Abstract
The coronavirus disease 2019 (COVID-19) pandemic provided an existential threat the world has rarely seen and forced Americans to make meaning in a world of uncertainty surrounding what most have taken for granted, being healthy. Reviewing data from several studies collected throughout the COVID-19 pandemic, this article uses COVID-19 as a case study to understand reasoning to follow (or not) the recommendations set forth by government agencies through understanding the effects of longitudinal death salience (i.e., long-term awareness of death). The Terror Management Health Model (TMHM) argues that death is a key component to the condition of human behavior to elongate life. If the TMHM is correct, then Americans should have widely followed government recommendations, but instead violence and a polarized America ensued. Implications for health communication and the TMHM are discussed, providing a path forward for health communication and existential psychology scholars.
The coronavirus disease 2019 (COVID-19) pandemic presented a rare existential threat to humanity. The constant awareness of death over time (i.e., longitudinal mortality salience) provided an inescapable fear of death. Healthy individuals realized for the first time that good health is not guaranteed. And, in an attempt to make meaning out of the unfamiliar, people flocked to social media for community, but were instead met with images and videos of death. This was often accompanied by anger for those not following the guidelines (and anger for those that were) as well as a fear of missing out for those that perceived some as having “better” quarantine experiences (e.g., bigger houses, being alone vs. having roommates, etc.). In fact, social media could be seen as both a help and a hindrance to following governmental guidance, oftentimes igniting fierce interpersonal discussion among social media users regarding prevention practices. Unlike most mortality-inducing experiences, COVID-19 was special. It provided longitudinal mortality salience (i.e., mortality salience over an extended period of time) and mortality salience that is very much still present at the time of this writing, leading to life-long effects that are just now beginning to be understood. While Terror Management Theory (TMT) has long provided guidance on how humans handle the certainty of death (see Rosenblatt et al., 1989 for full review), the Terror Management Health Model (TMHM) was developed to help understand the role death plays in health behaviors (Goldenberg & Arndt, 2008). The TMHM when used to understand the pandemic, can help shed some light on why health-saving behaviors like mask wearing and getting vaccinated were not being followed. Specifically, this paper explores (1) why certain pandemic health prevention strategies were more successful than others, (2) how longitudinal mortality salience affected the abilities of Americans to follow government recommendations, (3) the role of social media in health behaviors and overall mental health, and (4) how the focus of the pandemic in interpersonal communication affected the inability to follow government recommendations.
Terror Management Health Model
The Terror Management Health Model, developed by Goldenberg and Arndt (2008) explains how thoughts of death may influence decisions about one’s health. This model is derived from TMT, which argues how humans manage thoughts of death with the knowledge that death is inevitable (Greenberg et al., 1986). This is accomplished through the realization of belonging to a set of cultural beliefs and then viewing oneself as a valuable piece to that belief system (Arndt & Goldenberg, 2017). Decades of research clearly suggests that humans react to both conscious and unconscious thoughts of death in specific ways; however, when making decisions related to health (e.g., smoking, fitness, cancer screening, tanning, etc.) and when natural reminders of mortality salience are present, the impetus for engaging in such behaviors often hinges on whether the thoughts of death are conscious or not. By applying TMT to decisions about health, two ways of managing death thoughts occur (see Figure 1). First, when thoughts of death are conscious, they mirror the research on fear appeals. So, when efficacy is high for the behavior and it is viewed as effective in reducing the threat, there will be a compliance with a health behavior when the thoughts of death are conscious (Goldenberg & Arndt, 2008). When death thoughts are not conscious, these health behaviors are heavily rooted in the meaning and value in cultural contexts (Goldenberg & Arndt, 2008). The TMHM has been robustly tested with real-world-producing mortality salience events. For instance, unconscious mortality salience reminders increased positive attitudes toward smoking (Hansen et al., 2010). Another example that is somewhat similar to the pandemic is cancer. Cancer naturally makes people think about death (Moser et al., 2014) and like cancer, the pandemic produced a reality where health behaviors were critical to survival (Courtney et al., 2020).
Terror Management Health Model.
However, the pandemic offered a look at health-saving behaviors like wearing masks and getting vaccines, an easy solution to staying safe, and was not chosen by many, suggesting that constant exposure to death may change the original TMHM (see Figure 2).
Terror management health for pandemics.
