APPENDIX C: Literature Review

Converting Ineffective Behaviors Motivated by Unconscious Psychological Defense Mechanisms into Consciously Determined Effective Coping Behaviors

The National Highway Traffic Safety Administration contracted with The Media Network, Inc. (TMN) to conduct this review of research on the topic of converting ineffective behaviors motivated by unconscious psychological defense mechanisms (e.g., denial, repression, and rationalization) into consciously determined effective coping behaviors.¹ NHTSA’s interest is in the context of safety belt use in automobiles. While many people now routinely wear safety belts, some do so only in the presence of enforcement efforts, and others use safety belts only when driving long distances, in bad weather, or in unfamiliar areas. NHTSA researchers have hypothesized that these part-time wearers use defense mechanisms (e.g., repression, denial, rationalization) or fatalistic beliefs (e.g., “when it’s my time to go, I’ll go”) to avoid conscious consideration of the true consequences of non-belt use. NHTSA’s hope is that this literature review, in combination with an expert panel meeting NHTSA is sponsoring, can assist in the development of innovative approaches to overcoming the interference of such unconscious motivations, thus leading to an increase in the adoption of appropriate coping behaviors in response to real safety threats.

In addition to safety belt usage, the question of how unconscious motivators may interfere with the adoption of appropriate coping behaviors has broad implications for a variety of other safety threats. For example:

• Why do people at risk for HIV/AIDS fail to take protective behaviors (i.e., wearing condoms) even when they know that condoms reduce their risk of becoming infected?
  
  
• Why do industrial workers fail to wear protective hearing devices even though they know that excessive noise can lead to hearing loss and that protective devices reduce that risk?
  
  
• Why do sunbathers fail to wear protective sun block even though they know that use of such sun block reduces their risk of acquiring skin cancer?

Numerous such examples could be provided on a variety of topics related to health, environmental, safety, and other societal issues. In such situations, the mere provision of correct “knowledge” is often inadequate to persuade the target population to adopt the correct coping response. In other words, knowing that a protective coping response exists is not sufficient to motivate the target population to take corrective action. Simply put, people do not always do what is “good for them,” despite knowing that their behaviors put them at increased risk for adverse outcomes. This suggests that unconscious barriers may be a significant reason coping behaviors are not adopted.

This project will identify and discuss the unconscious reasons for such seemingly irrational behaviors. In other words, what are the psychological defense mechanisms (e.g., denial, repression, and rationalization) that trigger these ineffective coping responses? More importantly, how can these unconscious reactions be overcome, thus leading to the adoption of effective coping strategies?

This literature review briefly examines seven areas of research related to this topic, followed by a conclusion section. These topics are:

1. Models of behavior change, with an emphasis on the role of unconscious thought in motivating behavior change;
   
   
2. The formation of risk perceptions in response to safety threats;
   
   
3. Precursors to message resistance;
   
   
4. How threat messages are resisted;
   
   
5. How to convert defensive reactions to coping reactions;
   
   
6. Case studies where ineffective coping responses have been converted to effective coping responses; and,
   
   
7. A summary of existing research on part-time users of safety belts, as a specific population to which the above research may be applied.

This review, as noted, is designed to serve as background material for a panel discussion with experts in risk communication, risk perception, social marketing, cognitive psychology, and psychodynamic psychology. There are two main purposes of this expert discussion: (1) to discuss how to convert ineffective behaviors motivated by unconscious psychological defense mechanisms into consciously determined effective coping behaviors, and (2) to generate ideas for NHTSA on how such ineffective coping mechanisms can be overcome in the specific case of safety belt usage.

Research Process:
To begin this review, relevant articles, case studies, and book chapters were identified. Two Ph.D. candidate graduate students hired by TMN to assist in this project conducted the literature search. The graduate students conducted a search for relevant articles, chapters, and other information, using the following criteria:

• Any theoretical or clinical literature on anxiety, risk perception, and fatalism in response to safety threats;
  
  
• Any theoretical or clinical literature on converting defensive mechanisms to coping reactions, particularly in response to risks;
  
  
• Any theoretical or clinical literature on adopting appropriate coping actions to ameliorate the consequences of risky events;
  
  
• Any theoretical or clinical literature that addresses the key question: How do you change defensive behaviors to coping mechanisms and apply them to the world of safety belt usage? Ideally, case studies of successful campaigns at a societal level were desired; or,
  
  
• Any theoretical or clinical literature that addresses the key question: How does behavior change happen for unconscious behaviors? Ideally, case studies of successful campaigns at a societal level were desired.

The graduate students searched for articles in various academic databases (e.g., ProQuest, PsychArticles, Sociology Abstracts, and Medline), as well as in specific academic journals (e.g., Risk Analysis and Cognitive Psychology). Additionally, relevant literature was identified through personal communication with experts in this field, and through Internet searches for relevant information. In total, 162 citations were identified for this review. Each citation was indexed and summarized in an EndNotes database, and complete copies of each article were provided to TMN. The TMN Project Director prepared this review. A subcontractor from Low + Associates served as a reviewer.

Of these 162 citations, only about 60 were found to be relevant to this review, and, thus, are discussed here. Even among these relevant citations, however, there was little specific research on unconscious defense mechanisms as these mechanisms pertain to mass social change. Altering unconscious motivations has historically occurred in a therapeutic setting via extensive personal intervention, and appears not to have been attempted frequently, if at all, in a mass setting such as that required by NHTSA for any eventual campaign. This presents both a challenge and an opportunity for NHTSA and the expert panel, as overcoming unconscious barriers to persuasion at a societal level appears to be somewhat unprecedented.

Theoretical Models Related to Behavior Change:
This project and this review, ultimately, concern behavior change. Thus, this review begins by briefly describing several theoretical models of behavior change, with an emphasis on what these models have to say about the role of unconscious thought in motivating such change. In particular, what do various behavior change theories have to say about how to convert unconsciously motivated behaviors to rationally controlled behaviors? Please note: this review does not discuss theories that primarily assume behaviors are consciously governed (e.g., the Theory of Reasoned Action).

• Psychoanalytic Model: To begin, it is worthwhile to discuss Freud’s ideas about the unconscious and behavior change. Freud divided the configuration of the mind into conscious, preconscious, and unconscious thought, with almost all mind space (75-80%) devoted to the unconscious (Neill, 2005). This makes the unconscious vitally important in cognition. Indeed, Freud saw most behaviors as being governed by unconscious thought: to wit, “we are governed by hidden mental processes of which we are unaware and over which we have no control” (Internet Encyclopedia of Philosophy, 2005). In Freud’s model, unconscious thought is crucial to controlling behaviors. However, and most importantly, unconscious thought cannot be accessed voluntarily, but only through the techniques of psychoanalysis.

