health: An Interdisciplinary Journal
for the Social Study of Health,
Illness and Medicine
Copyright © 2009 SAGE Publications
(Los Angeles, London, New Delhi,
Singapore and Washington DC)
DOI: 10.1177/1363459308336793
Vol 13(5): 000 –000
Effects of exposure to the
suffering of unknown persons
on health-related cognitions,
and the role of mood
Evangelos C. Karademas
University of Crete, Greece
a b s t r a c t The purpose of the present study was to examine whether
exposure to the suffering of unknown persons, as an inevitable part of life,
influences cognitions about health. Our assumption was that exposure to suffering affects cognitions in a negative way, as well as this influence being exerted
directly and through negative mood. Eighty-nine participants were randomly
assigned to two groups. The experimental group was exposed to a series of
photos presenting situations of human suffering, whereas the control group
was exposed to a series of photos showing relaxing situations. Participants in
the experimental group reported higher health anxiety and health value, and
lower internal health locus of control, in comparison to the control group. No
differences were found in self-rated health. Exposure to suffering affected
cognitions directly and through decrease in positive mood. It seems that an
‘in vitro’ exposure to human suffering activates a cognitive and emotional
reaction, which affects evaluations about self and personal well-being.
keywords
health cognitions; human suffering; mood
a d d r e s s Evangelos C. Karademas, Department of Psychology, University
of Crete, 74100, Gallos, Rethymnon, Greece. [Tel. +30 28310 77532; fax: +30
28310 77578; e-mail: [email protected]]
Introduction
Health cognitions, such as health locus of control or health value, are associated with health-related behaviors, health status and well-being (e.g.
Pennebaker and Watson, 1988; Benyamini and Idler, 1999), and they form
a central topic in health psychology theories (see, for example, Martin and
Leventhal, 2004). Health cognitions are determined by a series of factors:
demographic variables; personality; the social environment; personal
experiences; emotions and so on (Smith and Ruiz, 2004). One such factor is
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exposure to suffering. There is research suggesting that personal suffering,
as a result of major personal difficulties or exposure to traumatic events, is
negatively related to health and health cognitions (Brewin et al., 2000;
Miller, 2005). Also, the exposure to the suffering of close persons (such
as the experience of living with an ill person) is negatively associated with
health cognitions (Benyamini et al., 2003). However, a question arises: is
also exposure to the suffering of unknown others associated with beliefs
about personal health? The purpose of the present, explorative in nature,
study is to examine whether exposure to suffering of unknown persons influ
ences certain health cognitions. The examination of this relationship will
help us understand the association between exposure to human affliction,
as an inevitable part of life, and health cognitions, as important aspects of
well-being.
Human suffering and well-being
Almost every philosophical or spiritual endeavor constitutes a significant
effort to come to terms with human suffering (Miller, 2005). Human suffering involves the horrible problems and life experiences that can provoke
pain, great distress and considerable difficulties (Miller, 2005; Honkasalo,
2006). Therefore, suffering has been used as a synonym for pain, loss and
grief. Arthur Kleinman (1988) defined suffering as an inter-subjective experience of affliction, resulting from either major dramatic events or everyday
life. Suffering takes place in relation to threats towards important things
in life, such as health and well-being, close relationships, personal worth
and ability to function (Kleinman, 1999). Suffering is also closely related to
the experience of morality, both in the sense of doing something wrong
(e.g. intentional harm to others), and in the sense of feelings of compassion
towards sufferers (Miller, 2005).
Personal suffering and exposure to the suffering of other people may
shake personal worldviews (e.g. beliefs to a just or predictable world; JanoffBulman, 1992), and modify beliefs and perceptions about self (KoltkoRivera, 2004), through many possible pathways. For example, suffering
resulting from a disaster could act as a reminder or even a verification of uncertainty and fragility of life, thus, affecting emotion and thoughts (e.g.