Courtney et al. (2020) offer a revised model of the TMHM for pandemics. First, when thoughts of death are conscious (i.e., proximal), there is an influx in avoidance behaviors, specifically things like denying susceptibility to COVID-19 and suppressing deadlines to reduce threat. In this phase, people faced with a pandemic are reducing perceived risk by engaging in actual behaviors that reduce actual risk. In this case, Courtney and colleagues (2020) argue that adding guidelines for easily actionable behaviors that mitigate risk may be the ideal route for persuasion. However, cultural factors also can influence behaviors, especially as thoughts of death move to the unconscious (i.e., distal). Second, because of the proximal defenses, death becomes less salient (i.e., through denial or actions like social distancing). As these thoughts of death become more unconscious, the threat is perceived to be reduced. The framing of President Trump’s rhetoric at the beginning of the pandemic can help explain this. Often, he would cite the pandemic as something to not worry about. Therefore, the framing of his messages as not being an important issue further makes the threat of the pandemic to be perceived as not immediate, further lowering the salience of the immediate death thoughts that a pandemic produces. Because distal defenses ignite the need for health behavior decisions to be rooted in meaning and value, this could help explain the polarized responses to government mandates of mask wearing and voluntary vaccines. One concern with government mandates is the perception that freedom of choice is taken away. When freedom of choice is perceived to be eliminated, a reactance effect will take place and the message will not be effective (e.g., Reynolds-Tylus, 2019). For instance, research has shown this to be the case with safe sex, as there was a decrease to engaging in safe sex when people felt their freedoms were being threatened, even when engaging in safe sex could save their life (Bessarabova & Massey, 2020). Reactance has always been a concern when framing advocacy messages, as messages that are too forceful do have the potential to not be effective (e.g., Richards et al., 2021), especially with fear appeals (e.g., Shen, 2015).
Reactance can be defined as an effect that occurs when rules or regulations threaten (or even eliminate in some cases) specific behavioral freedoms; ultimately, a person feels their choices are being limited (Brehm, 1966). However, when considering health prevention measures, choices are often limited in what you can do to save your life. The desire to preserve freedoms naturally undermines the efficacy of health messages (e.g., Richards et al., 2017). This has also been directly linked to actions to adhere to COVID-19 guidelines (DeFranza et al., 2020), something that has also been realized with personal freedom during the pandemic (Chappell, 2020) and with President Trump (Walker, 2020). These reactions were seen throughout the pandemic, but especially when there began to be the defiance of the shelter-in-place mandates to attend church services and choir practices (Aschwanden et al., 2021). Reactance is a concern because of the nature of fear appeals and health.
Fear appeals and health messages tend to go hand in hand, and during the pandemic, it was no different. Typically, when fear appeals are used for health advocacy, these messages tend to be contextual with a strong emphasis on self-efficacy (Kok et al., 2018). Because of the effects from the pandemic, research has urged message designers to not use fear appeals with health messages (Stolow et al., 2020); however, to save lives, many thought fear was the key to successful advocacy during the pandemic.
Advocacy During A Pandemic
The art of persuasion has always been a delicate balance of contexts and relationships, where how one persuades is dependent on the type of relationship of the parties involved and the context in which the persuasion occurs. However, during the pandemic, traditional means of persuasion were not available. As everyone was mandated to stay inside, with many fearful of emerging outside and contracting COVID-19, advocacy strategies had to change. Raeymaeckers and Van Puyvelde (2021) outline both direct and indirect strategies as helpful when advocating during a pandemic. When considering more direct approaches, they argue that it is still important to maintain close relationships and continue to collaborate with policy makers, albeit no longer in person. They go on to argue that it is crucial to maintain constant dialog with local governments by sharing data. For more indirect approaches, Raeymaeckers and Van Puyvelde (2021) argue that using news media, newspapers, social media, and blogs to celebrate people like social and community workers showcase the importance of keeping in contact with their target vulnerable populations. Social media is key in creating awareness (Guo & Saxton, 2014). In fact, when Ebola was present, social media was extremely successful in creating awareness and informing people about interventions (Tully et al., 2019). While there seemed to be best approaches when faced with a deadly disease, there was an infodemic, defined by the World Health Organization as a flood of information, including both false and misleading, during a disease outbreak (WHO, 2022), raging of false information that often led to life-altering consequences.