APPLICATION: If Freud’s thinking is correct, it is “bad news” for a project such as this one because Freud’s theory suggests that only through a lengthy psychotherapy process can unconscious thought be revealed, understood, and changed. Thus, it would be nearly impossible to address or change unconscious thought for a mass audience. Freud’s thinking, does, however, support the notion that unconscious thought may be a significant barrier to the adoption of appropriate reactions to safety threats. Specifically, this model emphasizes that people may resist appropriate coping responses for reasons they are not consciously aware of, which makes changing such behaviors more difficult.

• Stages of Change or Transtheoretical Models: The idea behind these models is that information related to behavior change will only be received and acted upon when message recipients are at the appropriate stage in terms of message readiness. The initial stage in this theory is pre-contemplation, where change is not being contemplated and/or is seen as unnecessary; fear, denial, and/or resignation are often present at this stage. The next stage is contemplation, where benefits and costs are considered. This is followed by the stages of preparation (small steps) and action (initiating the change). Even once the change has occurred, maintenance is required to prevent relapse.

APPLICATION: These theories temporally position unconscious barriers as occurring during the first stage (pre-contemplation). Merely addressing such barriers does not lead to behavior change; however, successfully addressing such barriers is seen as a prerequisite to the next stage: contemplation. Of interest here, this theory suggests that pre-contemplation is where unconscious barriers are most prevalent. The goal during pre-contemplation is to motivate thought about change (attempting persuasion before such barriers are addressed is thought to induce resistance). Zimmerman, Olsen, and Bosworth (2000) suggest motivational interviewing as one technique to use at this pre-contemplation stage. Such interviews should indicate empathy, and utilize thought-provoking questions (e.g., “What would have to happen for you to know that this is a problem?” or “What would have to happen for you to change this behavior?”). Again, the goal is not to directly induce the behavior change, but merely to increase readiness to change when action messages are encountered at the contemplation stage.

• Threat/Efficacy Models (e.g., Extended Parallel Process Model or Protection Motivation Theory): These models assume that responses to threats are based on a dual assessment of (1) risk/threat, and, (2) efficacy/ability to cope. The theories suggest that behavioral responses are based on the joint product of these two assessments. Inappropriate coping mechanisms are most likely to occur when threat appraisals are high but coping ability is low. In such situations, fear control, defense avoidance, or denial reactions are likely to occur.

APPLICATION: Unconscious barriers to change are most likely to occur, according to these theories, when threat appraisals are high and efficacy is low. Thus, the way to overcome these faulty strategies is to increase coping by increasing response efficacy (i.e., how effective treatment is) and/or decreasing barriers to coping (e.g., cost) (Neuwirth, Dunwoody, and Griffin, 2000).

• Mental Models Decision Framework Theory: This theory combines mental models research (looking at the topic-specific knowledge held by individuals) with expectancy value models (looking at how cognitive inputs combine to lead to decisions) (Hine, Summers, Tilleczek, and Lewko, 1997). In other words, when confronted with a behavioral decision, the theory assumes that people construct a mental model of the situation, and then “run” this model to produce likely outcomes. These likely outcomes influence behavioral choices.

APPLICATION: This theory assumes a relatively conscious decision making process, but this process occurs only after unconscious thought influences the production of a mental model. Therefore, it is in the construction of the mental model that unconscious thoughts can lead to biases, and, in turn, ineffective coping responses. To decrease the influence of these “incorrect” unconscious thoughts (e.g., thoughts that assign incorrect probabilities to risks), the theory says that communicators need to target information gaps in mental models.

Discussion:
Existing behavioral change models shed some light on this problem, but do not provide a great deal of insight into how to overcome unconscious barriers to change. At best, existing theories acknowledge that unconscious barriers exist, and that such barriers manifest themselves in the symptoms of denial, fear, repression, or avoidance. However, only limited guidance is provided by these theories on how to replace inappropriate coping responses driven by unconscious thought with consciously considered coping responses. Freud suggests that psychotherapy is the answer. Stages of change models suggest that such unconscious barriers should be addressed as the first stage to change, i.e., communicators should focus on getting people to recognize the existence of such barriers in a non-threatening and thought-provoking way. Threat/efficacy models suggest that inappropriate coping responses are most likely to occur when people feel threatened and unable to deal with the threat. Thus, the models emphasize enhancing efficacy as a solution to changing behaviors. Finally, mental models decision framework theory suggests that the role unconscious thought plays is in influencing projections of likely outcomes in response to risk events. Thus, unconscious thought may manifest itself in the form of a threat denial, which then leads the person to access the risk level as low and thus project that no action is necessary to cope with the threat.

Risk Perceptions:
This section of the review identifies factors that may make safety threats seem less hazardous. Such factors are important because insufficient risk perceptions are related to an inadequate behavioral response, and because inadequate risk perceptions may be formed unconsciously. While a sufficient risk perception does not guarantee a protective response, such perceptions are prerequisite to adopting appropriate coping behaviors (Gordon, 2003). Thus, a tenet of effective risk communication is that messages need to first establish that a significant threat exists, and then that protective actions can be taken to reduce this risk (McMahan and Meyer, 1997). This section identifies factors that may interfere with the formation of such risk perceptions. The discussion begins with a brief review of how people are thought to understand risks.

How Risks are Understood:
Recent research suggests that risk information is processed in two distinct manners. The first is analytical, and involves a conscious effort to balance benefits and costs. The second is more emotion-centered, and relies on affect and feelings (Slovic, Finucane, Peters, and MacGregor, 2004). This second way of processing information is more closely related to the unconscious influencers being discussed in this review. Affective responses are more common, occur quickly, and associate “goodness” or “badness” with stimuli (Slovic et al., 2004). Thus, “affective reactions may serve as orienting mechanisms” enabling quick decision-making (Slovic et al., 2004). The existence of these two systems is one of the primary reasons that human decision-making in response to safety threats is less-than-ideal from a purely analytic perspective (e.g., analytic reasoning would suggest that the appropriate coping behavior is to always wear a safety belt, but affect may suggest that such use is only sometimes appropriate). It is worth noting that such use of affect in reasoning is not, as sometimes suggested, irrational. Affect serves many purposes in reasoning, and without such orienting mechanisms the cognitive burden of constant decision-making would be overwhelming. However, there are times when it would be more appropriate to use analytic reasoning and not affect-based reasoning. For example, affect may interfere with judgments of sexually transmitted disease risk, as more attractive partners are seen as less risky (Blanton and Gerrard, 1997). This literature review, ultimately, discusses how to encourage analytical reasoning in situations when the use of affect may interfere with the adoption of appropriate behavioral responses.

