the rocess nutrients and can lead to severe medical complications (e.g., exhaustion, immunodeficiency, neurological deterioration, and early death). This video explained that 20% of college students have TAA deficiency and that most are unaware that they have it. After watching the video, participants completed a hypothetical risk calculator (Appendix B ) and viewed a screen indicating that, based on their responses to the risk calculator, the computer could calculate their lifetime risk for TAA deficiency ( App endix C). Participants then received three choices: (1) they could receive their lifetime risk feedback immediately, (2) they could receive an email link to the risk calculator allowing them to learn their lifetime risk at another time, or (3) they could e lect not to receive their After selecting a choice, participants completed several manipulation check and process items (Appendix D). When all participants had completed the onl ine survey, they were debriefed and thanked by the experimenter. Measures Primary dependent measure: a voidance. I measured avoidance on the three option scale mentioned above. Because the information, people who chose to receive feedback at a later date were classified as but also to mirror real life decision making processes in which the decision to undergo

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22 (seeking, delaying, and avoiding) separately as a dependent measure, the pattern of results was similar to the one presented here. Moreover, on me asures in which the responses of seekers and avoiders differed significantly, the responses of delayers were almost always in line with the responses of avoiders. In Study 1, 5% of people Process and individual difference measures. Unless otherwise mentioned, all variables used a 7 point likert scale ranging from 1 (Strongly Disagree) to 7 (Strongly Agree). For all scale reliabilities see Table 2 1. Dispositional health avoidance. I measured individual differences in information avoidance using a 10 item measure (Howell & Shepperd, 2011). The measure allows researchers to tailor the instrument to specific information peopl e might choose to avoid. For the present study, I tailored the instrument to assess avoidance of health There is some information that I would rather not s ignorance is We are in the process of collecting reliability and validity information on the measure. Importantly, the scale has shown satisfactory internal consistency across Anticipated neg ative affect I assessed anticipated negative affect associated that my risk f

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23 news should I learn that I am at ris Learning that I am at high risk for TAA deficiency would make me feel bad Anticipated regret I assessed an Imagine that you chose NOT to learn your TAA Deficiency risk. How much do you anticipate regretting that decision later? ( This is a hypothetical question. To answer this question, imagine choosing not to learn your persona l risk in the previous part of the questionnaire, Participants responded using a 7 point scale ranging from 1 (Very Little) to 7 (Very Much). Positive and negative affect. One possible alternative explanati on for the effects investigate this alternative hypothesis, I assessed positive and negative affect using the Short form of the Positive and Negative Affect scale ( S PANAS ; Mackinnon, Jorm, Christensen, K orten, Jacomb, & Rogers, 1999) both before and after the self affirmation manipulation (Appendix E). The S PANAS asks participants to rate their current feelings using five positive adjectives (e.g., excited, inspired) and five negative adjectives (e.g., upset, distressed). The S PANAS is both reliable and valid across a variety of samples, producing a consistent two factor structure, and yielding of .75 for positive affect and .87 for negative affect (Mackinnon et al., 1999). Results and Discussion Analyses I conducted the analysis in three parts. First, I evaluated the effects of the manipulation. Second, I evaluated possible suppressors and additional explanatory

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24 variables. Third, I evaluated the feasibility of mood differences as an alternative explanation. Information Avoidance and Affirmation Hypothesis 1 stated that affirmed participants would avoid information l ess than would non affirmed participants. As predicted, logistic regression revealed that fewer participants declined to learn their lifetime risk of TAA deficiency in the Affirmation condition (16%) than in No Affirmation condition (55%), 2 = 7.00, p < .01, R 2 = .17. Additional Variance To detect possible suppressor effects, and to account for additional variance in the data, I entered the remaining variables into a prediction model in two steps. In Step 1, I entered dispositional health avoidance into the model to evaluate suppressor effects. In Step 2, I entered anticipated negative affect and anticipated regret to account for additional variance. Step 1: Dispositional health avoidance. Dispositional health avoidance did not significantly predict in formation avoidance beyond the affirmation manipulation, 2 = 3.00, p = .08, R 2 change = .07. Moreover, even when accounting for dispositional health avoidance, the affirmation manipulation remained a significant predictor of information avoidance, 2 = 6. 00, p < .01. Step 2: Anticipated negative affect and anticipated regret. information, I added anticipated negative affect and anticipated regret to the model as predictors. Adding anticipated negative affect and anticipated regret to the model significantly improved model fit, 2 (2) = 16.17, p < .001, R 2 change = .27. However, the

