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date: 23 July 2017

Procrastination, Health, and Health Risk Communication

Summary and Keywords

Whether viewed as a domain-specific behavior or as an enduring tendency, procrastination is a common form of self-regulation failure that is increasingly recognized as having implications for health-related outcomes. Central to procrastination is the prioritization of reducing immediate negative mood at the cost of decisions and actions that provide long-term rewards, such as engaging in health behaviors. Because people tend to procrastinate on tasks they find difficult, unpleasant, or challenging, many health-promoting behaviors are possible candidates for procrastination. As modifiable risk factors for the prevention of disease and disability, health behaviors are often the target of health risk communications aimed at health behavior change and reducing health procrastination. Research has consistently demonstrated the deleterious effects of chronic procrastination on health outcomes, including poor physical health, fewer health promoting behaviors, and higher stress in healthy adults and those already living with a chronic health condition.

Examining the factors and psychological characteristics associated with chronic procrastination can provide insights into the processes involved in procrastination more generally, as well as the qualities of the health messages that can promote or prevent procrastination of the targeted behaviors. Low future orientation, avoidant coping, low tolerance for negative emotions, and low self-efficacy need to be considered when designing effective health risk communications to reduce procrastination of health behaviors. Yet, health risk communications aimed at reducing procrastination of important health behaviors such as healthy eating, regular physical activity, screening behaviors, and cessation of risky health behaviors often use fear appeals to motivate taking protective actions to reduce health risks. Such approaches may not be effective because they amplify the negative feelings towards the health behaviors, which can engender maladaptive coping responses and motivate procrastination rather than adaptive responding. This is especially likely among individuals prone to procrastination more generally, or specifically with respect to health. Health risk communication approaches that minimize the negative emotions associated with risk messages and instead highlight short-term benefits of engaging in health behaviors may be necessary to reduce further health behavior procrastination among individuals prone to this form of self-regulation failure.

Keywords: procrastination, health risk communications, health-promoting behaviors, health behavior change, avoidant coping, mood regulation, disease prevention, future orientation, health and risk message design and processing

Introduction

Procrastination is a common behavioral issue that is increasingly being recognized as having implications for physical health. Procrastination is commonly defined as the unnecessary and voluntary delay of necessary and important intended tasks, despite recognizing that such delay will result in negative consequences (Lay, 1986; Steel, 2007). Recent conceptualizations of procrastination have moved from more behavioral economist perspectives on procrastination that highlight preference reversal and hyperbolic discounting of future rewards (Ainslie, 1975; Steel, 2007), towards models that underscore the need to understand procrastination from the perceptive of mood regulation (Sirois & Pychyl, 2013). From a mood regulation perspective, procrastination is a temporally-related behavior that involves prioritizing the need to minimize negative emotional states and maximize positive emotional states over considering the future consequences of current choices and behaviors (Pychyl & Sirois, 2016; Sirois & Pychyl, 2013). This latter view is particularly relevant for the topic of health and health risk communication, as many of the health behaviors necessary for the maintenance of health and the prevention of disease can be challenging and unpleasant to integrate into one’s lifestyle. More importantly, the health risk messages designed to promote important health behavior and lifestyle changes, such as increasing physical activity, eating healthy, and reducing smoking and alcohol consumption, may amplify the negative feelings that some individuals have towards such behaviors and motivate procrastination rather than adaptive responding (Rogers, 1975). Whether viewed as a temporary behavior or as enduring tendency, procrastination and the underlying processes that contribute to this tendency have clear relevance for understanding whether health risk communications will be followed or evoke further procrastination.

Situational Versus Dispositional Procrastination

An important consideration when discussing procrastination is that it can be construed in a number of different ways. One way of thinking about procrastination is that it occurs as an occasional behavior within a specific situation or context. For example, if an individual makes an intention to go to the gym after work, but then starts thinking about how difficult this might be and, encouraged by his co-workers to watch the latest new release, he instead decides to go home and watch a movie, this would be a form of situational, health-related procrastination. Viewing procrastination as a behavior that is influenced by the context it occurs within has the advantage that this behavior can be potentially changed by altering the aspects of the situation that might be contributing to, for example, the socially introduced temptation to delay acting on the intention to go to the gym. From a public health perspective, this can be particularly beneficial when the domain in which the procrastination occurs involves health and the practice or exclusion of health behaviors known to contribute to poor health outcomes.