Individual Level Characteristics and Perceptions of Risks:
There are several personality traits and other individual-level characteristics that are known to influence how people perceive risks. For example, some people appear to be more risk seeking than others, e.g., smokers have been found to be more likely to engage in all sorts of risky behaviors, including not wearing safety belts, not monitoring blood pressure, and not flossing (Hersch and Viscusi, 1998). This is perhaps because individual-level differences in characteristics such as sensation-seeking and tolerance of ambiguity affect risk and benefit perceptions (Weber, Blais, and Betz, 2002). Another individual level characteristic that may influence how people perceive risks is anxiety. Anxious people are more likely to perceive risks than non-anxious people, and also encode a higher level of threat when encountering risk information (Ruiz-Caballero and Bermudez, 1997). Over-confidence is another such trait. For example, in a study of how people respond to hazards, Lindell and Whitney (2000) found that overconfident people may adopt fewer coping reactions because they see themselves as more skillful at avoiding danger than other people.

Controllability of Risk:
Risk perceptions are downgraded when the risk is seen as uncontrollable. For example, a meta-analysis of how people respond to the threat of earthquakes showed that people living in an earthquake prone area tended to de-personalize and minimize the threat (Lindell and Perry, 2000). Likewise, workers may downplay workplace risks to justify their decision to work in a hazardous environment; unfortunately, this ignoring of threats is further manifested in unsafe workforce behaviors, such as a failure to use safety equipment (Akerlof and Dickens, 1982).

Attractiveness/Social Acceptability of the Risk:
Risk perceptions are also dependent on behavioral motivations – that is, if a behavior is highly desirable, the behavior may be perceived as less risky (Blanton and Gerrard, 1997). This is partly because most individuals do not want to consciously see themselves as knowingly and willingly engaging in risky behaviors (Blanton and Gerrard, 1997). Additionally, part of how people respond to risks is based on social modeling. For example, both friendly and unfriendly role models have been shown to influence how people respond to threats (DeTurck, Chih, and Hsu, 1999). Risks can also be understood socially, i.e., via shared understandings/dialogues. For example, an ethnography of cigar smokers found that when new information about the health threats of cigar smoking are raised, cigar smokers’ discourse with one another works to discredit and discount the threat (DeSantis, 2003). Finally, peer influence is an important factor in many risk behaviors, e.g., whether adolescents smoke (Hafstad, Aaro, and Langmark, 1996). In general then, the more attractive, common, or socially acceptable a risk is, the less threatening it is perceived to be.

Personal Threat of Risk:
There is evidence to suggest that people are biased towards seeing themselves as less susceptible to risks than others (Kunda, 1987). People generate self-serving theories, using their own life events to position themselves as less vulnerable to risks than other groups: “Such self-serving theory generation is possible because people have great facility in generating causal theories linking any attribute to just about any outcome, and they have no way of determining the correctness of their theories” (Kunda, 1987). Individuals can easily generate theories that suggest that, while others might be at risk, they personally are not. This may especially be true when their personal risk level is high. For example, sex workers and their clients downgraded and denied the personal risk of HIV infection, despite knowing about the risks of HIV and how it is contracted (Varga, 2001). In other words, they knew that HIV was dangerous, they knew that multiple sexual partners increased the risk of HIV in general, yet they all could identify specific features of their lives that allowed them to view themselves as not at risk. Interestingly, personal relevance has the positive benefit of increasing attention to risk messages; thus, messages that are highly personally threatening are more effective in gaining attention but also seem to trigger additional defense mechanisms (Witte and Allen, 2000).

Risk Fatigue:
A final factor that inappropriately reduces risk perceptions is a sense that some level of risk is unavoidable. That is, understanding of risk information is often tempered by a belief that “everything is risky” (Walter and Britten, 2002). This belief is manifested in several ways. Information may be explicitly rejected, such as when cigar smokers say “all of life is a health risk, so there’s no point worrying about something as insignificant as cigars” (DeSantis, 2003). It may be manifested in the form of general skepticism about heeding risk claims. This is especially likely when experts have lost their authority to convey risk messages because of a prior failure to fully disclose risk information or if expert opinion has changed (Frewer et al., 2002). Finally, risk fatigue may contribute to a tendency to simply ignore information about risks (Witte, Stokols, Ituarte, and Schneider, 1993), thus never allowing risk perceptions to form.

Summary:
It is necessary for people to perceive a risk before they can individually and voluntarily adopt an appropriate coping behavior to deal with safety threats. Risk perceptions are based not only on analytical reasoning (which is how most risk assessors characterize risks), but also on affective responses to risks, which may be unconscious. Affect is a necessary component in understanding risk, but affective responses to risks can lead to inappropriate coping behaviors. Other factors may mitigate the formation of appropriate risk perceptions. For example, certain individuals may be more accepting of a wide variety of risks. Additionally, risks are seen as less risky when people see themselves as having no choice in accepting the risk (e.g., as a function of their work) or no control over the risk. Furthermore, risks are socially understood, and more likely to be seen as acceptable if they are accepted within a peer group or if role models are seen ignoring a risk. In addition, there is evidence that all people are cognitively biased towards processing risk information in a way that suggests that they personally are not at risk. In other words, downgrading and depersonalization of risk information appears to be an automatic response. Finally, there is evidence of societal risk fatigue. All these factors work together to interfere with the formation of sufficient risk perceptions in the face of safety threats, and some of these factors may operate at an unconscious level.

Precursors to Message Resistance:
One reason people fail to adopt appropriate coping responses in response to a safety threat, as discussed in the previous section, is a failure to perceive the threat. Another reason appropriate coping responses may not be enacted is because of resistance to persuasive messages. Resistance is “a motivated state in which the goal is to withstand the effects of a persuasive communication … resistance is not necessarily the same thing as not being persuaded” (Jacks and O'Brien, 2004). Resistance can be conscious or unconscious. There are many reasons why persuasive communications may be resisted. This section discusses some of these reasons.

Loss of Freedom:
One reason people resist persuasive messages is because complying requires compliance. Complying with a request entails a “loss of freedom,” and people are motivated to maintain their freedom of choice (Worchel and Brehm, 1971). Thus, a significant barrier to persuasion is the simple fact that people tend to resist being told what to do if they feel as though they are being coerced. Note, however, that people are open to instruction (i.e., persuasion) in a less threatening context, e.g., a classroom setting with a well-regarded teacher. Thus, loss of freedom only sometimes causes resistance. A challenge for researchers is to determine why loss of freedom (and other factors identified in this section) only sometimes evokes resistance.

Readiness to Discuss Risk:
Stages of change theories suggest that messages may also be resisted if the target audience is not yet ready to hear them. For example, a physician trying to encourage a patient to stop smoking may repeatedly provide information on cancer hazards. Such information is likely to be resisted if the patient is not yet ready to consider a change (Zimmerman et al., 2000). These theories suggest that all such persuasive messages will be resisted if the target audience is not yet ready to hear them.