There was an abundance of false information floating around the internet and social media regarding COVID-19. This information could be seen in conspiracy movies like Pandemic, released during 2020 and more traditional “fake news” reports such as the vaccines contain tracking devices or alter your DNA. Whether it was that wearing masks provided less oxygen saturation or that the vaccines altered your DNA, this information damaged the effectiveness of advocacy messages for preventative behaviors. Social media was key in spreading this misinformation. Scuotto and colleagues (2021) showed that increases in levels of objective knowledge helped to strengthen true memories, whereas it decreased false memories after using social media. However, not all of the information was fully false—some of this information only had pieces that were false and did include some correct information, which proved problematic for correcting the misinformation. Specifically, partially false information is more persuasive and credible than fully false information and more difficult to correct, according to Hameleers et al. (2023). And, negative misinformation is much harder to correct than positive misinformation (Van Huijstee et al., 2022). Fact-checking can play a key role in correcting this information, but it either was not readily available or people had not seen it (Singh et al., 2022). In Singh and colleague’s research, a study surveying 18,400 people from 40 different countries showed a strong association between perceived believability and vaccine hesitancy. What may be even more troubling, however, is that only half of those exposed to misinformation may have seen the fact checks, suggesting that a fair amount of this information is not being corrected for the consumer. Politics played in to the digestion of this information in that those that viewed conservative sources were more likely to endorse COVID-19 misinformation and those that viewed liberal sources were not, suggesting the importance of customizing messages to correct misinformation and increasing self-efficacy for preventative behaviors (Dhawan et al., 2021). In a campus campaign on masking, the strongest predictors of behavior were politics and the actions of others (Dillard et al., 2023), highlighting the importance of political ideas and social norms in advocacy messages advocating for a specific health behavior. Further research suggests that infographics from the World Health Organization to combat misinformation did not affect misperceptions about the prevention of COVID-19, but did lower misperceptions of one singular prevention strategy (Vraga & Bode, 2021), that suggests a potential cognitive overload of information, which could also have impacted advocacy message effectiveness.
Increasing Effectiveness of Advocacy Messaging During A Pandemic
America, as an individualistic society, was always going to have trouble adopting messaging that required Americans to engage in inconveniences for the greater health of society. Individualistic societies are focused on the benefit of the individual, so any messaging that is focused on the benefit of the greater society will not be effective, along with the fact that collectivist cultures are generally more persuadable (Orji, 2016). A look to Australia, another individualistic society, can help shed some light on what happened. When looking specifically at social distancing and willingness to get vaccinated, Lake and colleagues (2021) found that social focus was the key predictor for compliance, even after controlling for concerns for COVID-19 and socio-demographics. Further research suggests that effective COVID-19 messaging not only benefited those in direct contact with the message, but also produced an increase in intention to persuade others to take COVID-19 preventative measures (Bokemper et al., 2021). Lake and colleagues (2021) further argue that framing government messages around preventative behaviors is key for the success of a message. The framing of a message, whether positive or negative, played a key role in the acceptance of pandemic spread preventative messages. Historically, whether a message is framed positively or negatively can make a difference, especially when looking at health messaging. For instance, when considering anti-smoking public service announcements, research has shown that loss-framed appeals tended to work better when increasing intentions for friends to talk to others about quitting smoking (Wong et al., 2013). Loss-framed messages are typically spread more on social media (Sleigh et al., 2021). However, whether or not a loss-framed message was successful during the pandemic depended on whether or not it was primed with high uncertainty. Huang and Liu (2022) found that loss frames were more effective when primed with high uncertainty, but less persuasive under low uncertainty due to reactance. Consequently, they recommend (1) always consider public uncertainty and (2) local agencies may be better for adoption of preventative behaviors when certain beliefs are held or they are less motivated to process campaign messages. In fact, public health messages should be tied to specific public activities (e.g., crowded locations lead to increases in the spread of COVID-19) (Klise et al., 2021). Doctors can further aid in the effectiveness of these messages and combatting vaccine hesitancy by supporting public health campaigns (Sellner et al., 2021). Last, prosocial appeals tend to yield greater compliance if they evoke positive emotional responses (Heffner et al., 2021). While all of these are key to generating effective messages that can save lives, incorporating cultural sensitivity is key (Chan & Litam, 2021), something that would ignite an awareness of one’s cultural worldview, per TMT. There were several common approaches to messaging during the pandemic. Messages included gain and loss framing while emphasizing the importance of personal relationships. For instance, a gain-framed pandemic message would have focused on the amount of lives saved by taking certain precautionary measures, whereas a loss-framed pandemic message would have focused on the amount of lives lost by not taking certain precautionary measures, while emphasizing the lives saved or lost would highlight saving or losing personal relationships. Additionally, virtual advocacy took a key role during the pandemic, focusing on moving campaigns online and using trending hashtags (Bowater, 2020). The other key to pandemic messaging is to humanize it—allowing the public to interact with your campaign and generating conversation around it (Bowater, 2020). A key way to do this is through social media. At the beginning of the pandemic, most people were retweeting preventative messages that came from the media and government officials featuring topics such as staying at home and wearing a mask (Sleigh et al., 2021). Twitter was key in engaging advocates and influencers, consequently making the spread of health risk messaging more effective (Sleigh et al., 2021). And, when fundraising for issues surrounding COVID-19, the number of likes and shares significantly correlated to donations (Rashid et al., 2021). At the end of the day, COVID-19 guidelines and messaging did restrict freedoms by their very nature (Dimoff et al., 2021). However, it was for the greater good, which, as an individualistic society, Americans were never going to agree with. While there are a lot of reasons why advocacy during COVID-19 did not work, the individualistic characteristic of Americans lies at the root of all of the other reasons set forth in this paper.