Procrastination is also commonly viewed by researchers as a relatively stable and chronic tendency towards avoiding unpleasant or challenging tasks. From this dispositional perspective, procrastination may be conceived of as developing over time, perhaps with repeated reinforcement of the relief from unpleasant tasks that is afforded when such tasks are avoided. When measured as an enduring, trait-like quality, procrastination scores have demonstrated very good stability over a 10-year period (Steel, 2007). More importantly, recent behavior genetics work with over 300 same-sex twin pairs found that procrastination when measured by Lay’s General Procrastination Scale (1986), demonstrated a moderate degree of heritability (46%; Gustavson, Miyake, Hewitt, & Friedman, 2014), supporting the view that this behavioral tendency can be considered a personality trait with evolutionary roots.

A third and more recent view of procrastination blends the situational and trait perspectives. From this perspective procrastination can be considered a characteristic way of responding to certain challenges from the environment that is akin to a coping strategy (Sirois & Pychyl, 2016a). Procrastination is thus conceptualized as a form of emotion-focused coping for dealing with the unpleasant emotions associated with challenging tasks that is an expression of higher order personality traits, such as low Conscientiousness and high Neuroticism, rather than being an immutable trait. This particular view has the advantage of considering procrastination as something that is amenable to change rather than set, while still considering the tendency to disengage from or avoid threatening or unpleasant tasks as a concerning pattern of behavior that occurs across different contexts.

Procrastination and Mood Regulation

Many of the early conceptualizations of procrastination, including the more recent Temporal Motivation Theory (Steel, 2007), take a behavioral economics view that highlighted the role of rational trade-offs between immediate and distant rewards (Ainslie, 1975; Steel, 2007) in explaining the unnecessary delay of an intended action. This perspective proposes that people consciously discount larger and later rewards to value smaller, immediate rewards, with the net effect of this preference reversal being a trade-off of the distant rewards in favor of the immediate rewards. Although people may initially intend to favor the later reward (good health), as the time to act on this intention (eating healthy and exercising) approaches, the immediate reward (enjoying a decadent dessert while watching a movie) outweighs the value of the distant reward simply because it is more readily available, and good intentions are not acted upon. The result is that the good intentions to heed warnings about the risks for future health associated with not making healthy lifestyle choices are devalued and not acted upon. From this perspective, people typically intend to forfeit immediate rewards for longer-term rewards, and this apparent rationalization (closer rewards are more tangible and therefore more valuable than distant rewards) is viewed as the reason people procrastinate. Although abandoning intentions to engage in health behaviors is clearly irrational under these circumstances, this account of procrastination emphasizes decision-making processes rather than primacy of emotions and emotion regulation processes per se.

Growing evidence supports an alternative view of procrastination that highlights mood regulation as a central feature. A mood regulation perspective on procrastination extends the common view of procrastination as the quintessential form of self-regulation failure that is apparently irrational (Steel, 2007), to include failure in regulating emotional states, and negative moods in particular (Sirois & Pychyl, 2013). From this view, procrastination for a given task occurs when the task elicits negative or uncomfortable feelings. Disengaging from or avoiding the task serves as an immediate and external strategy of regulating the difficult feelings associated with the task and feeling less negative mood, which manifests as what we commonly observe as procrastination. Indeed, procrastination most commonly occurs for tasks viewed as aversive, boring, frustrating, unpleasant, lacking meaning, or structure (Blunt & Pychyl, 2000, 2005). By turning away from such tasks towards those that are less aversive or more pleasant, procrastination becomes an avoidant coping strategy that helps reduce task-related negative emotions, and perhaps even replaces them with more positive ones. As some researchers have noted, when we procrastinate we “give in to feel good” (Tice & Bratslavsky, 2000), or rather to avoid feeling bad now (Sirois & Pychyl, 2013). This coping view of procrastination is also consistent with the findings from a recent meta-analysis of 15 studies (N = 4,357) which found that procrastination as an enduring, trait-like tendency was robustly associated with the use of maladaptive and avoidant coping strategies, such as behavioral disengagement, self-blame, and denial (Sirois & Kitner, 2015).

Whether a particular behavior is viewed as aversive may also involve the individual’s relationship to that behavior, their past experience and success with that behavior, as well as the relevance of that behavior for their sense of self-esteem. Behaviors that threaten one’s identity or remind one of past difficulties in carrying out a behavior can evoke anxiety, stress, worry, shame, and guilt. For example, individuals who routinely procrastinate on certain tasks report intense feelings of guilt, shame, and anxiety about their past procrastination (Fee & Tangney, 2000; Ferrari, 1991), which in turn can trigger further procrastination on the task as a means of down-regulating these difficult emotions (Giguère, Sirois, & Vaswani, 2016). Thus, a personal history of difficulty with starting or completing a behavior can be enough to trigger avoidance of that behavior and contribute to a cycle of procrastination.