Personal Threat-Level of Message:
Messages that are personally threatening are also more likely to be resisted; e.g., personal relevance has long been linked with increased defensiveness regarding health messages (Sherman, Nelson, and Steele, 2000). One study found that subjects threatened by a health message (e.g., who engaged in the behavior described as threatening) were critical of the threatening portions of a message but less critical of the nonthreatening portions (Liberman and Chaiken, 1992). This type of resistance is especially likely to occur (as noted by threat/efficacy models, see page 34) when personal threat is high and perceived efficacy is low. Likewise, Witte and Allen (2000) found that stronger fear appeals result in stronger defensive reactions, especially when the message does not provide coping information. As noted in the previous section, however, personal threat is positively related to attention to risk messages.

Efficacy of Coping Response and Self-Efficacy:
Messages are more likely to be resisted if the behavior being promoted is seen as nonattainable. If the behavior being promoted is difficult to achieve (e.g., because of cost or inconvenience) it is more likely to be rejected. Likewise, if the target audience is low in self-efficacy related to the desired behavior the message is likely to be rejected. For example, in a study of readiness to receive a Hepatitis B vaccination, self-efficacy was linked to both behavioral readiness and message receptiveness (Rhodes, Grimley, and Hergenrather, 2003). In the same way, messages are likely to be resisted if people see themselves as unable to change. One study of sexual behavior among men at risk for HIV found many subjects reporting that their behaviors were fixed or habitual and unlikely to change, even though the men knew they were at risk (Guest et al., 2005).

Fatalism and Denial:
Fear and fatalism are known to cause resistance to risk messages. For example, African Americans may be less likely to be screened for cancer because of fear-based resistance (Beeker, Kraft, Goldman, and Jorgensen, 2001). In another example, sex workers (i.e., prostitutes) did not want to get tested for HIV because they would rather not know they had the disease than confront the consequences. The same women cited fatalism as a reason for not using condoms (Varga, 2001). Fatalistic responses are especially likely when a risk is seen as uncontrollable. For example, an ethnographic study of how a working-class community rejected a cancer prevention message suggested that cancer evokes a fatalistic response because it is seen as uncontrollable (Balshem, 1991).

Summary:
There are many reasons why persuasive messages may be resisted. Complying with a persuasive message involves a loss of freedom, which is a negative drive state. Messages are also likely to be resisted if the target audience is not yet at a stage to consider a behavior change. Message resistance is common when the behavior being targeted is personally relevant, especially when the target audience feels the behavior change is unattainable or that the skills required to complete the change are unavailable. Fear and fatalism also can cause resistance to messages.

How Messages are Resisted:
The previous section identified precursors to message resistance. This section discusses some of the ways in which messages are resisted. Again, resistance can be conscious or unconscious. Resistance can take many forms, or even multiple forms: resistance may be shown in cognitive, affective, or behavioral responses. Indeed, “individuals have a number of resistance strategies at their disposal, and, when motivation to resist is high, they will engage in a variety of these strategies in their efforts to resist change” (Jacks and O'Brien, 2004).

Biased Processing:
One of the primary ways resistance can occur is via biased cognitive processing of risk messages. Such biases are typically unconscious. The hallmark of this processing is that individuals strategically use information to support their desired outcome, e.g., through selective attention to supporting information or by giving more weight to supportive evidence while discounting evidence that is non-supportive (Blanton and Gerrard, 1997). This may be referred to as defensive processing, because people process information to be consistent with preferred outcomes (Brown, 2001). A specific form of such biased processing is repression. Repression involves decreased attention to negative stimuli and reduced emotional attention in particular. Messages that induce strongly negative emotions may be especially likely to trigger repression (Brown, 2001). Note that defensive processing of information involves significant cognitive effort. Research has found that people have a remarkable, innovative, and extensive capability to generate and combine arguments with other information “in support of the desired position” (Lundgren and Prislin, 1998). The extensiveness of this processing is one reason that people are unaware that they are using biased thinking; they equate effortful thought with balanced thought.

Generation of Self-Serving Causal Theories:
Another way in which message resistance can occur is through the generation of self-serving causal theories, i.e., “people tend to generate and evaluate causal theories in a self-serving manner; they spontaneously generate theories that view their own attributes as more predictive of desirable outcomes and are reluctant to believe theories that imply that their own attributes might be related to undesirable events … these self-serving tendencies seem to be explained best as resulting from cognitive processes guided by motivational ends” (Kunda, 1987). Such biased processing is magnified when the information being discounted is personally threatening or otherwise relevant. To wit, “personal relevance can amplify biased message processing” (Liberman and Chaiken, 1992). The generation of self-serving causal theories appears to be automatic and unconscious.

Reactance:
Reactance involves a negative reaction to messages that are seen as threatening behavioral freedom (that is, messages which are seen as overly limiting individuals’ choices pertaining to their behaviors). For example, messages with an aggressive or controversial tone may trigger reactance. Reactance appears to be more common in social groups that are engaging in unsafe behaviors, which suggests that it can be socially reinforced (Brown, 2001).

Reconstruction of Risks as Non-Hazardous and the Use of Exemplars:
Another method of resistance is by constructing arguments, either individually or collectively, which discount the threat or discredit the advocated behavior. Such arguments frequently include exemplars (i.e., single cases where the hazard turned out to be overstated or where the advocated behavior was not protective), as well as references to the unpredictability of life and to the inconsistencies of science. For example, one study found that regular cigar smokers justified their risk-taking by developing a core set of beliefs that allowed them to resist persuasive messages about the health hazards of smoking. These arguments included: (1) all things are safe in moderation; (2) cigars are not cigarettes, which are indeed harmful; (3) research on cigar smoking is flawed (this perception is heightened when reversals of medical opinion regarding what is “safe” occur); and, (4) life is dangerous anyway, with or without cigar smoking. Thus, anxiety over the potential dangers of smoking was alleviated for these cigar smokers by a new, shared interpretation of risks that discounted threat information (DeSantis, 2003). In another example, an ethnographic study of how a working-class community rejected a cancer prevention message found that community members cited exemplars (e.g., the long-living person who smoked, the healthy-eating person who died young) to reject the message (Balshem, 1991). Such arguments are another form of biased cognitive processing, because such arguments are examined one at a time, and rarely examined collectively for consistencies (DeSantis, 2003). Finally, downward comparisons allow risks to be reconstructed as non-hazardous. In downward comparisons, people downgrade their personal risk by comparing themselves to someone or something perceived to be at even greater risk (e.g., the cigarette to cigar comparison cited above). Individuals or groups at especially high risk may be particularly vulnerable to this type of bias (Brown, 2001).