The Prominent Role of Social Media and Interpersonal Communication
Social media was key to getting valuable health information out to the public during the pandemic and was desperately needed during the pandemic to fill existential needs, but instead it promoted further isolation, negatively affecting self-esteem (Harvell-Bowman et al., 2021). The unregulated nature of the internet did prove to be quite problematic, leading researchers to call on social media platforms to play a larger role in fact-checking and regulation of their content (Samy et al., 2020). The information put forth on social media affects viewers—something research consistently shows over time. However, with pandemic information, these effects became life and death. Headlines and images in news stories on social media affected anger, anxiety, and risk perceptions, showing that graphics and constructive journalism affected users in less than desirable ways during this crisis (Overgaard, 2021). In China, frequent social media use led to an increase in mental health problems, specifically depression and anxiety (Gao et al., 2020). In America, higher social media use led to increased negative perceptions of one’s health (Harvell-Bowman et al., 2022). So, research has called for there to be subtle changes to how the news is presented, which can further help protect the consumer while also allowing him/her to be informed (Overgaard, 2021). Mental health concerns with social media are a growing concern and the long-lasting effects are yet to be determined. However, there are still lessons to be learned, especially as one considers the impact of social media. Su and colleagues (2021) state that there is a way to alleviate mental health issues with COVID-19 social media coverage: (1) Develop evidence-based disaster preparedness plans, (2) Execute the plan with speed and precision, and (3) communicate the plan and procedures effectively to the public in a timely and transparent fashion. They further argue that these messages should have three main objectives: (1) communicate credible and reliable information to the public in a timely and transparent manner, (2) eliminate misinformation and connected infodemic, and (3) make sure communication information does not have unintended consequences. While social media certainly caused negative mental states, it is possible that social media during the pandemic provided a more accurate view of social media, providing more existentially meaningful interactions with social media (Harvell-Bowman et al., 2021), such as a medium for much-needed interpersonal communication. It is common that people seek interpersonal communication to gather information and interpretation while making meaning out of their surroundings, especially in their immediate social network (Wagner & Reifegerste, 2023). Fear at the beginning of the pandemic motivated the use of media and interpersonal communication, but later those things also strengthened the perceptions that their interpersonal conversations emphasized the danger aspect (Li, 2021). Everyday conversations with close attachments exerted social influence on health decisions and behaviors (Cline, 2003; Waeterloos et al., 2021). In fact, conversations about COVID-19 and the media coverage of it with friends, family, and colleagues occurred often (Link et al., 2021). However, the need for information and the need to talk about it tended to fluctuate throughout the pandemic (Betsch et al., 2020; Tang & Zou, 2021). And, counter-arguing within interpersonal relationships helped lower the fear of the pandemic, and proved to be quite a good maladaptive coping strategy to control fear (Li, 2021). During the pandemic, people relied on their informal social networks to gather information (Wagner & Reifegerste, 2023), something that can be referred to as “communication ecologies” (Houston, 2021). This ultimately helped to dispel COVID-19 myths and false information (Melki et al., 2021). In a recent study featuring participants from 27 countries during the pandemic, in-person communication benefited mental health for individuals older than 60 more so than digital communication (Skalacka & Pajestka, 2021). This research also suggests that the older one is, the less helpful digital communication is for mental health. Media use and interpersonal communication, when considering COVID-19 exposure, had effects on stress and depression (First et al., 2020). When looking at advocacy in political messaging, priming political ideology was key to building messages with mortality salience as the main persuasive tool, however only when individuals felt a strong affiliation to their political ideology (Harvell-Bowman et al., 2021). The same thing worked with pandemic messages. If an individual did not feel strongly about the pandemic (i.e., not thinking it was a big deal), then the messages that are designed to have Americans defend that part of their worldview would not be effective, because these individuals do not believe that COVID-19 was a problem. Similar research has argued that pro-life topics can provide an override of ideologies with a desire to survive (Harvell-Bowman et al., 2021). However, the pandemic messaging did not provide that effect, suggesting that the effect of COVID-19 may have impacted how people cognitively processed preventative messaging, but not as expected. There are two major reasons why traditional advocacy strategies did not work during the pandemic. First, the constant levels of mortality salience provided by COVID-19 put people in constant worldview-defending mode, if they felt that COVID-19 was a problem. And, while many may not have viewed the pandemic as problematic in the beginning, as deaths were showcased front and center on social media sites like Facebook including watching livestreams of people within hours of death, it became harder to ignore. So, when messages were displayed to mask up and the importance of getting vaccines, if not for ourselves then for others, the individualistic nature was heightened in Americans. If the preventative action did not directly benefit them, then Americans did not see the point and did not engage in the behavior suggested by the messaging. Second, the government mandates and mandatory lockdowns threatened the worldview of being able to freely move about society. This impacted the effectiveness of the messages. These mandates most likely caused that particular worldview to be threatened, so when the messages were advocating for further things to do, it most likely caused a reactance effect, as several studies have already found to be the case.