Although down-regulating negative moods can be an important mood regulation strategy when used appropriately (Gross & Thompson, 2007), the emotion regulation issues underlying procrastination and the use of this strategy reflects a prioritization of short-term mood regulation over long-term goals and rewards (Sirois & Pychyl, 2013). Procrastination can therefore be viewed as an unsuccessful resolution of a temporal dilemma in which immediate emotion regulation rewards take precedence over the future rewards gained from initiating and persisting with a given task. This strategy can be particularly problematic in the health domain where the timely and consistent practice of health-promoting behaviors is necessary to maintain heath and reduce the risk of disease. Indeed, the World Health Organization (2011) has identified physical inactivity and an unhealthy diet as two key modifiable risk factors that contribute to obesity and in turn to the development of a number of chronic diseases, such as diabetes, arthritis, cancer, and heart disease. Negotiating whether or not to engage in health behaviors is considered a key temporal dilemma that can have considerable consequences for lifelong health. For individuals with a tendency to procrastinate in general or with respect to the health domain, the immediate goal of reducing any negative feelings about engaging in these behaviors takes precedence over the long-term and often dire consequences of forgoing these behaviors.

However, simply pointing out the long term consequences of this trade-off in health risk messages may not be effective for individuals prone to procrastination. A meta-analysis of 14 published and unpublished studies (N = 4,312) examining the associations between procrastination and time perspective found that procrastination measured as an enduring tendency was robustly associated with being less future-oriented and modestly associated with being more present-oriented (Sirois, 2014). This short-sightedness, or temporal myopia associated with procrastination can have implications for how or whether individuals think about the health of their selves that will exist in the future, and therefore the health-related choices they make now. Specifically, procrastination is associated with having less consideration for, and feeling less connected to, a future self, and this in turn is linked to less frequent practice of health-promoting behaviors (Sirois, Shucard, & Hirsch, 2014). In the context of health and health behaviors, focusing on current rather than future needs can reflect motivations for immediate mood regulation in response to health threats, as well as the need to restore self-esteem when faced with past procrastination with respect to one’s health (Sirois, 2004a).

Procrastination and Physical Health—A Historiography

Research into the potential health consequences of procrastination, and specifically chronic or trait procrastination, is relatively new, with the first study published in 1997 by Tice and Baumeister. In this initial study, college students who self-reported being chronic procrastinators were assessed at the beginning and the end of the academic term. At the beginning of the term, those with a tendency to procrastinate reported lower levels of stress, and better physical health (via self-report and medical visits) than non-procrastinators (Tice & Baumeister, 1997). However, by the end of term these associations had reversed, and student procrastinators now reported higher stress and made more medical visits for illness in comparison to student non-procrastinators. A key drawback of the study was that the reasons students who procrastinated might have poorer health and more stress at the end of term were not formally investigated, although the authors speculated that the stress from trying to finish tasks at the last minute might be a contributing factor.

This initial and important study laid the foundation for a more systematic and theory driven line of research spearheaded and developed primarily by Sirois and her colleagues to better understand why procrastination may confer risk for poor health, as well as the different health-related outcomes that may be affected by a tendency towards chronic delay of intended tasks. The procrastination-health model (Sirois, Melia-Gordon, & Pychyl, 2003) was introduced as a model to help guide this line of inquiry. Based on accepted models of the linkages between personality and health (Smith, 2006), the procrastination-health model proposed that procrastination as a trait-like tendency creates vulnerability for poor health through two routes. The first route is considered a direct route in that the effects of procrastination were proposed to directly affect physiological systems including the activation of the stress response. This response involves two separate systems, the hypothalamic-pituitary-adrenal axis (HPA) and the sympathetic nervous system, which function in a coordinated manner to prepare the individual to deal with a perceived threat. The activation of these systems results in a number of physiological changes, some which occur more immediately, such as increased heart and respiration rates and the suppression of digestive functioning, and others which occur later, such as the suppression of the immune system. However, chronic or repeated activation of the stress response over time can take a cumulative toll on physical health that can result in a number of adverse health outcomes including obesity, dysregulation of inflammation, and increased risk for the development of disease (Cohen et al., 2012; Lupien, McEwen, Gunnar, & Heim, 2009).

The second route proposed to explain how procrastination can affect health is considered an indirect route primarily because the effects on health occur over time as a result of procrastination of health behaviors (Sirois et al., 2003). In contrast to the direct route in which any form of procrastination can impact health by eliciting a stress response, the indirect route involves procrastination specifically with respect to the practice of health-promoting behaviors, and/or procrastinating the cessation of unhealthy behaviors, both of which are considered to be modifiable risk factors for the development of disease. Health-promoting behaviors such as starting an exercise regime and changing to a healthier diet can be challenging and stressful initially for some individuals and may trigger avoidant responses such as procrastination. This may be especially true for individuals who are prone to procrastination and use avoidance as a strategy for dealing with unpleasant emotions (Pychyl & Sirois, 2016). Similarly, many preventive and protective health behaviors require undergoing unpleasant screening tests, seeking timely medical care, or engaging in inconvenient behaviors such as using sunscreen that can trigger procrastination as a response. Health risk behaviors, such as excessive alcohol consumption and smoking, provide the experience of feeling good now, whereas reducing or ceasing these behaviors can be unpleasant in part because of their addictive nature and the associated psychological and physical withdrawal symptoms. Because procrastination is most likely to occur for behaviors that are aversive or difficult, not following through with recommendations to cease health risk behaviors is another possible route through which procrastination can have negative health consequences.

