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Anticipated Regret and Health Behavior: A Meta-Analysis
Noel T. Brewer
University of North Carolina and Lineberger Comprehensive
Cancer Center, Chapel Hill, North Carolina
Jessica T. DeFrank
RTI International, Research Triangle Park, North Carolina
Melissa B. Gilkey
Harvard Medical School
Objective: Risk beliefs are central to most theories of health behavior, yet many unanswered questions
remain about an increasingly studied risk construct, anticipated regret. The authors sought to better
understand anticipated regret’s role in motivating health behaviors. Method: The authors systematically
searched electronic databases for studies of anticipated regret and behavioral intentions or health
behavior. They used random effects meta-analysis to synthesize effect sizes from 81 studies (n⫽
45,618). Results: Anticipated regret was associated with both intentions (r
⫹
⫽.50, p⬍.001) and health
behavior (r
⫹
⫽.29, p⬍.001). Greater anticipated regret from engaging in a behavior (i.e., action regret)
predicted weaker intentions and behavior, whereas greater anticipated regret from not engaging in a
behavior (i.e., inaction regret) predicted stronger intentions and behavior. Anticipated action regret had
smaller associations with behavioral intentions related to less severe and more distal hazards, but these
moderation findings were not present for inaction regret. Anticipated regret generally was a stronger
predictor of intentions and behavior than other anticipated negative emotions and risk appraisals.
Conclusions: Anticipated inaction regret has a stronger and more stable association with health behavior
than previously thought. The field should give greater attention to understanding how anticipated regret
differs from similar constructs, its role in health behavior theory, and its potential use in health behavior
interventions.
Keywords: anticipated regret, health behavior theory, systematic review, risk appraisal, regret manage-
ment theory
Supplemental materials: http://dx.doi.org/10.1037/hea0000294.supp
Regret is an aversive cognitive emotion that “we experience
when realizing or imagining that our current situation would have
been better, if only we had decided differently” (Zeelenberg &
Pieters, 2007, p. 3). Over time, experience shapes our expectations
of regret related to decisions and the ensuing outcomes (Baumeis-
ter, Vohs, DeWall, & Zhang, 2007). Although anticipated regret is
an expectation that is primarily cognitive, it likely also has an
affective component, as imagining an unpleasant future may elicit
emotion in the present. Studies have located neural substrates of
anticipated regret during decisions as reactivation of the orbital
prefrontal cortex and the amygdala, which is consistent with an-
ticipated regret having cognitive and affective components (Cori-
celli et al., 2005;Coricelli, Dolan, & Sirigu, 2007).
Expectancy value theories suggest that motivators of health
behavior include expectations about the chances (such as per-
ceived likelihood) and extent (such as perceived severity) of future
outcomes (Edwards, 1954;Weinstein, 1993). The intuition that
anticipated regret motivates behavior dates back at least 2,500
years to Buddhist scriptures that suggest regret is a useful marker
for something to be avoided in the future (Bodhi, 2012). Health
behavior research has seized on anticipated regret as a novel risk
appraisal (Sheeran, Harris, & Epton, 2014), useful above and
beyond the other more traditional risk constructs (Weinstein et al.,
2007;Ziarnowski, Brewer, & Weber, 2009). Empirical study of
anticipated regret’s role in motivating health and risk behaviors
began in the mid-1990s (Richard, van der Pligt, & de Vries, 1995),
and the pace of this research has increased markedly in the last
decade. A growing body of evidence suggests that anticipated
regret motivates people’s actions (Sandberg & Conner, 2008).
This article was published Online First September 8, 2016.
Noel T. Brewer, Department of Health Behavior, Gillings School of Global
Public Health, University of North Carolina and Lineberger Comprehensive
Cancer Center, Chapel Hill, North Carolina; Jessica T. DeFrank, Center for
Communication Science, RTI International, Research Triangle Park, North
Carolina; Melissa B. Gilkey, Department of Population Medicine, Harvard
Medical School & Harvard Pilgrim Health Care Institute.
Noel T. Brewer and Jessica T. DeFrank are joint first authors.