Greco and Roger, 2003). Exposure to suffering could also act as a reminder
of an ‘unfair treatment’, a feeling negatively related to health and related
beliefs (Guyll et al., 2001), or as a threat to self-concept (Crocker et al.,
1998). In addition, reactions to others’ suffering could be explained in
part through empathic engagement (Figley, 1995). Empathy is a process
that leads to several emotional and cognitive reactions (Davis, 1983), and
it is stronger when the person is confronted with the vulnerability of the
sufferers (Regehr et al., 2002). Overall, exposure to suffering appears
to precipitate a crisis of personal and social meaning (Wilkinson, 2006),
while it also seems to affect personal perceptions about self and the world
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Karademas: Effects of Exposure to the Suffering of Unknown Persons
(Kleinman, 1988). Besides these, however, there is evidence suggesting that
exposure to the suffering of others results in significant amounts of negative
emotions (Kleinman, 1999).
Exposure to the suffering of other people, emotions and
health cognitions
Lang et al. (2000) recently presented a series of findings according to which
aversive sensory, representational input (such as pictures or sounds) can
directly activate emotional networks in the brain. These emotional networks mediate a broad range of physiological and behavioral events, such
as evaluative judgments, heart rate, cortical-related events and so on. In
other words, exposure to stimuli of danger or harm, even if brief or of low
clarity, can provoke a ‘startle’ reaction, which involves negative emotions
and thoughts. However, since people use their emotional state as a source of
information about their current condition (Schwarz and Clore, 1996), then
emotion might be another pathway through which exposure to suffering
leads to changes in perceptions.
According to many correlational studies, positive emotions are related
to more positive evaluations about current and future personal health,
whereas negative emotions are related to more negative evaluations and
overestimation of vulnerability (see Mayne, 2001, for a review). Additionally, three experimental studies (Croyle and Uretzky, 1987; Salovey
and Birnbaum, 1989; Abele and Hermer, 1993) have examined the issue.
In general, they showed that the induction of a negative mood was related
to more negative health-related appraisals and greater discomfort. On the
other hand, Gendolla et al. (2005), in a combination of correlational and
experimental studies, found that negative mood promotes symptoms experience only when combined with self-focus, whereas Barger et al. (2007)
found no relation between induced mood and global self-rated health or
reported symptoms.
The present study
Despite the importance of human suffering regarding the ways people perceive the world and self, no study to our knowledge has ever examined the
impact of exposure to suffering of unknown persons on cognitions about
personal health. The present study aims in examining this relationship.
The nature of this study is explorative. However, based on the abovementioned studies, we assume that exposure to the suffering of distant
people affects health-related thoughts (i.e. health anxiety, health value,
health locus of control and self-rated health). We also assume that this
influence is exerted both directly and through negative mood. In order to
test our assumptions, we performed an experimental design, in which two
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groups of participants were exposed to a series of either suffering-related
stimuli (experimental group) or relaxing stimuli (control group).
Method
Participants
Participants were 89 healthy undergraduate students (57 females and 32
males; all were white, Caucasian, coming from families of middle socioeconomic status; mean age = 21.34 years, SD = 3.21). They were randomly
assigned to two groups, the first of which was exposed to images (photos)
of human suffering, whereas the second was exposed to relaxing images.
Students were recruited through announcements in class and participated voluntarily.
Suffering-related and relaxing images
A series of 25 photos were presented to each group. The experimental group
was exposed to photos of natural and manmade disasters, ruin and grief.
These photos were derived from a larger pool of 80 photos downloaded
from the official websites of major broadcasting networks. This initial pool
of photos was displayed to a small group of three post-graduate students,
who were asked to rate the degree to which each image was ‘representative
of human suffering, that is situations which provoke great pain and distress
to those involved’. They used a scale ranging from 1 (not representative at
all) to 10 (extremely representative). The 25 images with the higher mean
rating were included in the experiment. Using the same procedure, from an
equal initial pool of photos presenting relaxing situations, the 25 with the
highest mean rating were included in the experiment. The set of sufferingrelated images consisted of five photos showing accidents or explosions
(e.g. a car accident with victims), five photos of war acts (e.g. wounded
persons), four photos of natural disasters (e.g. a demolished house), four
photos of human misery (e.g. malnourishment), three photos of people
grieving, two photos of terrorism acts, as well as two photos of violenceinvolving situations (e.g. a violent confrontation between demonstrators
and the police). The set of relaxing images consisted of six photos showing
friends in several activities (e.g. playing music; in a bar), five photos of
parents with their kids or kids alone, four photos of calming down activities
(e.g. swimming), four photos of beautiful scenery, two photos of couples in
relaxing activities (e.g. walking by the beach), two photos of people playing
with animals, as well as two photos of sportive activities (e.g. playing
football).