To date, a number of studies have tested and found support for the procrastination-health model as a framework for understanding how procrastination as an enduring tendency is implicated in health-related outcomes. An initial test of the model found that among undergraduate students, trait procrastination was associated with poor self-reported health, less frequent health behaviors, delayed medical care seeking, and higher levels of stress (Sirois et al., 2003). However, in a direct test of the model, only stress and medical delay explained in part the illness reported by the student procrastinators. One reason proposed for why less frequent health behaviors did not explain the procrastination-health link was the relative youth and good health of the sample. Because most health behaviors can take time before they have a noticeable effect on physical health, and young adults tend to be relatively robust to the effects of poor health habits, this finding was not surprising. For example, having an unhealthy diet or frequently eating junk food is unlikely to cause any immediate health concerns. However, if this poor diet is eaten regularly, over time it could lead to weight gain or digestive issues especially among individuals with pre-existing genetic vulnerabilities that predispose them to these outcomes.

A follow-up study, this time with a community sample of adults, addressed this issue by retesting the model (Sirois, 2007). In addition to medical check-ups, engaging in timely dental check-ups was added to the health behaviors examined. A more sophisticated statistical technique (i.e., structural equation modelling) was also used, which permitted a reciprocal relationship between stress and health behaviors noted in other research (Rod, Grønbæk, Schnohr, Prescott, & Kristensen, 2009). The results of this test replicated those found in the initial test conducted with students, but in addition found support for the role of health behaviors. When considered without the effects of stress, less frequent practice of health behaviors explained the poor self-reported physical health of the procrastinators, consistent with the indirect route of the procrastination-health model. However, when stress was included in the model, it was the stronger predictor of poor health, and was negatively related to health behaviors.

Although there are few tests of the full procrastination-health model, a growing body of research provides some support for the notion that procrastination is linked to each component of the model, namely higher stress, poor health behaviors, and poor health (Sirois, 2016). Emerging evidence also suggests that these linkages, which have been primarily noted in North American samples, may also apply to international samples. For example, procrastination has been linked to poor health behaviors in Dutch adults (Kroese, Evers, Adriaanse, & de Ridder, 2014), and to poor health behaviors and higher stress among Greek students (Argiropoulou, Sofianopoulou, & Κ‎alantzi-Azizi, 2016). Nonetheless, many of the tests of the individual paths within the model have been cross-sectional and used trait measures of procrastination to assert the temporal precedence of procrastination as proposed in the model, rather than the reverse possibilities that stress, poor health behaviors, and illness “cause” procrastination. However, among the limited number of longitudinal studies available, there is support for the assumption that procrastination precedes health outcomes, with procrastination demonstrating prospective links to stress (Rice, Richardson, & Clark, 2012; Sirois, 2013; Sirois, Voth, & Pychyl, 2009), poor physical health, and health behaviors (Sirois et al., 2009). Importantly, the cross-sectional and longitudinal tests of the procrastination-health model have been conducted among both student and community adult populations, with very little differences in the results (Sirois, 2016).

Much of the research examining the implications of procrastination for physical health has focused on healthy, general medical populations, rather than populations with pre-existing health issues. Nonetheless, there is emerging evidence that a tendency towards procrastination can increase the risk for poor disease management and outcomes in the context of chronic illness. In a study comparing individuals with self-reported hypertension or cardiovascular disease to those with no chronic health issues, individuals with higher levels of trait procrastination in both groups reported using maladaptive coping strategies that were in turn related to higher levels of stress, and poor health behaviors (Sirois, 2015). In comparison to the healthy control group, the relationship of procrastination to poor coping and health outcomes was much stronger in the poor heart health group, indicating that procrastination created added vulnerability for health-related outcomes.

Similar results have been noted in individuals with fibromyalgia. In one study procrastination was linked to having less confidence and ability in coping with the challenges of fibromyalgia, including day-to-day illness management, symptoms, and the emotional issues associated with living with fibromyalgia (Beauregard, Ioachim, & Sirois, 2015). More concerning was that procrastination was also associated with low levels of health-promoting behaviors and adherence to doctor’s recommendations, and the relations were explained by the higher levels of stress reported. These findings highlight the need to account for the dynamic relations between stress and health behaviors when developing communications to target tendencies towards procrastination in the context of chronic illness.