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25 added variance explained came primarily from anticipated regret, 2 = 14.85, p < .01, R 2 = .24. The an alysis indicated that the more participants believed they would regret their decision, the less likely they were to avoid receiving feedback about their risk of having TAA deficiency. Anticipated negative affect was not a significant predictor of avoidance 2 = 1.31, ns, R 2 = .03. As before, the affirmation manipulation continued to significantly predict information avoidance, 2 = 5.42, p < .03. Overall Model Overall, the 4 decision to seek vs. avoid their risk estimate for TAA deficiency, 2 (4) = 26.16, p < .001, R 2 = .51. Most of this variance was accounted for by the affirmation manipulation and anticipated regret. Positive and Negative Affect To ensure that the changes in avoidance were no t due to a change in affect, I correlated scores on the S PANAS, avoidance, and affirmation condition. Positive and negative affect were uncorrelated with both the self affirmation manipulation and the evealed no support for the possibility that differences in avoidance were resulted from the manipulation producing differences in mood. Summary As expected, affirming participants significantly reduced avoidance of TAA risk feedback. In addition, greate r anticipated regret predicted less avoidance. Contrary to expectations, dispositional health avoidance did not serve as a suppressor.

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26 Table 2 1. Scale Reliabilities Study Study 1: Affirmation Study 2: Behavioral Obligation x Affirmation Study 3: Con trollability x Affirmation Scale Time 1 Time 2 Time 1 Time 2 Time 1 Time 2 Positive Affect (PANAS) = .83 = .87 = .81 = .89 = .86 = .85 Negative Affect (PANAS) = .89 = .90 = .83 = .87 = .84 = .88 Dispositional Health Avoidance = .81 = .83 = .84 Anticipated Negative Affect = .79 = .75 = .75

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27 Figure 2 1. Percentage of participants avoiding their risk feedback in the affirmation and no affirmation conditions in Study 1. % of Pa rticipants Avoiding TAA Risk Feedback Affirmation Condition 0 10 20 30 40 50 60 70 80 Not Affirmed Affirmed High Obligation No Obligation

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28 CHAPTER 3 STUDY 2 Study 2 exami ned the effect of affirmation in the presence of a known motivator of avoidance: behavioral obligation (Howell & Shepperd, 2011). Method Participants Participants were 113 undergraduates (81 women) who participated in partial fulfillment of an experimental participation requirement. Design and Procedure Procedures were identical to Study 1, with the following addition: Before deciding whether to learn their lifetime risk TAA deficiency, participants read one of two statements. In the High Obligation condit ion, participants read that, if the test results indicated that they were at high risk for TAA deficiency, they would be legally obligated to go to the university medical hospital for a definitive physical examination. In the Low Obligation condition, par ticipants read that if the test results indicated that they were at high risk for TAA deficiency, they should visit their regular doctor for a physical examination. Results and Discussion Analyses As in Study 1, I conducted the analysis in three parts. F irst, I evaluated the effects of the manipulations. Second, I evaluated possible suppressors and additional explanatory variables. Third, I evaluated the feasibility of mood differences as an alternative explanation.

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29 Information Avoidance and Affirmation U sing logistic regression, I tested Hypothesis 2, that affirmation could reduce the effects of obligation on information avoidance. The results revealed a significant main effect of affirmation on information avoidance, 2 = 16.44, p < .001, R 2 = .15, such that affirmed participants avoided their results significantly less (20%) than did non affirmed participants (53%). Additionally, a significant main effect of behavioral obligation emerged, 2 = 4.23, p < .05, R 2 = .04. Participants avoided TAA feedback mo re in the High Obligation condition (47%) than in the Low Obligation condition (29%). These main effects were qualified by an interaction (Figure 3 1 ), 2 (3) = 22.77, p < .001, R 2 = .18. Simple effects tests revealed that, non affirmed participants avoid ed information more in the High Obligation condition (72%) than in the Low Obligation condition (40%), 2 = 4.77, p < .03, R 2 = .11. However, affirmed participants avoided learning their feedback equally in both the High Obligation (21%) and Low Obligation (19%) conditions, 2 = .04, ns, R 2 < .01, indicating that the affirmation manipulation eliminated the effects of behavioral obligation. Additional Variance To detect possible suppressor effects, and to account for additional variance in the data, I enter ed the remaining variables into a prediction model in two steps. In Step 1, I entered dispositional health avoidance into the model to evaluate suppressor effects. In Step 2, I entered anticipated negative affect and anticipated regret to account for addit ional variance.

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30 Step 1: Dispositional health avoidance. Dispositional health avoidance predicted information avoidance beyond the main effect and interaction terms, 2 = 12.28, p < .001, R 2 change = .09. Specifically, the higher people rated themselves i n general avoidance of health information, the more likely they were to avoid information. Moreover, even when accounting for dispositional health avoidance, the affirmation and obligation effects remained unchanged, indicating that dispositional health av oidance was neither a mediator nor a suppressor, 2 (3) = 20.61, p < .001. Step 2: Anticipated negative affect and anticipated regret. Adding measurements of anticipated negative affect and anticipated regret significantly improved model fit, 2 (2) = 8.8 4, p = .01, R 2 change = .06. This effect was primarily driven by anticipated regret, 2 = 6.63, p = .01, R 2 = .05. The analysis indicated that the more participants believed they would regret their decision, the less likely they were to avoid receiving fe edback about their risk of having TAA deficiency. As in Study 1, anticipated negative affect was not a significant predictor of avoidance, 2 = .23, ns. Further, the effects of affirmation and behavioral obligation continued to significantly predict people 2 (3)= 18.56, p > .01, as did dispositional health avoidance, 2 = 10.26, p > .01. Overall Model Overall, the 6 decision to seek or avoid their risk estimate f or TAA deficiency, 2 (6)= 43.89, p < .001, R 2 = .32.