Measures
Health anxiety Health anxiety was assessed with the relevant scale from
the Multidimensional Health Questionnaire (Snell and Johnson, 1997).
The scale consists of five items (e.g. I feel anxious when I think about my
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health; Cronbach α = .83). Participants responded on a five-point Likert
type scale ranging from 1 (‘not at all characteristic of me’) to 5 (‘very characteristic of me’).
Health value The Health Value Scale (Lau et al., 1986) was used to assess
the value attached to health. It is a four-item scale (e.g. There is nothing more
important than good health; Cronbach α = .65). Participants responded
using a seven-point Likert type scale ranging from 1 (‘strongly agree’) to 7
(‘strongly disagree’).
Health locus of control Health locus of control was measured with the
Multidimensional Health Locus of Control Scale (Wallston et al., 1978).
The scale consists of 18 items and provides measures of three dimensions of
health locus of control: internal (six items, e.g. I am in control of my health;
Cronbach α = .74), chance (six items, e.g. My good health is largely a matter
of good fortune; Cronbach α = .75) and powerful other (six items, e.g.
Health professionals control my health; Cronbach α = .61). Participants
responded on a six-point Likert type scale ranging from 1 (‘strongly
disagree’) to 6 (‘strongly agree’).
Self-rated health Participants were asked to rate their current physical
health status using a scale ranging from 1 (worst possible health) to 100
(best possible health).
Positive and negative mood Mood was assessed with the Positive and
Negative Affectivity Schedule (PANAS; Watson et al., 1988), which consists of 10 adjectives describing negative mood (e.g. distressed, ashamed;
Cronbach α = .90) and 10 adjectives describing positive mood (e.g.
interested, inspired; Cronbach α = .86). Participants responded on a fivepoint Likert type scale ranging from 1 (‘very slightly or not at all’) to 6
(‘extremely’).
Procedure
The experiment was ‘advertised’ in class as involving reactions to certain
visual stimuli. At the day of the experiment ninety-three (93) students
showed up and were administered a set of questionnaires (i.e. health value,
health anxiety, health locus of control, self-rated health, current mood).
They were instructed to complete the questionnaires having in mind their
thoughts and feelings at that particular moment. They were also asked
about their current and recent health status. Four students who reported a
recent or current health problem were excluded from the procedure. Thus,
89 participants were randomly assigned to the experimental or the control group. Participants were seated in a quiet square room, at separate
desks behind a data projector that projected against the wall. Desks were
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separated with dividers so that participants could not interact with each
other. The distance between the desks and the projection point was about
3.5 meters. When seated, participants were instructed to make themselves
comfortable, relax and stay quiet with their eyes shut for about two minutes.
After that period, the presentation commenced. Each photo was projected
for 10 seconds. Participants in both groups were instructed to carefully
watch and reflect on the projected photos. No other instruction was provided. At the end of the presentation, participants were asked to complete
the same set of questionnaires, having in mind their thoughts and feelings
at that particular moment. After that, all participants received information
about the nature, the purpose and the procedures of the study to exclude
the possibility of a longer negative impact of the procedure (especially,
of the exposure to the suffering-related images). It should be noted that
the study was conducted in accordance with the ethical standards adopted
by the European Federation of Psychologists’ Association (available at
http://www.efpa.be/ethics.php).
Results
Preliminary results
A one-way multivariate analysis of variance (MANOVA) across all variables assessed before the experiment with group as the independent
variable was performed. No significant differences were observed (Wilks
λ = .89; F(8, 80) = 1.30, p > .05). The means and standard deviations of all
variables, before and after the experiment, are presented in Table 1.