Considering the risk associated with chronic procrastination for poor health behaviors and high stress, and the importance of health behaviors and stress for the management of chronic disease (e.g., Gulliksson et al., 2011), the relationship between chronic procrastination and health is an important yet understudied area for understanding the role of procrastination in health risk communication. Although a full discussion is beyond the scope of this article, adherence to medical recommendations may also be compromised by a chronic tendency to procrastinate. This may be particularly problematic when the recommendations involve challenging lifestyle changes or medication and disease monitoring procedures such as blood tests that are unpleasant or intrusive. However, to date there is little if any published research on this topic. Finding ways to communicate the risks of not engaging in important health behaviors without eliciting avoidant responses is both challenging and critical to ensure effective self-care and disease management behaviors.

Understanding Procrastination and Health Behaviors

Understanding how and why tendencies towards procrastination play a role in the practice of health behaviors is key for designing effective health risk communications. By examining the psychological characteristics of individuals who chronically procrastinate insights can be gained into the processes involved in procrastination more generally, as well as the qualities of the health messages that may promote or prevent procrastination of the targeted behaviors.

As might be expected, procrastination as a chronic tendency is consistently linked to less frequent practice of health-promoting behaviors such as having a healthy diet and regular physical activity. These associations have been noted across student and community adult samples, and in cross-sectional (Sirois, 2007; Sirois et al., 2003, 2014), and longitudinal research (Sirois & Giguère, 2013; Sirois et al., 2009). In terms of understanding the underlying processes involved, evidence to date is consistent with the procrastination-health model and indicates that stress is a disruptive influence for following through with health behaviors.

In addition to exercise and diet, procrastination has been examined in relation to sleep behaviors. Sleep is an important behavior to consider as it is increasingly be recognized as a contributing factor to the self-regulation of other key health behaviors such as diet and exercise, and can have synergistic effects with the experience and management of stress (Lund, Reider, Whiting, & Prichard, 2010). Links between trait procrastination and poor sleep quality due to higher stress have been noted across both North American and Greek student samples (Sirois, Van Eerde, & Argiropoulou, 2015). However, because this research used a cross-sectional design, it was difficult to disentangle the potential bi-directional relations between stress and sleep, or how much poor sleep may have increased any chronic tendencies towards procrastination. Nonetheless, this research further underscores the complex relations of procrastination to stress and health behaviors, and the need to consider these relations when designing health risk messages that target health behaviors.

Research has also begun to examine procrastination more directly as a behavior in relation to sleep. Defined as delaying going to bed at an intended time resulting in a lack of sleep (Kroese, De Ridder, Evers, & Adriaanse, 2014), bedtime procrastination is a specific domain of procrastination that can have significant impacts on health. Sleep insufficiency is associated with a number of health-related problems including obesity, poor health behaviors, cardiovascular events, and adverse changes in inflammatory biomarkers (Buysse, Grunstein, Horne, & Lavie, 2010), and has been referred to by the Centers for Disease Control and Prevention as a “public health epidemic” given its rise in recent years. The contribution of bedtime procrastination to this problem is evidenced by findings from a representative sample of 2,431 Dutch adults which excluded those who worked night shifts or who had a sleeping disorder (Kroese, Evers, et al., 2014). A surprising 50% reported bedtime procrastination, and 45% reported feeling tired frequently after staying up later than intended. Given that self-regulation is compromised when people feel fatigued or tired, bedtime procrastination is a concerning and potentially cyclic problem that can take a toll on the regulation of a number of health behaviors, which makes it a key issue to consider when designing effective health behavior change messages.

With respect to understanding the factors that contribute to the procrastination of health behaviors, evidence suggests that key self-perceptions can play a role. As noted previously, feeling disconnected with the future, and specifically the future consequences of current actions and decisions, is a potential reason people may procrastinate on important health behaviors such as diet and exercise. When assessed as feeling closeness to a future self, being disconnected from the future accounted for the link between procrastination and less frequent health behaviors (Sirois et al., 2014). However, when assessed as a more general tendency towards considering the future consequences of current actions, being disconnected from the future failed to account for the link between procrastination and intentions to engage in health behaviors. This divergent evidence suggests that health communications, which encourage a more specific and personal connection to a future self, rather than a more general awareness of the future, may be most effective for reducing procrastination of health behaviors. This idea has been put into practice by the Heart and Stroke Foundation of Canada (2013) in their Make Health Last campaign. The series of short televised ads display side-by-side vignettes of day-to-day life for two “future” selves, one that has made choices to engage in health-promoting behaviors and lives out his last years with vitality, and one who has neglected these health behaviors and lives out his life with disease and disability in an institutional setting. By personalizing the future self and showing not only a negative, but a positive future that is attainable, this message enhances the possibility for positive responses rather than procrastination.