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31 Positive and Negative Affect To examine whether changes in avoidance were due to a change in affect, I correlated scores on the S PANAS, avoidance, obligation condition, and affirmation condition. Pos itive and negative affect were uncorrelated with the manipulations and the decision to avoid feedback, rs (113) < .15, ns. Thus, Study 2 provided no support for the possibility that differences in avoidance were resulted from the manipulation producing dif ferences in mood. Summary As expected, non affirmed participants avoided learning their risk for TAA deficiency when they believed it would obligate them to take an undesired behavior than when they believed it would not obligated them to take an undesire d behavior. However, affirmed participants were unaffected by obligation. Two additional predictors emerged in the model: dispositional health avoidance and anticipated regret. People were more likely to avoid learning their risk for TAA deficiency to the extent that they rated themselves as likely to avoid health information, and less likely to avoid information to the extent that they anticipated regretting avoiding the information.

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32 Figure 3 1. Percentage of participants avoiding their risk feedback as a function of affirmation and behavioral obligation. 0 10 20 30 40 50 60 70 80 Not Affirmed Affirmed High Obligation No Obligation % of Participants Avoiding TAA Risk Feedback Affirmation Condition

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33 CHAPTER 4 STUDY 3 Study 3 examined whether affirmation could remedy the effects of controllability. Method Participants One hundred and four undergraduates (68 women) participated in partial fulfillment of an experimental participation requirement. Design and Procedure Procedures were identical to Study 1, with the following addition: In the Controllable condition, participants watched a video that indicated that TAA deficiency could be treated through a simple pill regimen. In the Uncontrollable condition, the video indicated that there was currently no effective treatment for TAA deficiency. Results and Discussion Analyses As in Study 1, I conducted the analysis in three parts. Fir st, I evaluated the effects of the manipulations. Second, I evaluated possible suppressors and additional explanatory variables. Third, I evaluated the feasibility of mood differences as an alternative explanation. Information Avoidance Hypothesis 3 stat ed that affirmation could remedy avoidance typically seen for uncontrollable diseases. Specifically, although non affirmed participants were expected to avoid more in the uncontrollable condition than in the controllable condition, affirmed participants we re expected to avoid equally regardless of condition. As hypothesized, analysis revealed a

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34 their risk feedback. Affirmed participants avoided information significantly less (15%) than no n affirmed participants (54%), 2 = 14.26, p < .001, R 2 = .17. As seen in Figure 4 1 the main effect of Affirmation was qualified by an Affirmation by Controllability interaction, (3) 2 = 16.24, p < .001, R 2 = .22. Simple effects tests revealed that non a ffirmed participants avoided their risk more for an uncontrollable disease (68%) than for a controllable disease (35%), 2 = 4.17, p < .04, R 2 = .11. However, affirmed participants avoided learning their feedback equally for both controllable (11%) and unc ontrollable (17%) diseases, 2 = .55, ns, R 2 = .01, indicating that affirmation eliminated the effects of controllability. Additional Variance To detect possible suppressor effects, and to account for additional variance in the data, I entered the remaini ng variables into a prediction model in two steps. In Step 1, I entered dispositional health avoidance into the model to evaluate suppressor effects. In Step 2, I entered anticipated negative affect and anticipated regret to account for additional variance Step 1: Dispositional health avoidance. Dispositional health avoidance did not significantly predict avoid information above and beyond the main effect and the interaction effect, 2 = 2.93, p = .09, R 2 change = .03. Moreover, even when accounting for dispositional health avoidance, the affirmation and obligation effects remained unchanged, 2 (3) = 14.90, p < .002. Step 2: Anticipated negative affect and anticipated regret. Adding anticipated negative affect and anticipated regret significantly improv ed model fit, 2 (2) = 13.57, p < .001, R 2 change = .11. The analysis indicated that people