Also, in order to identify possible gender differences, we performed
another MANOVA with gender as the independent variable. No significant
Table 1 Means and standard deviations of the health cognitions and mood before and after
the experiment
Experimental group
Control group
Before
Before
After
After
Self-rated health
85.04 (8.10)
85.82 (8.17)
86.73 (8.28)
86.75 (8.99)
Health anxiety
13.22 (2.41)
15.13 (3.47)
14.11 (4.04)
13.04 (4.22)
Health value
21.67 (3.18)
22.76 (3.49)
20.29 (3.53)
19.63 (4.31)
HLoC – Internal
23.76 (3.99)
21.18 (2.79)
24.98 (3.83)
25.66 (3.34)
HLoC – Chance
17.51 (4.86)
17.56 (5.51)
17.41 (3.18)
17.27 (3.66)
HLoC – Significant other
19.44 (4.12)
20.33 (3.90)
19.68 (3.89)
19.91 (4.52)
Positive mood
28.98 (6.03)
24.40 (6.26)
27.25 (5.26)
30.95 (5.19)
Negative mood
20.89 (4.28)
24.62 (7.83)
20.20 (3.14)
18.11 (7.23)
Note: HLoC = Health locus of control. Standard deviations are presented in parentheses.
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gender differences were found (Wilks λ = .94; F(8, 80) = .67, p > .05). Thus,
all subsequent analyses were pooled over gender.
Impact of exposure to suffering on health cognitions and mood
In order to test our assumptions, the mean differences due to the experiment manipulations were examined. Results indicated that those exposed
to images of suffering reported more negative mood (t (87) = 4.07, p < .01,
effect size r = .40 (Rosnow and Rosenthal, 1998)), whereas those exposed
to relaxing stimuli reported more positive mood (t (87) = 5.37, p < .01, effect
size r = .50). Participants exposed to images of suffering also reported higher
anxiety (t (87) = 2.55, p < .05, effect size r = .26), higher value attached to
health (t (87) = 3.70, p < .01, effect size r = .37) and lower internal health
locus of control (t (87) = 6.87, p < .01, effect size r = .59). There were no differences regarding the other two dimensions of locus of control, chance
(t (87) = .28, p > .05, effect size r = .03) and significant other (t (87) = .47,
p > .05, effect size r = .05). Also, no significant differences were found in
self-rated health ratings (t (87) = .51, p > .05, effect size r = .05).
Paired t-tests were used to test the mean differences within groups
before and after exposure to images. Participants in the experimental group
reported higher health anxiety (t (44) = 4.37, p < .01, effect size r = .55),
higher health value (t (44) = 2.86, p < .01, effect size r = .40), but lower
internal health locus of control (t (44) = 3.49, p < .01, effect size r = .47) after
the experiment (see Figures 1–3). They also reported lower positive
mood (t (44) = 3.67, p < .01, effect size r = .48) and higher negative mood
(t (44) = 2.73, p < .01, effect size r = .38). On the other hand, participants
exposed to relaxing images reported lower health anxiety (t (43) = 2.07,
p < .05, effect size r = .30), and higher positive mood (t (43) = 2.96, p < .01,
effect size r =.40). No other significant differences were found.
Figures 1–3 Health anxiety, health value and internal locus of control before and after the
experiment
Note: HLoC = Health locus of control.
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Table 2 Descriptive statistics and intercorrelations of group, health cognitions and mood
Variable
1
1. Group
1.00
2. Self-rated health
2
3
4
.05
1.00
3. Health anxiety
–.26*
–.17
4. Health value
–.37**
.03
.14
1.00
.49**
–.04
–.11
5. HLoC – Internal
5
–.15
1.00
–.03
.04
.29**
.08
–.01
7. HLoC – Other
–.05
–.03
.28**
.33**
.44**
.02
9. Negative mood
–.35**
–.10
Mean
1.49
SD
.50
–.31** –.11
.22*
86.28 14.10
8.55
7
8
9
1.00
6. HLoC – Chance
8. Positive mood
6
3.98
.19
.42**
1.00
.05
1.00
–.10
.01
1.00
.12
–.18
.15
–.07
21.17
23.39
17.42
20.12
27.64
–.24*
21.40
1.00
4.13
3.80
4.67
4.20
6.61
8.18
Note: HLoC = Health locus of control. SD = Standard deviation. Group coding:
1 = experimental, 2 = control.
*p < .05; **p < .01.
Direct and indirect influence of exposure to suffering on health
cognitions
The intercorrelations of all variables included in the study are presented
in Table 2. With respect to mood, significant correlations were identified
between positive mood and the group (Pearson r = .44, p < .01), health
anxiety (Pearson r = –.31, p < .01) and internal locus of control (Pearson
r = .42, p < .01). There was also a significant negative correlation between
negative mood and the group (Pearson r = –.35, p < .01), as well as a significant positive correlation between negative emotion and health anxiety
(Pearson r = .22, p < .05).