People may avoid engaging with important health behaviors when messages prompting these behaviors highlight past failures or delays in taking action and the associated negative consequences. Such messages can pose a threat to self-esteem that can trigger defensive rather than proactive responses. For example, in one study participants read two anxiety-provoking scenarios, one of which involved procrastination of an important health-protective behavior, wearing sunscreen while on vacation in a sunny tropical location (Sirois, 2004a). In the health scenario, a troublesome skin blemish had developed and medical care was sought with the suggestion that the blemish was possibly the first signs of skin cancer. When asked to list thoughts about how the situation could have been different, individuals with low tendencies towards procrastination generated more thoughts focused on preventive actions such as wearing sunscreen and taking precautions to minimize sun exposure. However, those scoring high on the measure of chronic procrastination generated more thoughts about how things could have been much worse to minimize their feelings of guilt and anxiety about the situation. Although this could be construed as another instance of short-term mood repair, these downward counterfactual thoughts are also well-known to be generated to help restore self-esteem in response to self threats (Sanna, 2000). Indeed, the link between downward counterfactual thoughts was much stronger for the health scenario than a generic anxiety-provoking scenario, suggesting that procrastinators responded defensively to the idea that their lack of precautions may have created a negative health outcome.

Health Risk Communication and Procrastination

Framed from a procrastination perspective, health risk communications can be viewed as aiming to reduce the delay in (a) engaging in important health-promoting behaviors such as eating healthy and being physically active, or (b) ceasing or minimizing health risky behaviors such as alcohol use and smoking. To the extent that people know that not changing these behaviors will lead to negative consequences, and that there is some contemplation of the need to make these changes, not following through can be considered akin to health procrastination. This seems reasonable given that the health risk message includes information about the negative consequences of not making certain health behavior changes. Although an intention to engage in a behavior is a necessary prerequisite for procrastination to occur (Sirois & Pychyl, 2016b), the tacit assumption that most people will recognize that they need to do things to stay healthy could be viewed as a reasonable proxy for intention. It is important to note here that individuals may not want to exercise regularly or change their eating habits, as such lifestyle changes can be initially aversive until such time that they become routine. Yet, recognizing that they nonetheless need to make such changes, and that the actions required to make these changes are somewhat unpleasant (healthier food may not taste as good as unhealthier food) or aversive (exercising vigorously may be painful), is enough to trigger an avoidant response.

Many health risk communications rely on fear appeals to persuade the recipient to engage in the targeted health behavior change. These fear appeals use the threat of impending harm or danger as a motivation to change people’s attitudes and behaviors (Rogers, 1975). For example, messages warning about the increased risk of lung cancer from smoking, skin cancer from not using sunscreen or protective clothing, or diabetes from not engaging in regular exercise and eating healthy, are commonly used to convince people to change their health behaviors. Protection Motivation Theory (PMT; Maddux & Rogers, 1983; Rogers, 1975) was developed as a conceptual model to help understand the reasons such fear appeals may or may not be effective for behavior change. According to PMT, people go through two different appraisal processes when faced with a health threat. First, people engage in a threat appraisal process, which involves assessing the severity of the perceived health threat (e.g., having an upset stomach from eating unhealthy vs. developing diabetes), as well as evaluating the probability that one is vulnerable to the health threat (e.g., family risk of diabetes vs. no risk). Having assessed the severity and vulnerability to the health threat, the coping appraisal process is initiated. In this process the efficacy of the recommended health behavior change, or response efficacy, is evaluated (e.g., “Will weight management behaviors reduce my risk of diabetes?”), as well as the perceived self-efficacy for engaging in the recommended behavior (e.g., “To what extent am I confident that I can successfully eat healthy and stay active?”) contribute to perceptions of coping. Together the threat and coping appraisal processes determine the motivation to engage in protective behaviors to reduce the health threat communicated, or the protection motivation.

From the lens of PMT, protection motivation is the adaptive and desired response to an effective fear appeal communication. Importantly, the motivation can extend beyond a single act of the targeted health behavior to provide sustained motivation to make more lasting health behavior changes, such as quitting smoking (Maddux & Rogers, 1983). However, for some individuals the fear appeal may not result in protection motivation and instead lead to maladaptive responses that place the individual at further risk, such as avoiding the recommended behaviors (e.g., health procrastination), or increasing rather than decreasing health risk behaviors. PMT posits that this is likely to occur when the individual perceives barriers or response costs to engaging in the recommended health behavior change, and/or when the rewards for engaging in maladaptive responses outweigh the perceived severity and vulnerability to the health threat. Meta-analyses of the effectiveness of PMT for understanding health behavior change have provided some support for utility of the model, and further highlighted which components are most robustly linked to behavior change intentions and actual behavior (Floyd, Prentice-Dunn, & Rogers, 2000; Milne, Sheeran, & Orbell, 2000). Overall, the coping appraisal process (response efficacy and self-efficacy) have greater predictive validity than does the threat appraisal process (threat severity and vulnerability).