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35 avoided learning their risk more as their anticipation of negative affect increased, 2 = 7.92, p < .01, R 2 = .07. Additionally, the more participants believed they would regret their decision, the less likely they were to avoid receiving feedback about their risk of having TAA deficiency, 2 = 5.65, p < .02, R 2 = .05. Importantly, the effects of affirmation and controllability continued to significantly predict info rmation avoidance even after entering anticipate negative affect and anticipated regret, 2 (3) = 15.22, p < .01. Overall Model Overall, the 6 decision to seek or avoid their risk estimate for TAA deficiency, 2 (6) = 35.94, p < .001, R 2 = .35. Positive and Negative Affect To ensure that the changes in avoidance were not due to a change in affect, I correlated scores on the S PANAS, avoidance, controllability condition, and affirmation conditi on. Consistent with Studies 1 and 2, positive and negative affect were not indicating no support for the notion that differences in avoidance were resulted from the m anipulation producing differences in mood. Summary As expected, non affirmed participants were more likely to avoid learning their risk for TAA deficiency when the disease was described as uncontrollable than when it was described as controllable. By cont rast, few affirmed participants avoided learning their risk for TAA deficiency regardless of whether the disease was described as controllable or uncontrollable. Anticipated negative affect and anticipated regret also

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36 emerged as predictors in Study 3. Peop le were more likely to avoid learning their risk for TAA deficiency to the extent that they anticipated negative affect as the result of being diagnosed, and they were less likely to avoid learning their risk for TAA deficiency to the extent that they anti cipated regret about avoiding.

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37 Figure 4 1. Percentage of participants avoiding their risk feedback as a function of affirmation and disease controllability. 0 10 20 30 40 50 60 70 80 Not Affirmed Affirmed Uncontrollable Disease Controlable Disease % of Participants Avoiding TAA Risk Feedback Affirmation Condition

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38 CHAPTER 5 GENERAL DISCUSSION Summary Across three studies, self affirmation si avoid learning their risk for TAA deficiency. Affirmation also remedied the effect of situational factors known to prompt greater avoidance. Specifically, although non affirmed participants avoided information more in the High Obligation condition than in the Low Obligation condition, affirmed participants displayed relatively little avoidance regardless of condition. Additionally, non affirmed participants avoided more when a disease was described as uncontrollable (vs. controllable). By contrast, affirmed participants displayed relatively little avoidance regardless of disease controllability. In addition to affirmation, three other variables predicted the decision to seek or avoid information. The most robust of t hese predictors was anticipated regret, which across all three studies predicted beyond affirmation. Additionally, anticipated negative affect emerged as a significant predictor of information avoidance in Study 2, and dispositional health avoidance emerge d as significant predictors of information avoidance in Study 3. However, because the effect of these variables was inconsistent across studies, they should be interpreted cautiously. The Importance of Situational Factors Although self affirmation dramat ically reduced information avoidance in the present study, I acknowledge that it may not always do so. Indeed, affirmation may only reduce information avoidance in certain circumstances. First, for self affirmation to affect avoidance, the information must be self relevant. If information is seen as irrelevant, then motivated avoidance will likely be low. Further, when information is not

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39 self et al., 2000). Therefore, affir ming people for whom information is not relevant will not change their avoidance. Second, because affirmation works only if a person is affirmed prior to being threatened ( Critcher et al., 2010), it is essential that any affirmation precede the opportunity to attain information. Finally, research suggests that the effects of affirmation are weaker when a person is aware that he or she is being affirmed (Sherman, Cohen, Nelson, Nussbaum, Bunyan, & Garcia, 2009). Thus, it is important that people be unaware o f the goal of an affirmation manipulation. Limitations and Future Directions The present study provides evidence that affirmation can reduce information avoidance. However, several aspects of the present study limit its scope. One potential limitation is that the study used a fictitious disease. I chose to use a fictitious disease for three reasons. First, it allowed me to manipulate elements of the disease to fit the sample and to create the independent variables. That is, by indicating that TAA deficienc y affects college students, I was able to a mirror real life disease (i.e., diabetes) but still make it relevant to a college sample. Second, by using a fictitious disease, I could manipulate controllability in Study 3 without raising concerns from health literate which they had no preexisting bias. Because TAA Deficiency is fictitious, no one had preconceptions in the way people have preconceptions about existing diseases such as diabetes and HIV. Although I believe using a fictitious disease is defensible, its use undoubtedly limits the generalizability of these findings. There are certain threatening aspects of real diseases (e.g., social stigmas, family history of the disease, personal experiences with

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40 people diagnosed) that cannot be fabricated in the lab. Thus, real diseases may seem more threatening than TAA deficiency, and therefore be more likely to elicit avoidance responses. As such, a simple affirmation manipula tion might be insufficient in reducing avoidance. Needed are studies that address the effects of affirmation on avoidance of feedback about real medical conditions and diseases. A second limitation is that I assessed only college students. Although using a college sample is common in exploratory research like mine, college students are generally healthy and thus may respond differently than a less healthy sample. Specifically, to the extent that a disease is threatening, people should be more likely to avo id it. However, college students are generally unlikely to be diagnosed with a life threatening disease. Because their risk for most diseases is statistically lower than the risk of older adults, college students may be comparatively less threatened by ris k feedback. By contrast, in an older, less healthy, population, the statistical likelihood of contracting many diseases is much higher. Thus, the same disease may thus be more threatening to an older adult than to a college student. To address this limita tion, it is imperative that future research investigates the affirmation avoidance relationship in older populations. The Process of Affirmation Although I showed that affirmation can decrease information avoidance, the process underlying self affirmation remains unclear. One possibility is that affirmation decreases avoidance by reducing the amount of resources required to deal with bad news. As mentioned at the onset of this paper, self affirmation diminishes the relative threat associated with receiving bad news by refocusing attention to overall integrity.