Implications for Health Communication and Advocacy
As the world slowly emerges from this pandemic and awaits a new pandemic, the COVID-19 pandemic can provide key insights into how to potentially curb some of the effects generated from preventative health messaging. The TMHM for pandemics suggests specific changes for pandemic messaging (See Figure 3), focusing on priming collectivism (e.g., a focus on engaging in a prevention behavior for the benefit of society versus engaging in the behavior solely for individual benefit) (Courtney et al., 2020). However, priming collectivism may not always be the best strategy. By having messages that provide individuals with actionable behaviors after mandates are in place, this type of message will most certainly cause reactance. However, priming collectivism could work if it triggered an individualistic response. Individuals would be doing the preventative measure for themselves, but it would also benefit society as a secondary effect, an ideal way of priming one’s worldview during pandemics.
Proposed changes to COVID-19 messaging.
When death is either explicitly mentioned or subtly, priming a relevant aspect of someone’s worldview, and building the message around that is key. This could be collectivism as the TMHM for pandemics suggests, or something else. In fact, the Ernest Becker Foundation (Ernest Becker Foundation, 2022) recently published an advocacy guide that can help provide some guidance for mitigating reactance. First, make your audience an in-group. For pandemics, this could translate to showing how the preventative behavior is part of someone’s core beliefs. Second, instill a sense of common humanity in your messaging. This is where the priming for collectivism that TMHM for pandemics discusses. By priming collectivism, people can feel good about their actions. Third, provide worldview-consistent and credible action steps. Efficacy is key to this step, by ensuring that this action can be accomplished, something that research in health communication has consistently argued for several decades (e.g., Li & Huang, 2020; Maloney et al., 2011; Witte, 1992). Fourth, try the “funnel approach” when messaging—start discussions at a distance while utilizing research and communication experts. Last, ending on a hopeful note will help bring positivity to the message. As the TMHM for pandemics suggests in one of the revised messages for the Centers for Disease Control and Prevention, “we can all slow the spread together.” The Ernest Becker Foundation has provided a great guide for advocacy and when combined with the TMHM for pandemics, health communication and advocacy researchers have a great foundation to build from whenever the next pandemic arrives.
Conclusions
When Americans were first forced into lockdown, something many had never experienced, they felt existentially isolated. Americans, and the world, were in unfamiliar territory and struggled to find meaning when death seemed so certain for all of us. Social media provided the itch for interpersonal connection and discussion to make meaning out of this experience. However, while social media could have provided an existential outlet for Americans and those around the world, it turned into a space for jealousy of quarantine experiences, shaming of those not following the suggested, and sometimes required, preventative measures, as well as a constant reminder of death through first-hand accounts of those actively dying. For existential psychology scholars, these situations provide interesting insight into how those around the world struggled to find meaning and how social media, usually providing great meaning for individuals through interpersonal connection, did the opposite and potentially aided in additional existential worrying.
The pandemic has clearly changed the way we view the world, and advocacy is no different. Many who advocated for preventative measures were met with defiance of those measures, with some even turning violent. Traditional means of persuasion in health communication were not effective. The constant and never-ending mortality salience threat and health danger that the pandemic caused forced message developers and advocates to not only change the way messages were delivered, but change how the messages were developed. The pandemic has changed the way we advocate. The knowledge gained from advocacy of health during the pandemic will provide health communication and advocacy scholars new insight into creative and novel ways to persuade when faced with health situations with extreme awareness of mortality for years to come.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