Building on and extending the PMT and other similar fear appeal theories, the Extended Parallel Process Model (EPPM; Witte, 1994) was developed to address some of the gaps and inconsistencies in the literature. Specifically, the EPPM posits that people can have one of three responses to a threatening health message: (1) non-response, (2) danger control response, or (3) fear control response. The type of response that will result is dependent on the interaction between the individual’s threat and efficacy assessment with respect to the health message. If the threat is not perceived to be high, then no fear is aroused and there is no motivation to consider the message further (Witte, 1994). If the message does present a threat, then fear is aroused and the individuals’ efficacy assessments come into play. When efficacy to deal with the threat is perceived as high, then individuals will engage in active responses to control the perceived danger, such as intention and behavior change. If, however, the individual perceives that they do not have enough efficacy to reduce the threat, that is they do not feel competent in their ability to engage in effective danger control responses, they can become preoccupied with the fear associated with the threat and instead engage in responses to control and reduce the fear aroused by the threat. Such responses can include defensive avoidance, reactance, and denial to cope with the fear (Maloney, Lapinski, & Witte, 2011; Witte, 1994).

Considering the psychological processes involved in procrastination and the characteristics of chronic procrastinators, EPPM provides a useful framework for understanding when and why some people may respond maladaptively to health risk communications, and how such responses might be reduced. Moreover, mapping procrastination science onto the EPPM provides a more complete explanation for the role of emotions in responses to health risks communications, a gap that other researchers have noted is not fully explained with the PMT (Tanner, Hunt, & Eppright, 1991). Although previous research is equivocal about the role individual differences in responses to fear appeals as framed by the EPPM (So, 2013; Witte & Morrison, 2000), there is some evidence that anxiety levels influence how both threat and efficacy appraisals are perceived, and that defensive avoidance is linked to fear control responses (Witte & Morrison, 2000).

With respect to threat appraisals, the negative affect and anxiety elicited by the fear appeal may fall above the threshold of what is tolerable for some individuals, increasing the chances of fear control responses such as disengaging from the message and the recommended health behavior change. For individuals already prone to procrastination in general or in the health domain specifically, a health threat may activate thoughts about past opportunities not taken to get into a healthy routine or engage in cancer screening behavior, for example. These recollections may remind the individual of the barriers and costs of attempting to engage in the health behavior (e.g., lower self-esteem, greater negative mood), and past failures, that together can lower perceived efficacy for reducing the health threat.

As noted previously, those prone to procrastinate will engage in mood repair strategies to reduce the fear associated with the health threat and defensive thoughts to protect their sense of self-esteem, rather than taking precautions to reduce the threat (Sirois, 2004a). If the behavior being targeted is one that has been repeatedly delayed despite past prompting or recommendations, this could also trigger procrastinatory cognitions, repetitive and automatic negative thoughts that involve brooding about past procrastination (Stainton, Lay, & Flett, 2000). These cognitions can increase stress and distress, making it more likely that the individual will avoid the health behavior change as a way of coping with the negative mood arising from the health threat and the associated negative cognitions.

Efficacy appraisals in response to a health risk communication may also be compromised in individuals prone towards procrastination generally, or with respect to health more specifically. Trait procrastination is consistently linked to lower levels of general self-efficacy (Ferrari, Parker, & Ware, 1992; Martin, Flett, Hewitt, Krames, & Szanto, 1996), and lower levels of health-specific self-efficacy (Sirois, 2004b). In one study participants were asked to recall a recent illness event and retrospectively identify one health behavior that may have reduced their risk for getting ill, and rate their intentions to engage in this protective behavior in the future (Sirois, 2004b). Those who were chronic procrastinators reported weaker intentions to engage in this health behavior in the future, in part because their self-efficacy for engaging in this behavior was low. Although the findings were framed in terms of another social cognitive health behavior change model, the Theory of Planned Behavior (Ajzen, 1991), the results are also in keeping with the EPPM, insomuch that the health threat and vulnerability were highlighted in the recall of the illness event.