This work was supported by grant 1P01HS021133-01 from the Agency
for Healthcare Research and Quality (AHRQ) and Grant R25 CA57726
from the Cancer Control Education Program at University of North Car-
olina Lineberger Comprehensive Cancer Center. The funders had no role in
the design, conduct, or analysis of this study or in the decision to submit the
article for publication. The authors would like to thank the many research-
ers who assisted with this study by providing their data and feedback on
this topic.
Correspondence concerning this article should be addressed to Noel T.
Brewer, Department of Health Behavior, Gillings School of Global Public
Health, University of North Carolina, 325 Rosenau Hall, CB7440, Chapel
Hill, NC 27599. E-mail: ntb@unc.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Health Psychology © 2016 American Psychological Association
2016, Vol. 35, No. 11, 1264–1275 0278-6133/16/$12.00 http://dx.doi.org/10.1037/hea0000294
1264
Regret management theory suggests that people act to reduce
the regret they experience and expect to experience from blaming
themselves (Zeelenberg & Pieters, 2007). Thus, anticipating regret
from taking action should discourage health and risk behaviors,
whereas anticipating regret from inaction should encourage these
behaviors (Hypothesis 1). Examples of how both types of antici-
pated regret (action and inaction) can motivate or discourage
behaviors appear in Table 1. For example, a retiree might expect to
regret getting a seasonal flu shot if she were to experience serious
side effects. Conversely, she might expect to regret not vaccinating
if she were to get the flu. Our conceptualization emphasizes
forgoing alternatives and feeling responsible for a decision that
could lead to a bad outcome: “I’ll wish I hadn’t done it.”
The difference between action and inaction (Knobe, 2003;
Thomson, 1976) has been a central concern of the regret literature
(Gilovich & Medvec, 1995). Some of this interest comes from
research on the omission bias, the tendency to judge harmful action
as worse than equally harmful inaction (Ritov & Baron, 1990,
1995). Based on this literature, we propose the action regret
enhancement hypothesis that suggests a stronger role for antici-
pated action regret than for inaction regret (Hypothesis 2a). People
feel more responsible for action than for inaction (Knobe, 2003),
and it follows that feeling culpable should enhance anticipated
regret (Anderson, 2003;Zeelenberg & Pieters, 2007). Research
shows greater experienced regret as a result of greater perceived
opportunity (Roese & Summerville, 2005) or lost opportunity
(Beike, Markman, & Karodogan, 2009). Several predictions fol-
low from this hypothesis. First, mean ratings of anticipated regret
should be higher for taking action than for inaction (Ritov &
Baron, 1995), as the greater feelings of culpability for action can
lead people to expect greater regret (Anderson, 2003). Next, the
association of anticipated regret with health behaviors should be
larger in absolute terms for actions than inactions. Finally, antic-
ipated action regret’s impact may be more potent when feedback
about the results of the behavior is expected or imminent (Ander-
son, 2003). We build on this idea to suggest a larger role for
anticipated action regret when the behavior is linked to a hazard
that is more proximal (e.g., vaccination that can cause immediate
side effects vs. smoking that can cause cancer later in life) or that
is a more severe consequence (e.g., death vs. illness).
We propose a competing hypothesis, the action regret minimi-
zation hypothesis (Hypothesis 2b). Some researchers suggest that
regret is more potent for inaction than action in the longer term
(Gilovich & Medvec, 1994;Kahneman, 1995). As health behav-
iors generally concern the longer term, inaction regret may be of
greater interest. Researchers have also questioned the relevance of
work on the omission bias to understanding anticipated regret
(Connolly & Reb, 2003). Further, although norms surround com-
monly studied behaviors such as gambling or financial investing,
health behaviors often are accompanied by an added layer of
medical guidelines and societal expectations on how to act (e.g.,
believing that cancer screening is “almost always a good idea”;
Schwartz, Woloshin, Fowler, & Welch, 2004). Such norms and
expectations and the feelings of blame they generate may make
inaction even more regrettable. Three predictions follow from this
hypothesis: people should report less anticipated action regret than
inaction regret; anticipated action regret should be a less potent
motivator of behavior; and it should have less ability to motivate
behaviors that address proximal hazards or have more severe
consequences.
Regret is an emotion that is specific to making decisions, and,
for this reason, anticipated regret may be different from expecta-
tions about other negative emotions (Zeelenberg & Pieters, 2007).
This approach fits with previous empirical findings (e.g., Saffrey,
Summerville, & Roese, 2008) and the broader theoretical frame-
work of regret management theory (Zeelenberg & Pieters, 2007).