Locus of Control:
Another way to resist persuasive messages is to re-direct responsibility from oneself to another. That is, message recipients may assign responsibility for controlling the risk elsewhere, thus removing the burden of an appropriate response. For example, people may assign responsibility for protection from natural disasters to the government, thus removing the burden to prepare by stocking emergency supplies, etc. (Lindell and Whitney, 2000). In another example, clients of sex workers avoided personal responsibility by assigning the responsibility to take protective actions to the sex-workers (Varga, 2001).

Occasional Use as Protective:
Finally, one study suggested that the occasional use of advocated protections may lead to a false sense of security. In other words, the occasional exercise of protective behaviors may induce risk complacency. For example, sex workers believed that the occasional use of protection (e.g., sometimes using condoms) was sufficient to reduce their overall risk of acquiring HIV (Varga, 2001). Significantly, this assumption was based on sex workers’ beliefs that they were able to correctly discern which clients posed a hazard and which did not. In other words, if people believe they can correctly predict when protective behaviors are needed, occasional compliance may be seen as sufficient.

Summary:
Persuasive arguments may be resisted in a variety of ways, and a large number of these resistance strategies happen at an unconscious level. Humans appear to be remarkably adept at resisting potentially threatening arguments via biased cognitive processing. For example, people selectively attend to information that supports their preferred viewpoints, are more critical of evidence that does not support their preferred viewpoints, and use exemplars and fatalism to reject message content. Messages are also resisted by assigning the responsibility for protective action elsewhere, or by collectively rationalizing risk information into a new, and less-threatening, format. Finally, messages appear to be resisted by partial or occasional compliance. In other words, people see themselves as protected if they occasionally adopt the prescribed behavior. It is worth noting that in many of these strategies, message resistance is unconscious, and is facilitated by automatic cognitive abilities to construct self-supporting arguments.

Converting Defensive Reactions to Coping Reactions:
The key goal of this project is to discuss how unconscious defensive reactions to safety threats can be converted into consciously adopted coping behaviors. This section of the report discusses various ways to increase risk perceptions, avert precursors to resistance, or otherwise overcome resistance. Each strategy has been shown to be successful in at least one circumstance. However, strategies for overcoming resistance must be carefully tailored to the target audience, issue, and type of resistance to be most successful. Thus, these strategies are offered as possibilities. The use of any strategy should be tailored to the unique situation being considered.

Promoting Consciousness or Mindfulness:
Because much resistance happens at an unconscious level, one key strategy to help overcome resistance is to increase consciousness or mindfulness. This has the effect of shifting risk processing from affective to analytical, which, as noted, has the desirable effect of making such perceptions more consistent with the assessments of risk made by experts. Additionally, increased consciousness makes people more aware of defensive processing, thus reducing the influence of such processing on decision-making. Indeed, increased consciousness in message processing (e.g., making specific plans in response to a message) has been shown to lead to greater adoption of positive behavioral changes (Michie and Abraham, 2004).

There are several ways to motivate increased conscious processing of messages. Louis and Sutton (1991) suggested that conditions to motivate people to switch from automatic to conscious thought include: (1) unusual or novel situations; (2) discrepancies or unexpected failures; and, (3) deliberate initiative (Louis and Sutton, 1991). Parrott (1995) offered the following suggestions to increased consciousness: (1) present information in unusual, unfamiliar, or novel ways (e.g., unexpected media or unusual or unexpected wording in printed material); (2) present information that is discrepant or unexpected (e.g., “we know you hate to wear your seatbelt”); (3) make explicit external requests for attention (e.g., “stop what you’re doing and listen to this message”); and, (4) prompt internal requests for attention by providing linguistic cues for such attention (i.e., verbal immediacy, denotative specificity, spatial and temporal immediacy, and excluding unnecessary qualifiers). An additional way to promote conscious processing and reduce biased processing is to specifically draw attention to the processes that maintain the bias (Brown, 2001). Finally, the use of special language features such as tropes (an advertising feature that deviates from consumer expectations through the use of nonliteral words, e.g., “our design is so good, other carmakers are going into the copier business”) may increase conscious processing (Toncar and Munch, 2001). Tropes may also decrease message resistance as claims in tropes are less likely to be challenged (Toncar and Munch, 2001).

Increasing Self-Efficacy:
Self-efficacy has frequently been identified as essential to helping people adopt appropriate coping responses. Thus, increasing self-efficacy, either at the level of individual target audience members (e.g., by promoting feelings of competence), or within the message itself (e.g., by providing information on how to engage in the behavior), is one strategy to help overcome resistance. Witte and Allen (2000) conducted a quantitative meta-analysis of all available literature exploring the persuasive impact of fear-inducing messages, including the efficacy components of such messages. They found that increased levels of fear, severity, susceptibility, self-efficacy, and response-efficacy in messages all resulted in greater “positive levels of attitude, intentions, and behavior change.” These relationships are generally linear, i.e., messages that generate more self-efficacy are generally more effective. Thus, there is strong empirical support that increasing the level of self-efficacy in messages leads to more behavioral change.

One way to increase self-efficacy at the individual level is to encourage social support. Social support has been linked to an improved ability to deal with health risks (Bandura, 2004). Another way to increase self-efficacy is to increase the amount of coping information in risk messages. One study on breast cancer found that women who read messages with high coping information responded with less fatalism than women who read a message with less coping information (Prentice-Dunn, Floyd, and Flournoy, 2001). In general, any message feature that reduces barriers to compliance or provides support to the individual can increase efficacy.

Increasing Social Desirability of Compliance:
Another strategy to overcome resistance is to highlight the social undesirability of failing to respond to risk messages. This is because people may be more likely to comply with a desired behavior to maintain social acceptability than for reasons of self-protection. For example, one study showed that greater attitude change may result from cues pertaining to social disapproval than from cues related to social approval or neutral cues, especially when the message comes from a highly credible source (Powell and Miller, 1967). Additionally, a study of the effect of advertisements on teen smoking found that messages indicating that smoking increased the likelihood of social disapproval (e.g., bad breath) were more successful than advertisements focused on the health risks of smoking (Hafstad et al., 1996). Thus, indicating that non-compliance is likely to meet with social disapproval may be one strategy to overcome resistance, as it appeals to a desire (which may be unconscious) to please others. Influential peers may also be successful conveyors of such messages.