Given these conditions, and consistent with the EPPM, individuals with tendencies towards procrastination (including those with poor emotion regulation skills) will be more likely to engage in maladaptive rather than adaptive coping responses to a health threat as a means of fear control. Indeed, procrastination is linked to avoidant coping responses as a way to regulate negative moods and distress (Sirois & Kitner, 2015). From the perspective of EPPM, the negative emotional states arising from the health threat become the target of coping efforts for individuals with a tendency to procrastinate, with disengagement, avoidance, and other mood repair strategies taking precedence over more active, and threat controlling behavior changes. When such fear control strategies involve engaging in more pleasurable health risk behaviors, such as alcohol use, smoking, unhealthy eating, or sedentary activities, as a way to cope with the negative mood from the risk communication, fear appeals may not only be ineffective, but also backfire with respect to health behavior change.

For the reasons outlined above, use of fear appeals on their own may not be the best approach when dealing with individuals who have already demonstrated a tendency towards procrastinating on important health behaviors. Using interventions to increase message receptivity may be needed for these individuals. Self-affirmation is one approach that could be beneficial as it has been shown to reduce defensive responding to health risk messages (Harris & Epton, 2009). This approach involves individuals affirming their core values prior to reading a health risk message as a means of bolstering self-consistency, which in turn allows for a more objective and less threatening evaluation of the message. However, this approach can be difficult to implement on a larger scale, outside of one-on-one encounters. Nonetheless, evidence to date supports the effectiveness of self-affirmation interventions for message acceptance and reducing defensive responding (Epton & Harris, 2008), making it a potentially effective approach for dealing with the habitual procrastination of health behaviors.

Given that prioritizing short-term mood regulation over long-term behavior change is a central process in procrastination, trying to motivate less health-related procrastination by highlighting risks to arouse fear is likely to be less effective than other health communication approaches that do not add to the already high levels of stress associated with chronic procrastination, and provoke responses aimed at controlling these distressing feelings. Finding ways to design health risk communications that do not arouse negative emotions and trigger procrastination may therefore be challenging, but not impossible. One potentially beneficial approach is to design health messages that work with the default tendencies of procrastinators rather than trying to significantly shift more ingrained patterns of responding that are biased towards immediate mood regulation. Experimental evidence supports taking a congruency approach when trying to deal with individuals who are more focused on short-term rather long-term rewards. Middle-aged adults who scored low on a measure of future orientation were more likely to be persuaded to engage in a colorectal screening program when the health messages highlighted the short-term rather than the long-term benefits of the program (Orbell, Perugini, & Rakow, 2004). An opposite pattern was found for those scoring high on future orientation, supporting a congruency hypothesis. Health communications that highlight the rewards rather than the risks for engaging in a health behavior, and frame these rewards as being more immediately available, will likely be more persuasive for individuals who tend to procrastinate than health risk messages focused on using fear-based motivation as a way to induce behavior change.

Further Reading

Armitage, C. J., Harris, P. R., & Arden, M. A. (2011). Evidence that self-affirmation reduces alcohol consumption: Randomized exploratory trial with a new, brief means of self-affirming. Health Psychology, 30(5), 633–641.Find this resource:

Baumeister, R. F., & Heatherton, T. F. (1996). Self-regulation failure: An overview. Psychological Inquiry, 7(1), 1–15.Find this resource:

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.Find this resource:

Maloney, E. K., Lapinski, M. K., & Witte, K. (2011). Fear appeals and persuasion: A review and update of the extended parallel process model. Social and Personality Psychology Compass, 5(4), 206–219.Find this resource:

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.Find this resource:

Sirois, F. M. (2004). Procrastination and intentions to perform health behaviors: The role of self-efficacy and the consideration of future consequences. Personality and Individual Differences, 37, 115–128.Find this resource:

Sirois, F. M., & Pychyl, T. (2013). Procrastination and the priority of short-term mood regulation: Consequences for future self. Social and Personality Psychology Compass, 7(2), 115–127.Find this resource:

Sirois, F. M., & Pychyl, T. (Eds.). (2016). Procrastination, health, and well-being. Geneva, Switzerland: Elsevier.Find this resource:

Steel, P. (2007). The nature of procrastination: A meta-analytic and theoretical review of quintessential self-regulatory failure. Psychological Bulletin, 133(1), 65–94.Find this resource:

Tice, D. M., Bratslavsky, E., & Baumeister, R. F. (2001). Emotional distress regulation takes precedence over impulse control: If you feel bad, do it! Journal of Personality and Social Psychology, 80(1), 53–67.Find this resource:

Wagner, D. D., & Heatherton, T. F. (2015). Self-regulation and its failure: The seven deadly threats to self-regulation. In M. Mikulincer, P. R. Shaver, E. Borgida, & J. A. Bargh (Eds.), APA handbook of personality and social psychology: Attitudes and social cognition (Vol. 1, pp. 805–842). Washington, DC: American Psychological Association.Find this resource:

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