Anticipated regret is similar to but distinct from expecting to feel
anxious about the future; guilty about one’s actions; disappointed
by an outcome; or angry with oneself about an outcome. Although
these anticipated emotions share a similar negative valence, they
do not have the added cognition of the wish to have made a
different decision. We focus specifically on anticipated regret as it
is future oriented, whereas experienced regret may or may not look
to the future. Anticipatory emotions like fear that one feels in the
present when considering a future action can also play an impor-
tant role in shaping behavior (Loewenstein, Weber, Hsee, &
Welch, 2001), but they are not our primary focus. We hypothesize
that anticipated regret is a more potent motivator of health behav-
ior than expectations about other negative emotions, due to its
special focus on the evaluation of one’s own decisions (Hypothesis
3). By enriching expectations with affect, anticipated regret may
make these imagined futures more meaningful (Peters, 2006;
Slovic, Finucane, Peters, & MacGregor, 2007). For this reason, we
expected anticipated regret would have a stronger association with
health behavior than more solely cognitive risk appraisals, includ-
ing perceived likelihood, perceived severity, and worry (Hypoth-
esis 4).
These hypotheses led us to predictions that we sought to test in
a meta-analysis of the literature on anticipated regret and health
behavior. A previous meta-analysis by Sandberg and Conner
(2008) examined a similar topic but focused only on studies testing
the theory of planned behavior/reasoned action (Ajzen, 1991;
Table 1
Hypothesized Relationships Between Anticipated Regret and Health Behavior
Anticipated regret of
Action Inaction
Discourages health behavior Encourages health behavior
Example: anticipated regret of vaccination (if it led to side
effects) discourages vaccination.
Example: anticipated regret of not getting the flu vaccine (if the person later
got the flu) encourages vaccination.
Discourages risk behavior Encourages risk behavior
Example: anticipated regret of smoking (if it caused cancer)
discourages smoking.
Example: anticipated regret of not trying cigarettes (if it led to being shunned
by friends) encourages trying cigarettes.
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1265
ANTICIPATED REGRET META-ANALYSIS
Fishbein & Ajzen, 1975) and did not examine our four hypotheses.
First, we expect that anticipating regret of action will discourage
health behavior, whereas anticipating regret from inaction will
encourage health behavior (Hypothesis 1). Second, the action
regret enhancement and minimization hypotheses offer competing
predictions. The former suggests higher means, larger effects, and
more stability across different situations, for anticipated regret of
action than for inaction, while the latter suggests the opposite
(Hypotheses 2a and 2b). Third, we expect larger effects for antic-
ipated regret than for other anticipated negative emotions (Hypoth-
esis 3). Finally, we expect larger effects for anticipated regret than
for other risk appraisals such as perceived likelihood, perceived
severity, and worry (Hypothesis 4).
Method
Data Sources and Searches
We systematically searched five databases (MEDLINE, Psyc-
Info, Web of Science, CINAHL, and EMBASE) to identify studies
published through December 2013. Searches of titles, abstracts,
and keywords used the following terms: (anticip
ⴱ
regret
ⴱ
)OR
(expect
ⴱ
regret
ⴱ
) OR (prospective regret
ⴱ
) OR (regret
ⴱ
avoid
ⴱ
)OR
(regret
ⴱ
avers
ⴱ
) OR (action regret
ⴱ
) OR (inaction regret
ⴱ
). To
identify additional studies, we manually searched the reference
sections of included articles, examined articles that the included
papers cited, and circulated requests for unpublished studies
among colleagues and the authors of included articles.
Study Selection
Two investigators (Jessica T. DeFrank and Melissa B. Gilkey)
independently reviewed titles and abstracts and, for relevant arti-
cles, we conducted full-text reviews. At this and subsequent steps,
we resolved disagreements about inclusion through discussion
with a third investigator (Noel T. Brewer). We included English-
language articles that assessed health behaviors or intentions to
practice health behaviors as an outcome. We defined health be-
haviors broadly as actions that may protect one’s own health or the
health of a child or dependent (Glanz, Rimer, & Viswanath, 2008).