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41 people are focused on their overall integrity than if they are focused only on their health (Steele, 1988). Followi ng this logic, it is possible that affirmation reduced the amount of resources required to deal with bad news. Reducing the demand for resources that are required to deal with bad news should decrease avoidance of that news. That is, because receiving an unexpected diagnosis can demand coping resources to deal with the news (Carver, Scheier, & Weintraub, 1989; Wolf & Mori, 2009), people who believe they lack the ability to cope might choose to avoid learning that information altogether (e.g., Walsh & Terdi man, 2009, Weitzman et al., 2001). If people avoid information more when they believe they lack the resources to deal with this information (e.g., Odedina et al., 2004), then diminishing the perceived impact of a negative outcome should decrease avoidance. Thus, it is possible that affirming participants reduces the resources required to deal with an outcome, thereby reducing avoidance. The notion that affirmation reduces coping resources required to manage threats represents only one of many potential exp lanations for how affirmation may reduce avoidance. Indeed, researchers have proposed a variety of processes that may underlie self worth, and augmenting self esteem (Sherman & Cohen 2006). This project is one of many self affirmation projects that lacks a clear identification of process. Indeed, research on self affirmation has not yielded a consistent process variable that specifies how affirmation works (Critcher et al., 2010, She rman & Cohen, 2006). As such, future research should focus on identifying the process behind the affirmation avoidance relationship.

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42 Despite the absence of such process data, the present study offers strong evidence that affirmation can reduce information avoidance and, thus provides a promising avenue for future research on avoidance. Implications These studies have several promising health implications. Perhaps the most direct and compelling implication is that affirmation can be used to reduce avoidanc e of risk feedback. The present results suggest that the simple process of having people consider their own successes on a self relevant global characteristic can reduce their avoidance of health information. As such, it might be worthwhile to affirm patie nts who are at particularly high risk for disease, but are afraid to undergo screening or to learn their screening results. As noted earlier, as many as 55% of people who undergo HIV testing fail to return to receive their results ( Hightow et al., 2003). T he present data suggest that affirming people when they undergo HIV testing may increase the return rate, and thereby allow for an earlier diagnosis and treatment. Another implication of this project is that affirmation may help reduce avoidance of unplea sant, but important, information following a diagnosis. In the course of treatment it is important for patients to learn information about both the disease and the treatment process. Unfortunately, the information can be frightening, especially when availa ble coping resources are devoted to dealing with the diagnosis. People sometimes manage this threat by shutting down and avoiding information altogether ( Carver, et al., 1989). By affirming participants already diagnosed with disease, it is possible to red uce the threat associated with learning further unpleasant, but necessary, information about the disease and treatment.

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43 Conclusions My findings offer a promising first step in understanding how to reduce avoidance health information. Although avoidance mig ht serve to save people from the negative emotions associated with disease diagnosis (Sweeny et al., 2010), in many health situations avoidance can cause more harm than good. For example, although a diagnosis of HIV can lead to social stigma (Neuberg & Cot trell, 2006) and negative affect, untreated HIV can develop into AIDS and eventually lead to death (Centers for Disease Control, 2011). In such situations, it is often wise to forego the temporary affective benefit provided by avoidance in exchange for th e long term benefits of learning the information. The present study demonstrates that self affirmation is one way to reduce such avoidance.

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44 APPENDIX A AFFIRMATION MANIPULA TION Please list six characteristics that you believe are admirable in a person. 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ 4.______________________________________ ______________________________ 5.____________________________________________________________________ 6.____________________________________________________________________ Now, please select the characteristic that is most important to you and circle it Short Writing Exercise Please write a paragraph below about several times in the past week that you (a friend) demonstrated (failed to demonstrate) the characteristic that you selected. _________________________________________________________________ _____ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________ _________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _________ _____________________________________________________________ ______________________________________________________________________ ____________________ ____________________ ____________________ __________