Creating Specific, Targeted, Communications:
Messages are most effective when they are carefully crafted for their target audience. For example, one study found that women were less persuaded by male-gendered language, while men were more persuaded by such language (Falk and Mills, 1996). Thus, the use of specific, targeted, communications may reduce barriers to resistance. One way in which messages should be carefully crafted pertains to matching speaker credibility and language use. Language expectancy theory says that messages are more credible when positive violations of expectancies occur: that is, when high credible sources deliver novel messages, or when less credible sources more closely perform to norms than expected (Buller et al., 2000). Additionally, language intensity needs to be matched to message explicitness for the most success. To wit, “highly intense language works best when conclusions and recommendations are offered explicitly to recipients” because definitive conclusions may avoid confusion, while “inductive messages generally work best with low language intensity” (Buller et al., 2000).

Disrupting and Reframing/Restoring Freedom:
Another technique to overcome resistance is to disrupt-then-reframe messages. This technique is designed to interfere with the resistance that occurs because of loss of freedom (i.e., the resistance that can be expected to follow any request). In this technique, a subtle disruption (e.g., an unusual appeal) takes the focus off of avoidance, and, when followed by an attractive reframe, results in greater compliance (Davis and Knowles, 1999). For example, Davis and Knowles attempted to sell cards at a price of 300 pennies (the disruption), which is “only $3” (the reframe). Additionally, if freedom can be restored after a request is made, people become more likely to comply with the request. In one study, decisional freedom was lost when an experimenter declared that one choice was clearly superior, and then restored when another said his mind was not yet made up (Worchel and Brehm, 1971). The result of this combination was greater support for the “obvious” choice.

Utilizing Self-affirmations:
Self-affirmations (e.g., positive messages about the self) may be one way to overcome message resistance. For example, affirming people’s honesty has been shown to increase acceptance of a message about affirmative action (Jacks and O'Brien, 2004). This is because “self-affirmations apparently have the power to attenuate the personal threat one feels at being confronted with a counter-attitudinal message” (Jacks and O'Brien, 2004). For example, in two studies, self-affirmations increased the acceptance of potentially threatening health information (Sherman et al., 2000). Proponents of this method caution, however, that affirmations should not be incompatible with the topic of the persuasive message, because then such affirmations can promote resistance (Jacks and O'Brien, 2004).

Encouraging Anticipatory Regret:
Yet another technique to overcome resistance is future contemplation, and, in particular, anticipatory regret. Future contemplation involves asking people to think about the future under various scenarios (e.g., engaging versus not engaging in certain behaviors). Anticipatory regret specifically asks people to imagine the regret they might feel if they do or do not do certain activities. The idea behind this is that “engaging in prefactual thinking and anticipating future regret for various choices and outcomes would affect decision strategies because people would be motivated to reduce the likelihood of future regret” (Sherman, Crawford, and McConnell, 2004). Thus, “simply asking people, prior to their behavioral choice, to anticipate the regret that they might feel in the future for complying with versus reacting against the persuasive attempt appears to be one way to overcome resistance and increase compliance” (Sherman et al., 2004).

Evoking Hypothetical Compliance:
Another strategy to overcome resistance is to ask people to anticipate whether they would engage in a behavior prior to making the actual behavioral request. Research shows that people are more likely to say they hypothetically would carry out a behavior (e.g., volunteer time) than they are to actually perform the behavior when asked. However, asking people to predict first what they would do and then following this with a request later on dramatically increases compliance (Sherman et al., 2004). The likely explanation for this is that hypothetically agreeing to do something is relatively non-threatening and allows people to maintain freedom of choice; subsequently, having stated that they would do something, the actual request may evoke more compliance because of the motivation to maintain consistency.

Alpha and Omega Approaches:
One set of authors described strategies to overcome resistance as either alpha or omega strategies (Knowles and Linn, 2004). Alpha strategies focus on increasing approach forces; e.g., making messages more persuasive, adding incentives, increasing source credibility, providing social confirmation of the importance of the message, emphasizing scarcity, invoking reciprocity, and emphasizing consistency and commitment. Omega strategies, which are more relevant to this review, focus on decreasing avoidance forces. Omega strategies include:

• Sidestepping resistance: e.g., redefining relationships (be a consultant, not a persuader), depersonalizing the interaction (people should, not you should), minimizing the request (foot-in-the-door techniques), raising the comparison (refuse a large request to make the actual request seem smaller), and pushing the choice into the future (e.g., buy now, pay later);
  
  
• Addressing resistance directly: e.g., offering a guarantee or offering counterarguments;
  
  
• Addressing resistance indirectly: e.g., raising self-esteem (offer compliments) or focusing resistance (train people to spot scams);
  
  
• Distracting resistance: i.e., providing distractions reduces counter-arguing;
  
  
• Disrupting resistance: i.e., confusion makes people less able to resist;
  
  
• Consuming resistance: i.e., intentionally give people several requests to deny, followed later on by the actual request; and,
  
  
• Using resistance to promote change: e.g., using reverse psychology, using paradoxical interventions, acknowledging resistance, and choosing between alternatives.

Recognizing the Role of Habit:
Finally, it is important to consider that modifying habitual behaviors may require unique approaches. Habitual behaviors are defined as “everyday activities [that] are repeatedly performed to the point where their performance becomes automatically controlled … intentions may play no role in performance” (Garling, 1992). For such behaviors, change is complicated because of the stronger-than-average disconnect between behavioral intentions and actual behaviors. Therefore, changing habitual behaviors is frequently more difficult than changing non-habitual behaviors. To wit: “A change of habit is tantamount to an investment in a superior decision strategy, and it follows that individuals will not always find it advantageous to change their habits in the face of small change in the decision environment” (Lindbladh and Lyttkens, 2002). Changing habits requires a great deal of energy which many people are not willing to expend. This is especially true for those lower in socio-economic status (who are more likely to rely on habit and also to associate habit with preferences) (Lindbladh and Lyttkens, 2002).

Habits are more likely to be changed when some interruption to routine behavior occurs which allows for the opportunity to reflect on habits (Lindbladh and Lyttkens, 2002). Thus, creating a disruption in routine behaviors is one way to promote the change of habits. Additionally, once habits have been changed, an on-going sense of risk may be needed to maintain changes. For example, an HIV vaccine study found that men who thought they had not received the vaccine (and thus were at continued risk) reduced their sexual risk behavior in the long term. However, men who thought they had received the vaccine reverted to their baseline level of risk behaviors (Guest et al., 2005). Thus, habits are difficult to change, and habit change requires maintenance to prevent relapse.

Discussion:
Several strategies were offered here to overcome resistance to persuasive messages. One strategy is to increase consciousness or mindfulness in the processing of messages. Yet another is to increase efficacy in response to safety threats. This review also suggested that increasing the social desirability of compliance, creating targeted communications, disrupting resistance, restoring freedom, utilizing self-affirmations, encouraging anticipatory regret, evoking hypothetical compliance, and decreasing avoidance forces may successfully reduce barriers to persuasion. Finally, this section noted that there may be special requirements related to changing habitual behaviors.