We broadened this definition of health behaviors to include avoid-
ance of risk behaviors (i.e., behaviors that may cause harm). We
excluded behaviors with health-related consequences that were a
matter of individual preferences rather than being recommended or
discouraged by medical guidelines or consensus. Excluded behav-
iors included elective and cosmetic surgery, blood and organ
donation, and fertility treatment as well as genetic testing and other
screening services that did not have medical guidelines (e.g.,
screening older adults for alcohol problems). We defined inten-
tions as plans (e.g., “I [intend/plan] to . . .”), desires (e.g., “I would
like to . . .”), and expectations (e.g., “I expect to . . .”) to practice
a health behavior (Conner & Sparks, 2005). We also included
behavioral expectation, perceived likelihood of engaging in the
behavior and willingness in intentions as the constructs share a
common psychological foundation (Kruglanksi et al., 2002,Krug-
lanski, Chernikova, Rosenzweig, & Kopetz, 2014). For behavior,
we accepted assessments based on self-report, insurance claims,
medical records, or direct observation.
We included studies of anticipated but not experienced regret.
To distinguish between anticipated regret and other constructs, we
required that measures include at least one item that used the
words “regret” or “wish” (e.g., “If I did not vaccinate my child, I
would [regret it/wish I had]”). We included two studies that did not
use these terms but used language we believed would elicit a
similar thought process (e.g., “If I don’t get the flu shot and end up
getting the flu, I’d be mad at myself for not getting the flu shot;”
Weinstein et al., 2007). For studies that used multi-item measures,
we noted whether at least one item assessed other anticipated
negative emotions including anxiety, guilt, disappointment, and
anger. We included only studies that had quantitative data on the
association of anticipated regret and health behavior or intentions.
Data Extraction
Two investigators (Jessica T. DeFrank and Melissa B. Gilkey)
independently extracted data using a standardized coding form.
For missing or ambiguous data, we contacted study authors to
request additional information. Study characteristics included
those related to design (cross-sectional or longitudinal), sampling
strategy (probability or nonprobability), sample size, and response
and retention rates. For behavioral outcomes, we extracted data on
source (self-report or other). We coded five characteristics of the
health behaviors: (a) frequency of behavior (infrequent or fre-
quent); (b) severity of health-related consequences associated with
the behavior (disease or death); (c) delay in time for those conse-
quences (shorter or longer, defined as less or more than a year); (d)
whether the behavior was a health or risk behavior; and (e) health
behavior category (e.g., vaccination, cancer screening). We con-
firmed categorizations for the first three characteristics through
coding by five behavioral scientists (⫽1.0, .67, and .66, respec-
tively).
For anticipated regret measures, we extracted data on type of
regret (action or inaction), number of survey items (1 or ⬎1),
inclusion of other anticipated emotions, specifying the time period
under consideration (e.g., regret felt in the next year), who the
harms affect (self or another person), and whether researchers
dichotomized anticipated regret. We extracted data on three other
risk appraisals related to the consequences of performing (or
failing to perform) a health behavior: perceived likelihood, per-
ceived severity, and worry. We defined perceived likelihood as an
individual’s assessment of the probability of experiencing a con-
sequence, perceived severity as an assessment of the seriousness of
the consequence (Brewer et al., 2007;Weinstein, 1993), and worry
as an anticipatory emotion of concern or anxiety about a future
consequence (Hay, McCaul, & Magnan, 2006).
Data Synthesis and Analysis
We conducted analyses using Comprehensive Meta-Analysis
(v. 2; Biostat, Inc., Englewood, NJ). We calculated effect size rfor
the association of anticipated regret with intentions and with
behavior (Chinn, 2000;Wolf, 1986), using multivariate data when
bivariate data were unavailable. We reverse coded associations if
the anticipated regret measure referred to action (e.g., anticipated
regret of getting cancer because of smoking) but the outcome was
inaction (e.g., intention to quit smoking) or the converse was
present. We also calculated effect sizes for the association of per-
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1266 BREWER, DEFRANK, AND GILKEY
ceived likelihood, severity, and worry with intentions and with be-
havior. For studies reporting multiple effect sizes for the same out-
come, we followed the approach described by Brewer et al. (2007).