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45 APPENDIX B TAA DEFICIENCY RISK CALCULATOR What is yo ur age? What is your gender? Female Male What is your height in inches? (12 inches = 1 foot) What is your weight in pounds? Have you ever been told that you have high blood pressure (hypertension) or have you ever been given blood pressure medicati on? YES NO NOT SURE Have you ever had a heart attack or been told that you have heart disease? YES NO NOT SURE Have you ever been told that you have diabetes or a problem with high blood sugar? YES NO NOT SURE Have you ever been told that you have high cholesterol? YES NO NOT SURE Do you exercise weekly? YES NO If yes how many hours a week do you exercise? 1 2 3 4 5 or more Do you smoke or chew tobacco? YES NO If yes how many times a day to you smoke or chew tobacco? 1 2 3 4 5 or more Are you exp osed to smoke from other people's cigarettes or cigars? Regularly Occasionally Rarely Never Do you have any relatives in your immediate family who have suffered from TAA Deficiency? YES NO If yes how many immediate relatives have suffered from TAA Defic iency? One Two M ore Than Two Do you usually eat fish two or more times per week? YES NO

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46 Do you eat 5 or more servings of fruit and vegetables per day? A serving is one medium apple, banana or orange, 1 cup of raw leafy vegetable (like spinach or lettuce ), cup of cooked beans or peas, cup of chopped, cooked or canned fruit/vegetable or cup of fruit/vegetable juice. YES NO Do you eat 3 or more servings of whole grains per day (wheat bread, whole grain pasta, brown rice, oatmeal, whole grain breakfas t cereal, bran or popcorn)? A serving is one slice of bread, 1 ounce of breakfast cereal or cup of cooked cereal, pasta or rice. YES NO Do you usually eat 3 servings of nuts per week? A serving is 1 ounce, which is about one airline packet of nuts or one tablespoon of peanut butter. YES NO Do you usually eat butter, lard, red meat, cheese or whole milk 2 or more times per day? YES NO Do you eat stick margarine, vegetable shortening, store bought baked goods (cookies, cakes, pies) or deep fried fast f oods on most days? YES NO Do you eat oil based salad dressing or use liquid vegetable oil for cooking on most days? YES NO Do you take a multivitamin or a B complex supplement on most days? YES NO

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47 How many servings of alcohol do you have on a typical da y? One serving is a can of beer, a glass of wine or a shot of hard liquor. 0 1 2 3 or more What is your total cholesterol level? Low Less than 200mg/dL Borderline High 200 239mg/dL High 240 mg/dL Know What is your Blood Pressure? Normal 139/ 89 or below Mild Hypertension 140/90 160/100 Moderate Hypertension 161/101 120/200 Severe Hypertension above 200/above 120 Know What is your ethnicity? Non Hispanic or Latino Hispanic or Latino Select one or more races to indicate what you co nsider yourself to be: American Indian/ Alaskan Native Black/African American Asian Native Hawaiian or Pacific Islander White

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48 APPENDIX C TESTING DECISION We can provide your risk estimate for developing TAA Deficiency right now. ( Please Remember: You r experimenter will never associate your response to this question with you personally. It is completely your decision whether or not you want to receive this risk estimate). Only select one of the options below if you do not want your risk estimate righ t now. Option 1__________ No, I am not interested in learning my risk for developing TAA Deficiency. Option 2__________ Yes, I would like know my risk for TAA Deficiency, but not today. I wish to do so at a later date. Option 3 __________ Yes please giv e me my risk feedback right now. We are very interested in your thoughts regarding this decision. Please write down any thoughts you had while making this decision, and provide your thoughts for each of the following questions. What thoughts led you to choose the option you chose? ______________________________________________________________________ ______________________________________________________________________ _________________________________________________________________ _____ ______________________________________________________________________ ______________________________________________________________________

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49 APPENDIX D THOUGHTS QUESTIONNAI RE 1. How worried are you about developing TAA Deficiency? 2. I n your opinion, how serious a problem is TAA Deficiency? 3. Please estimate the likelihood that you will develop TAA Deficiency in your lifetime. Your estimate should be between 0% and 100%. _________% 4. Please estimate the likelihood that the average person your age and sex will develop TAA Deficiency in his/her lifetime. Your estimate should be between 0% and 100%. _________% 1 2 3 4 5 6 7 n ot at all worried somewhat worried very worried 1 2 3 4 5 6 7 not at all serious somewhat serious very serious

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50 Feeling s Questionnaire The next items ask about your feelings concerning learning your TAA Deficiency risk. Please respond to all items even if you chose NOT to learn your TAA Deficiency risk. Strongly Disagree Neither Agree nor Disagree Strongly Agree 1. T he possibility that my results would make me feel bad influenced my decision to undergo the risk assessment. 1 2 3 4 5 6 7 2. The possibility that my test results would challenge my view of myself as healthy influenced my decision to undergo the risk assessm ent. 1 2 3 4 5 6 7 3. The possibility that my test results will require me to take action influenced my decision to undergo the risk assessment. 1 2 3 4 5 6 7 4. I can control whether I develop TAA Deficiency. 1 2 3 4 5 6 7 5. I would feel distressed if I lear ned that I was at high risk for TAA Deficiency. 1 2 3 4 5 6 7 6. I would feel happy if I learned that my risk for TAA Deficiency was low 1 2 3 4 5 6 7 7. It would be useful to know my risk for TAA Deficiency. 1 2 3 4 5 6 7 8. Knowing my risk for TAA Deficiency would allow me to take steps to improve my health in the future. 1 2 3 4 5 6 7 9. I am curious to know my risk of TAA Deficiency. 1 2 3 4 5 6 7 10. There are things I can do to decrease my risk should I learn that I am at a high risk for TAA Deficiency. 1 2 3 4 5 6 7