Our second assumption was tested through the application of Structural
Equation Modeling employing LISREL 8.54 (Joreskog and Sorbom, 1993).
Only those health cognitions with significant mean differences between the
exposure and the control groups were included in the analysis. According
to the model tested, group was assumed to predict positive and negative
mood, health anxiety, health value and internal locus of control, whereas
health anxiety, value and locus of control were also assumed to be predicted by both positive and negative mood. The model provided a fit to
the data. The chi-square was not significant (χ2(4) = 1.96, p = .74), while
statistical indices were indicative of a very good fit (AGFI = .96, NFI = .98,
CFI = 1.00, RMSEA = 0.0). Figure 4 displays the standardized estimates
of the model. Non-significant estimates are not presented. Results showed
that group predicted both negative and positive mood. Group directly predicted health value and internal locus of control, in a positive and a negative
way, respectively. Positive emotion predicted health anxiety negatively
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Figure 4
Path analysis between group, health cognitions and mood, and β-coefficients
Note: Group coding: 1 = experimental, 2 = control. R2health value = .14; R2health anxiety = .12; R2internal
= .29. Only significant paths are being presented.
locus of control
and internal locus of control positively, whereas negative emotion did not
predict any health cognition.
Discussion
The purpose of the present experimental study was to examine whether
exposure to suffering of unknown persons affects cognitions about personal health. According to our findings, exposure to unknown others’
suffering seems to result in higher health anxiety, higher value attached to
health and lower internal health locus of control, in comparison to exposure
to relaxing images. Also, more health anxiety and negative mood, higher
health value and lower internal health locus of control and positive mood
were reported by the participants exposed to suffering-related stimuli after
the experiment.
In many cases, exposure to human suffering results in shattered perceptions about safety and controllability, which in turn are responsible
for further negative thoughts and behaviors (e.g. Freedy et al., 1993).
Moreover, vicarious experiences with threatening situations increase the
perceived likelihood of and perceived susceptibility to a threat (Wardle,
1995). In other words, exposure to the suffering of distant persons could act
as a cue of a threatening world or a vulnerable self, affecting, thus, perceptions about personal health. When exposed, persons consider the value of
health, worry about it, but feel less able to exert personal control. Such
responses are more or less typical of a stress reaction, when a situation is
appraised as dangerous and the ability to cope with it is questioned (Ursin
and Eriksen, 2004).
Furthermore, the findings of the present study could be explained
within the theoretical framework of social comparison. The automatic
process of comparing the self and personal characteristics with others is
found not only in humans (Buunk and Gibbons, 2007), but also in many
other species (Gilbert et al., 1995). Self-evaluations are affected by social
comparison in multiple ways (Mussweiller, 2003), while there is evidence
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that social comparison makes relevant cognitive material more easily
accessible (Buunk et al., 2001). As Mussweiller (2003) noted, sometimes
the result of a social comparison is assimilation toward a given standard
(i.e. more positive reactions, in accordance to the characteristics of others),
whereas other times the result is a contrast effect (i.e. more negative evaluations about self, in contrast to the characteristics of the others). In five
studies, Mussweiller et al. (2004) showed that assimilation results if persons
selectively focus on similarities to the standard, whereas contrast occurs
if persons focus on differences. In other words, it is possible that through
social comparison mechanisms, exposure to suffering renders information
about self and personal well-being more easily accessible. At the same time,
it is possible that individuals, when exposed to suffering, focus on similarities with the sufferers, thus, assimilating their self-evaluations (i.e. more
negative evaluations about personal control). In that case, a key factor that
makes persons focus on similarities rather than on differences might be
empathy.
Several studies have demonstrated that perception of a specific behavior
or emotion in another person automatically activates a representation of
that behavior or emotion, which in turn prompts the observer to resonate
with the emotional state of the other (Carr et al., 2003; Jackson et al., 2006).
In addition, Jackson et al. (2006) argue that seeing another person suffer
in a naturalistic context can signify a danger and promote a withdrawal response. On the contrary, in controlled conditions (e.g. during a laboratory
experiment) the observation may not signal a threat. In fact, as Jackson et al.