Separately for behavioral intentions and for behavior, we cal-
culated pooled effect sizes (r
⫹
⫽) using random-effects meta-
analyses. To characterize heterogeneity among studies, we report
the Qstatistic. Analyses combining anticipated action and inaction
regret reversed the sign for action effect sizes. We stratified
analyses when separate effect sizes were available for action and
inaction regret. To compare pooled effect sizes for anticipated
regret to other risk appraisals, we identified a subset of studies that
assessed both constructs, meta-analyzed differences in effect sizes
(risk appraisal minus anticipated regret), and adjusted variances
according to methods described by Borenstein and colleagues for
dealing with correlated data (Borenstein, Hedges, Higgins, &
Rothstein, 2009). For studies that measured both anticipated regret
of action and inaction, we calculated standardized mean difference
scores (Cohen’s d) to compare the two measures. We meta-
analyzed the difference scores using random effects meta-analysis.
Results
We identified 81 studies of the role of anticipated regret on
health outcomes. The studies included 45,618 participants (see
Figure 1). Fifty-six studies were from Europe, 17 from North
America, six from Australia and New Zealand, and two from Asia
(Supplemental Appendix A). Studies were commonly cross-
sectional (58%) and relied on convenience samples (74%).
From the included studies, we calculated 128 effect sizes. We
found more assessments of intentions (k⫽80 effect sizes) than
behavior (k⫽48) and of inaction regret (k⫽81) than action regret
(k⫽47). The most commonly studied categories of health behav-
ior were vaccination (k⫽32) and cancer screening (k⫽14).
Studies of promotion of health behaviors (e.g., physical activity)
typically examined inaction regret only, whereas studies of risk
behaviors (e.g., speeding/unsafe driving) typically examined ac-
tion regret only (Supplemental Appendix B; Supplemental Table
S1). Studies of vaccination were a notable exception as they
commonly examined both inaction and action regret. We identified
39 effect sizes from studies that used single-item measures of
anticipated regret, 19 based on multi-item measures of anticipated
regret alone, and 70 based on multi-item measures that also in-
cluded other anticipated negative emotions.
Meta-Analyses of Associations
Anticipated regret was associated with having higher behavioral
intentions (r
⫹
⫽.50; 95% CI ⫽.46, .53; p⬍.001) and with being
more likely to engage in the health behaviors (r
⫹
⫽.29; 95% CI ⫽
.24, .34; p⬍.001), across 128 effect sizes, in combined analyses
that reversed the sign for anticipated action regret effect sizes.
Analyses of health behavior categories found stronger associa-
tions, when compared to vaccination, for physical activity (inten-
tions r
⫹
⫽.46 vs. .55, p⫽.03; behavior r
⫹
⫽.27 vs. .46, p⫽
.001) and speeding/unsafe driving (behavior r
⫹
⫽.27 vs. .45, p⫽
.01) (see Table 2).
Meta-Analyses of Associations, Stratified by
Action/Inaction
Anticipated regret of inaction and action had oppositely signed
associations with outcomes (see Table 3; Hypothesis 1). Antici-
1,529 Titles and abstracts reviewed
(excluding duplicates)
758 MEDLINE
425 Web of Science
216 PsycInfo
121 EMBASE
0 CINAHL
9 Reference sections of
articles, grey literature
176 Full-text articles reviewed
97 Articles excluded
32 Outcome was not a health behavior
37 Did not measure anticipated regret
12 Anticipated regret was the outcome
8 No data/could not use data
2 Experimental manipulation of
anticipated regret
2 Non-English language
4 Other criteria
81 Studies included in meta-analyses
(based on 79 articles)
1,353 Titles and abstracts not relevant
Figure 1. Flow Diagram.
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1267
ANTICIPATED REGRET META-ANALYSIS
pated action regret was associated with lower behavioral intentions
(r
⫹
⫽⫺.45; 95% CI ⫽⫺.51, ⫺.38; p⬍.001) and being less
likely to engage in health behaviors (r
⫹
⫽⫺.28; 95%
CI ⫽⫺.36, ⫺.19; p⬍.001). In contrast, anticipated inaction
regret was associated with higher intentions (r
⫹
⫽.52; 95% CI ⫽
.48, .56; p⬍.001) and being more likely to engage in behavior
(r
⫹
⫽.29; 95% CI ⫽.23, .35; p⬍.001). In absolute terms, the
association of anticipated inaction regret with intentions was
somewhat stronger than that for action regret (p⫽.06); the
associations were the same for behavior (p⫽.76). Forest plots of
the effect sizes appear in Supplemental Appendixes C and D.