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51 Strongly Disagree Neither Agree nor Disagree Strongl y Agree 11. I have someone to turn to should I learn that I am at risk for TAA Deficiency 1 2 3 4 5 6 7 12. I personally have what it takes to deal with the news should I learn that I am a t risk for TAA Deficiency. 1 2 3 4 5 6 7 13. I have the emotional help and support I need to deal with the news should I learn that I am at risk for TAA Deficiency. 1 2 3 4 5 6 7 14. It will be difficult for me to deal with the news should I learn that I am at r isk for TAA Deficiency. 1 2 3 4 5 6 7 15. I can remain calm in the face of the news should I learn that I am at risk for TAA Deficiency. 1 2 3 4 5 6 7 16. I would cope poorly if I learned that I am at risk for TAA Deficiency. 1 2 3 4 5 6 7 17. Imagine that you ch ose to learn your TAA Deficiency risk. How much do you anticipate regretting that decision later? ( This is a hypothetical question. To answer this question, imagine choosing to learn your personal risk in the previous part of the questionnaire, irrespectiv ely of what option you actually chose.) Very little 1 2 3 4 5 6 Very much 7 18. Imagine that you chose NOT to learn your TAA Deficiency risk. How much do you anticipate regretting that decision later? ( This is a hypothetical question. To answer this question imagine choosing not to learn your personal risk in the previous part of the questionnaire, irrespectively of what option you actually chose.) Very little 1 2 3 4 5 6 Very much 7

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52 APPENDIX E SHORT PANAS To what extent do you currently feel: Not At All Very Inspired 1 2 3 4 5 6 7 Alert 1 2 3 4 5 6 7 Excited 1 2 3 4 5 6 7 Enthusiastic 1 2 3 4 5 6 7 Determined 1 2 3 4 5 6 7 Afraid 1 2 3 4 5 6 7 Upset 1 2 3 4 5 6 7 Nervous 1 2 3 4 5 6 7 Scared 1 2 3 4 5 6 7 Distressed 1 2 3 4 5 6 7

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53 LIST OF REFERENCES Ajekigbe, A. T. (1991). Fear of mastectomy: The most common factor responsible for late presentation of carcinoma of the breast in Nigeria. Clinical Oncology, 3. 78 80. American Cancer Society (2009). Cancer Prevention & Early Detection Facts & Figures Atlanta, GA: American Cancer Society. Retrieved May 12, 2010 From: http://www.cancer.org/downloads/STT/860009web_6 4 09.pdf Carver, C. S., Scheier, M. F., & Weintrau b, J. K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology 56, 267 283. Centers for Disease Control and Prevention (2011). HIV Surveillance Report, 2009, 21 http://www.cdc.gov/hiv/topics/surveillance/resources/reports/ Critcher, C. R., Dunning, D., & Armor, D. A. (2010). When self affirmations reduce defensiveness: Timing is key. Personality and Social Psycholog y Bulletin, 36 947 959. doi:10.1177/0146167210369557 Journal of Applied Social Psychology, 3 6 751 768. Donavan, J.M., & Syngal, S. (1998). Colorectal cancer in women: An underappreciated but preventable risk. 45 48. Epton, T., & Harris, P.R. (2008). Self affirmation promotes health behavior change. Health Psycholog y, 27, 746 752. Harris, P. R., & Napper, L. (2005). Self affirmation and the biased processing of threatening health risk information. Personality and Social Psychology Bulletin, 31 1250 1263. Hart, W., Albarracn, D., Eagly, A. H., Brechan, I., Lindberg, M. J., & Merrill, L. (2009). Feeling validated versus being correct: A meta analysis of selective exposure to information. Psychological Bulletin, 135 555 588. doi:10.1037/a0015701 Hightow, L. B., Miller, W.C., Leone, P.A., Wohl, D., Smurzynski, M., & Ka plan, A. H. (2003). Failure to return for HIV posttest counseling in an STD clinic population. AIDS Education and Prevention, 15, 282 290. Howell, J.L., & Shepperd, J.A. (2011). Behavioral Obligation and Information Avoidance. Unpublished manuscript, Unive rsity of Florida. Howell, J.L., & Shepperd, J.A. (2011). Developing a Dispositional Measure of Information Avoidance. Unpublished manuscript, University of Florida.