Case Studies:
An important part of this review was to locate successful case studies where unconscious reactions leading to ineffective behaviors were effectively converted into conscious decisions to adopt effective coping strategies. While the project team found a few examples of such cases (described in more detail below), a limitation on these findings is that most involved a single complex intervention involving numerous components, with a single analysis to discuss whether the intervention as a whole was successful. Thus, as noted in Michie and Abraham (2004), it is “difficult to identify particular intervention techniques” that are responsible for any one campaign’s success. Because of this, Michie and Abraham called for more specific testing of theory-based behavior-change interventions, with well-designed evaluation plans a key component of eventual campaigns.

With this limitation noted, here are several examples of successful campaigns as well as some speculation on likely factors that contributed to their success. Note: none of the campaigns specifically included a discussion of unconscious barriers or of overcoming such barriers. However, these are campaigns where it is reasonable to assume such unconscious barriers might be present.

Sexual Risk Behaviors and HIV:
In this case, an experimental intervention was designed on the idea that motivation, in addition to information and behavioral skills, is required for the adoption of protective health behaviors (Carey et al., 1997). The specific intervention was designed to promote a reduction in risk behaviors associated with the contraction of HIV among low-income women, one of the groups most at risk for new infection. Women were recruited for participation through fliers, and all attended a screening session. Only women at an elevated risk for HIV were enrolled. The intervention consisted of four one-hour, small-group sessions with a trained facilitator/counselor. During these sessions, the counselor strove to express empathy, develop discrepancy between HIV knowledge and risk behaviors, avoid argumentation or confrontation, roll with resistance (i.e., offering new perspectives and reinforcing accurate perceptions), and support self-efficacy. During sessions, women viewed a tape presenting HIV information, discussed their concerns and possible ways to address these concerns, discussed the pros and cons of behavior change, developed action plans to reduce the risk of infection, and role-played effective communication strategies. There was a main effect for intervention both immediately afterward and at a two-month follow-up on HIV-related knowledge (intervention group knew more), risk perception (intervention group perceived themselves to be at greater risk), behavioral intentions (intervention group intended to engage in fewer risk behaviors), and some sexual risk behaviors (intervention group engaged in less substance use before sex and less unprotected vaginal intercourse).

LIKELY FACTORS CONTRIBUTING TO SUCCESS: The authors argued that the success of this campaign was attributable to, among other things, the fact that the women in the intervention developed their own plans to reduce risk and that they actively participated in the determination that risk behaviors had more potential cons than pros. Limiting its usefulness, however, was the extensiveness of the intervention. It would be very hard to specify why the intervention worked, or to replicate such an intervention on a mass scale.

Fruit and Vegetable Consumption:
In this case, an experimental intervention was designed to explore the impact of different types of counseling on the consumption of fruit and vegetables by low-SES individuals (Steptoe, Perkins-Porras, Rink, Hilton, and Cappuccio, 2004). Participants were recruited from a doctor’s patient list. The intervention consisted of two sessions of one-on-one counseling with a research nurse in a clinical setting. Half of the participants received behavioral counseling, which included personalized, specific advice, short-term and long-term goal setting, and the provision of information about barriers to change and strategies for overcoming those barriers. The other half of participants received nutrition counseling, which focused on information about the nutrient contents of vegetables and fruits and their functions within the body, stressing that health benefits would accrue for those who eat more fruits and vegetables. At 8 weeks and 12 months, follow-up was conducted in which participants reported their fruit and vegetable consumption. This measure was verified through measurement of key minerals and vitamins in participants’ bloodstream. In addition, measures of self-efficacy, anticipated regret, perceived barriers to and benefits of greater fruit and vegetable consumption, and encouragement by others was measured. While fruit and vegetable consumption improved in both groups, the behavioral counseling group experienced a stronger, larger, more durable increase. This may have been, in part, due to differences in self-efficacy, perceived barriers, and knowledge between the two groups. There were no differences in motivation between the groups. Social support predicted change in both groups.

LIKELY FACTORS CONTRIBUTING TO SUCCESS: As in the previous example, this was an extensive intervention utilizing many of the same techniques advocated in this review. Unfortunately, the extensiveness of the intervention limits its usefulness in terms of replicating the results. It is not clear which of the many interventions explain the behavior change. It is informative, however, that providing guidance which was individualized and behavior-oriented was more persuasive than providing information alone, although both were successful. Individual attention from a reputable source (medical professional) may have been a key factor, and the focus on behavior was likely also important. Finally, it is noteworthy that social support was found to be predictive, suggesting the importance of interpersonal communication pertaining to the target behavior.

Promoting Safety Belt Use: Bank Intervention:
In this study, safety belt usage was conceived of as a simple decision made repeatedly (Booth-Butterfield, 2003). Thus, this intervention tried to strategically place signs or other reminders to serve as direct cues to encourage the behavior at the point of decision-making. In other words, the hypothesis was that reminding people to buckle up at the point where they make this decision should positively increase the occurrence of this behavior. A bank drive-through was selected as the point of intervention. Small signs from the “Click It or Ticket” campaign were placed to encourage drivers to buckle-up. No other intervention occurred; there was no comparison site. During the course of the campaign, belt usage increased from 52 percent to 60.5 percent.

LIKELY FACTORS CONTRIBUTING TO SUCCESS: Unlike the previous two examples, this study involved only a single intervention. Thus, it appears that simply reminding people to wear their safety belts at a point where they might logically put them on was successful in increasing this behavior. What is unknown, however, is what effect the punishment nature of the reminder (the implication of a ticket for nonuse) had on the outcome. In other words, would a less threatening reminder have been more or less successful?

Promoting Safety Belt Use: Trauma Center:
Employees at a trauma center were encouraged to wear safety belts via an e-mail campaign, posters, pledge cards, a survey, and fact sheets (Scheltema, Brost, Skager, and Roberts, 2002). Observations were then made to compare staff wearing of safety belts (intervention) versus that of visitors (control) both pre- and post-intervention. Immediately after the intervention, employees showed a significant gain in belt usage, but this increase was not maintained at the one- and three-month follow-ups. No changes were noted in visitor behavior. Employees had high knowledge of the benefits safety belts provide, but “discomfort, forgetfulness, and short driving distance” were cited as key reasons for non-use.

LIKELY FACTORS CONTRIBUTING TO SUCCESS: This final example showed only limited success (i.e., it only temporarily increased the target behavior), but it is included because it targeted the same behavior under investigation here. This campaign suggests that frequent reminders and cajoling can increase belt usage, but that the behavior may revert to baseline levels in the absence of reminders. Thus, such campaigns appear unlikely to have the desired effect of creating permanent behavior change. The likely reason for this is that the campaign was unable to address the real reasons for non-belt usage. As hypothesized by NHTSA, such factors may include unconscious barriers and other motivators. It is noteworthy, however, in both this and the preceding example, that short-term change pertaining to belt usage can be induced via a campaign of this nature.