(2006) underline, such situations favor prosocial responses and attitudes
toward the suffering person. In our case, this might suggest that observing
human suffering from a ‘safe distance’ can provoke an empathetic reaction (i.e. negative emotions), as well as a focus on the similarities with the
suffering others, which in turn affects the results of the automatic social
comparison processes.
It is worth noting, however, that exposure to suffering did not affect
self-rated health. Previous experiments showed that the induction of a
negative state (i.e. negative mood) resulted in lower self-rated health or
more perceived symptoms (e.g. Croyle and Uretzky, 1987; Salovey and
Birnbaum, 1989). On the contrary, Barger et al. (2007) found no relation
between negative mood and self-rated health. The results of our study are
in accordance with the latter findings. A possible explanation might be that
self-rated health represents a central and more elaborated self-conception
not affected by situational factors (Sedikides, 1995).
Regarding our assumption that exposure affects health cognitions directly, as well as through negative mood, results were surprising. Exposure
to suffering was indeed directly related to internal locus of control and
health value. It was also related to health anxiety and internal locus of control through mood. It was, however, positive mood that accounted for this
relationship, and not negative mood as assumed.
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The role of positive mood is, of course, crucial. Positive emotional states
have repeatedly been related to health, symptoms perception and other
health cognitions (e.g. Salovey et al., 2000; Fredrickson and Losada, 2005;
Pressman and Cohen, 2005). The findings of the present study also underline
the role of positive mood by showing that changes in cognitions took place
through decrease in positive emotion. Yet, the puzzle remains. According to
our findings, exposure to suffering also led to more negative emotions, but
these were not actually related to health cognitions, contrary to the results
of previous studies. A possible explanation might be that negative emotions
are not undifferentially associated with all type of cognitions. Each emotion
has a distinct role in human functioning and may affect different cognitions
under different circumstances. It is worthy of note that positive and negative mood do not lie on the same continuum. They are strongly related, but
independent and not always opposite variables (Clark and Watson, 1991).
In any case, further research is needed to clarify this issue.
Overall, our findings showed that health cognitions are subject not just
to personal experiences or close social influences, but also to events that
take place in the broader context. The ways we perceive our well-being, or
at least some aspects of if, are possibly connected to the perception of the
well-being of others. It seems that exposure to human suffering activates a
cognitive and emotional reaction, which affects evaluations about self and
personal well-being. In fact, almost every day people are bombarded with
stimuli of human suffering (for example, through the media; McCleneghan,
2002), as well as with distressing messages showing people suffering from
an array of diseases (Førde, 1998). Eventually, it is possible that the ways
people think about their health are affected. Moreover, it is possible that
exposure to the suffering of others in real life also affects the ways we
view ourselves and the world. As mentioned before, such experiences may
represent signals of a threatening world and/or a vulnerable self and,
thus, alter self-perceptions and worldview (Freedy et al., 1993; KoltkoRivera, 2004). Of course, these reactions are probably influenced by the
frequency, the duration and the intensity of the exposure or mediated by
several personal and social factors. Future research will have to look into
this issue, while studies on personal exposure to major stressful events, such
as disasters and war conflicts, might provide some ideas regarding these
relationships (Schnurr and Green, 2004).
Some limitations to this study should be noted. No measures of participants’ cognitive reactions to the exposure to suffering were obtained and
consequently, other specific pathways through which exposure impacts
health cognitions, besides positive and negative mood, remain unidentified.
A future study could provide interesting findings about this issue. Additionally, our study does not address whether exposure to suffering impacts
health cognitions in the ‘real world’, outside a laboratory context. We used
several mild stimuli of dramatic events; but in everyday life, stimuli are
constantly mixed with other types of stimuli (relaxing, neutral, more
or less distressing ones) that come from diverse sources and include a
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variety of themes. Moreover, in this study the stimuli used related to situations unfamiliar to most participants. In real life conditions, an array of
perceptual and cognitive-emotional processes, as well as situational factors
and personal characteristics interact. Field studies are needed to validate
our results and further examine the associations found in this study.
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Author biography
evangelos c. karademas is an assistant professor of health psychology at the
Department of Psychology, University of Crete, Greece. His main area of interest is
individual differences in health, illness and quality of life. Much of his work focuses
on the socio-cognitive factors affecting health and illness, as well as stress and
adaptation to stress.
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