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54 Howell, J.L., & Shepperd, J.A. (2009). Contemplation and Avoidance. Unpublished manuscript, University of Florida. Kelly, S.E., (2009) Choosing not to choose: Responses of parents of children with genetic conditions or impairments. Sociology of Health and Illness, 31 81 97. Knobloch Westerwick, S., & Meng, J. (2009). Looking the other way: Sele ctive exposure to attitude consistent and counterattitudinal political information. Communication Research, 36 426 448. doi:10.1177/0093650209333030. Melnyk, D., & Shepperd, J. A. (2011). Information avoidance and breast cancer risk Unpublished data, Uni versity of Florida. Molitor, F., Bell, R. A., & Truax, S. R. (1999). Predictors of failure to return for HIV test result and counseling by test site type. AIDS Education and Prevention, 11 1 13. Mackinnon, A., Jorm, A., Christensen, H., Korten, A., Jacomb P., & Rodgers, B. (1999). A short form of the Positive and Negative Affect Schedule: Evaluation of factorial validity and invariance across demographic variables in a community sample. Personality and Individual Differences, 27 405 416. doi:10.1016/S019 1 8869(98)00251 7. Neuberg, S. L., & Cottrell, C. A. (2006). Evolutionary bases of prejudices. In M. Schaller, J. A. Simpson, & D. T. Kenrick (Eds.), Evolution and social psychology (pp. 163 187) New York: Psychology Press. Odedina, F., Scrivens, J., Eman uel, A., LaRose Pierre, M., Brown, J., & Nash, R. (2004). A Focus Group Study of Factors Influencing African American Men's Prostate Cancer Screening Behavior. Journal of the National Medical Association, 96 780 788. Sherman, D. K., & Cohen, G. L. (2002) Accepting threatening information: self affirmation and reduction of defensive biases, Current Directions in Psychological Science 11 119 123. Sherman, D. K., & Cohen, G. L. (2006). The psychology of self defense: Self affirmation theory. In M. P. Zann a (Ed.) Advances in Experimental Social Psychology (Vol. 38, pp. 183 242). San Diego, CA: Academic Press. Sherman, D. K., Cohen, G. L., Nelson, L. D., Nussbaum, A., Bunyan, D. P., & Garcia, J. (2009). Affirmed yet unaware: Exploring the role of awareness i n the process of self affirmation. Journal of Personality and Social Psychology, 97 745 764. doi:10.1037/a0015451. Sherman, D. K., Nelson, L. D., & Steele, C. M. (2000). Do messages about health risks threaten the self? Increasing the acceptance of threat ening health messages via self affirmation. Personality and Social Psychology Bulletin, 26, 1046 1058.

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55 Shepperd, J.A., & Howell, J.L., (2009). Avoidance of information about parents and children. Unpublished manuscript, University of Florida. Shipp, T., S hipp, D., Bromley, B., Sheahan, R., Cohen, A., Lieberman, E., et al. (2004). What Factors Are Associated with Parents' Desire To Know the Sex of Their Unborn Child?. Birth: Issues in Perinatal Care, 31, 272 279. doi:10.1111/j.0730 7659.2004.00319.x. Smith, S. M., Fabrigar, L. R., & Norris, M. E. (2008). Reflecting on six decades of selective exposure research: Progress, challenges, and opportunities. Social and Personality Psychology Compass, 2 464 493. doi:10.1111/j.1751 9004.2007.00060.x Steele, C.M. (19 88). The psychology of self affirmation: Sustaining the integrity of the self. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 21, pp. 261 302). New York; Academic Press Sweeny, K., Melnyk, D., Malone, W., & Shepperd, J. A. (2010). Information avoidance: Who, what, when & why. Review of General Psychology 14 340 353. Vargas, C. A. (2001). Coping with HIV/AIDS in Durban's commercial sex industry. AIDS Care 13 351 365. Walsh, M.E., & Terdiman, J.P. (2003). Colorectal cancer screeni ng: Scientific Review. Journal of American Medicine, 289, 1266 1296. Weitzman, E., Zapka, J., Estabrook, B., & Valentine Goins, K. (2001). Risk and reluctance: Understanding impediments in colorectal cancer screening. Preventive Medicine: An Internationa l Journal Devoted to Practice and Theory, 32, 502 513. doi:10.1006/pmed.2001.0838. Wolf, E., & Mori, D. (2009). Avoidant coping as a predictor of mortality in veterans with end stage renal disease. Health Psychology, 28 330 337. doi:10.1037/a0013583. Yani v, I., Benador, D., Sagi, M. (2004). On not wanting to know and not wanting to inform others: Choices regarding predictive genetic testing, Risk, Decision & Policy 9 317 336.

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56 BIOGRAPHICAL SKETCH Jennifer Howell was born and raised in Houston, Texas. Sh e graduated from Southwestern University in Georgetown, Texas in 2009 with a Bachelor of Arts in psychology. Additionally, she received a Master of Science degree in Social Psychology from the University of Florida where she is continuing her education in pursuit of a PhD. decision making.