Part-time Safety Belt Users:
Finally, this report briefly discusses what is known about part-time users of safety belts. Understanding the nature of the occasional user is key, because much of this review stresses the importance of tailoring interventions to audiences. Knowledge about the target audience enables messages to be more culturally informed, and culturally informed messages are more likely to change attitudes and beliefs. Peterson, Witte, et. al (1994) nicely sum up this point: “The potential value of any campaign is jeopardized if it disregards basic world views of its target audience. Understanding audience beliefs is especially salient for a campaign that attempts to motivate voluntary changes in audience behaviors.”

NHTSA and its partners have conducted prior quantitative and qualitative research on this topic. In this report, brief results from three previous NHTSA-sponsored studies are summarized [two qualitative research studies (utilizing focus groups) and one quantitative study (a national probability sample telephone study)]. Two key findings from these reports appear below, and more detailed findings follow.

• People do not think much about risk while driving. However, certain driving situations are perceived as riskier than others (e.g., driving faster or observing other drivers make reckless decisions), and safety belt usage does appear to increase in situations that are perceived as relatively riskier. Therefore, reminding people of these situations may increase belt usage.
  
  
• Safety belts are seen as effective by almost all audiences; that is, most people believe that a safety belt reduces their risk of harm in a crash. Thus, if crashes were predictable, most people would choose to have a safety belt on at the time of a crash. However, there is a group of people who express the belief that safety belts are as likely to harm them as help them, or that they are better off in a crash not wearing a safety belt. Such people are likely to be more difficult to reach with any campaign, and the existence of this portion of the population complicates risk communication on this topic.

Risk Perceptions:
The studies reported the following findings pertaining to risk perceptions:

• Drivers reported that they don’t think of risk issues much while driving, especially when in a familiar setting (Bradbard et al., 1998);
  
  
• Reasons cited for nonuse of safety belts included: taking short trips, making frequent stops, good weather, distractions which prevent belts from being worn, wearing nice clothing, low-speed driving, discomfort associated with belt wearing, shortage of time, the perception that driving is safe, and being a passenger (Bradbard et al., 1998);
  
  
• Young men said they don’t wear belts because: they forget, belts aren’t comfortable, they see them as unneeded (especially in familiar settings), and belts are not always perceived as helping (Bradbard, Panlener, and Lisboa-Farrow, 1996);
  
  
• 95 percent of the public age 16 and older would want a safety belt on if they were in a crash; but a third agreed that belts are as likely to harm you as help you (Boyle and Vanderwolf, 2004);
  
  
• Only 31 percent of people who report wearing belts all the time thought safety belts are as likely to harm as help you, while 72 percent of rare/never users held this belief (Boyle and Vanderwolf, 2004);
  
  
• Drivers reported being aware of situations (exemplars) where people survived crashes by not wearing belts (Bradbard et al., 1998);
  
  
• Fatalistic beliefs on belt usage were held more strongly by those who did not wear belts; Blacks and Hispanics were especially likely to hold these attitudes (Boyle and Vanderwolf, 2004);
  
  
• Frequent belt users were more likely to report injury avoidance as a reason for wearing a belt (Boyle and Vanderwolf, 2004); and,
  
  
• People who never wear a belt are more likely to report that putting one on makes them think about getting in an accident (Boyle and Vanderwolf, 2004).

Risk Behaviors:
The studies reported the following findings pertaining to risk behaviors:

• Reported belt usage was higher for passengers in the front seat than in the back seat (Boyle and Vanderwolf, 2004);
  
  
• Social pressure is a motivator for occasional wearers of safety belts (Boyle and Vanderwolf, 2004);
  
  
• 67 percent of rare/never users cited discomfort as a reason not to wear a belt, and 43 percent disliked being told what to do (Boyle and Vanderwolf, 2004);
  
  
• 33 percent of drivers reported there was something they disliked about safety belts; annoyance was lowest (31%) among all the time users and highest (49%) among rare/never users (Boyle and Vanderwolf, 2004);
  
  
• 97 percent of frequent users, and 82 percent of occasional users would want a safety belt on in a crash, but only 52 percent of rare/never users would (Boyle and Vanderwolf, 2004);
  
  
• Younger generations reported safety belts are a habit from childhood, while older generations did not (Boyle and Vanderwolf, 2004);
  
  
• Inclement weather, unfamiliar roads, young passengers, and observing dangerous driving behaviors all stimulated safety belt use (Bradbard et al., 1998);
  
  
• Shifting locus of control away from self to others may stimulate belt wearing (Bradbard et al., 1998); and,
  
  
• Young males need information that clearly specifies the consequences of not wearing a safety belt (Bradbard et al., 1996).

Conclusion:
In conclusion, this literature review represents an initial attempt to identify the role of unconscious barriers in interfering with the adoption of appropriate behaviors in response to safety threats. Such barriers include fear and fatalism as well as various defensive cognitive processing strategies. This review suggests that such unconscious defense mechanisms are extremely common in response to persuasive messages that are personally threatening. It appears that humans are remarkably adept at resisting or ignoring messages that are threatening, and at reinterpreting threat messages in such a manner as to make them nonthreatening.

Existing behavioral change models do not provide a great deal of insight into how to overcome such unconscious barriers to change. Partly, this is because there are many reasons why persuasive messages are resisted. Message resistance appears to be especially common when the behavior being targeted is highly threatening and personally relevant, and when the target audience believes behavior change is unattainable. Persuasive arguments may be resisted in a variety of ways, and a large number of these resistance strategies happen at an unconscious level (e.g., via defensive processing). For example, people selectively attend to information that supports their preferred viewpoints. Several strategies were described to overcome such resistance. These included increased consciousness or mindfulness in the processing of messages, disrupting resistance, restoring freedom, encouraging anticipatory regret, and decreasing avoidance forces.

An additional goal of this review was to identify large-scale campaigns where such unconscious behaviors were successfully changed at the societal level. Despite an extensive search for relevant cases, there did not appear to be many examples where such techniques were successfully applied at a mass level. Instead, it appears that most work at overcoming unconscious barriers has happened in the context of psychotherapy. This suggests that interventions that deal with the unconscious may be prohibitively expensive to apply on a mass scale; however, this question requires further exploration.

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¹“Ineffective” refers to a failure to adopt a proven coping behavior (e.g., failure to wear a safety belt), while “effective” refers to the consistent adoption of proven interventions. While there may be instances where a failure to adopt an “effective” behavior leads to a better outcome (e.g., if a crash victim is thrown clear of a crash scene), such outcomes are statistically rare and will be ignored for the purposes of this discussion.