Anticipated action regret showed weaker associations for inten-
tions to engage in health behaviors that were less frequent com-
pared to more frequent (r
⫹
⫽⫺.29 vs. ⫺.52, p⬍.001) (see Table
4; Hypothesis 2b). Anticipated action regret also showed weaker
associations for intentions to engage in health behaviors
(r
⫹
⫽⫺.29) that addressed less severe (r
⫹
⫽⫺.36) and more
distal hazards (r
⫹
⫽⫺.37) than for their counterparts
(r
⫹
⫽⫺.52, ⫺.55, and ⫺.53, respectively; all p⬍.05). These four
characteristics did not moderate the association of anticipated action
regret and behavior, though the pattern was the same and the findings
were all marginally statistically significant (p⫽.06 to .09). These
characteristics did not moderate anticipated inaction regret associa-
tions. Cross-sectional studies yielded a smaller pooled effect size than
longitudinal studies for anticipated inaction regret and behavior (r
⫹
⫽
.20 vs. .31, p⫽.02) but not for intentions or anticipated action regret.
We did not find any differences in effect sizes based on whether the
harm affected the self or another person such as a patient or child, the
anticipated regret item specified the time period, or anticipated regret
measure was dichotomous.
Effects were larger for multi-item measures of anticipated action
regret only compared to measures that included other anticipated
negative emotions (see Table 4; Hypothesis 3). The finding held
for intentions (r
⫹
⫽⫺.64 vs. ⫺.50, p⬍.05) and behavior
(r
⫹
⫽⫺.50 vs. ⫺.30, p⬍.05). Pooled effect sizes were also larger
for studies that used multi-item measures of anticipated regret only
(absolute value of range r
⫹
⫽.36 –.64) rather than single-item
measures of anticipated regret only (absolute value of range r
⫹
⫽
.17–.45) for three of four outcomes (all p⬍.05). Effect sizes for
anticipated inaction regret were similar when comparing multiple
item measures of anticipated regret alone and that includes other
anticipated negative emotions. In sensitivity analyses that repeated
our main analyses after dropping anticipated regret measures that
included other anticipated emotions, we again found anticipated
regret had a larger pooled effect size for inaction than for action as
a correlate of intentions (r
⫹
⫽.50 vs. ⫺.38, p⫽.04); there was
no difference for behavior (r
⫹
⫽.28 vs. ⫺.26, p⫽.79).
Meta-Analyses Comparing to Other Risk Appraisals
Anticipated regret was more strongly associated with intentions
than were perceived likelihood (r
⫹
⫽.47 vs. .15), perceived
severity (r
⫹
⫽.50 vs. .17) and worry (r
⫹
⫽.49 vs. .23) (all p⬍
.05; Table 5; Hypothesis 4). Anticipated regret was also more
Table 2
Pooled Effect Sizes for Anticipated Regret by Health Behavior Category
Health behavior category k
Outcome intentions
r
⫹
(95% CI) Q
Difference in r
⫹
pk
Outcome behavior
r
⫹
(95% CI) Q
Difference in r
⫹
p
Vaccination (ref) 24 .46 (.38, .54)
ⴱⴱ
534
ⴱⴱ
— 18 .27 (.19, .36)
ⴱⴱ
377
ⴱⴱ
—
Cancer screening 10 .54 (.49, .58)
ⴱⴱ
37
ⴱⴱ
.10 4 .17 (⫺.02, .34) 28
ⴱⴱ
.29
Safe sex/condom use 10 .50 (.42, .58)
ⴱⴱ
168
ⴱⴱ
.50 2 .23 (.15, .30)
ⴱⴱ
⬍1 .44
Speeding/unsafe driving 9 .50 (.37, .60)
ⴱⴱ
185
ⴱⴱ
.66 4 .45 (.34, .55)
ⴱⴱ
10
ⴱ
.01
Smoking 7 .47 (.42, .51)
ⴱⴱ
14
ⴱ
.94 5 .22 (.13, .31)
ⴱⴱ
21
ⴱⴱ
.39
Physical activity 7 .55 (.52, .58)
ⴱⴱ
3 .03 4 .46 (.40, .52)
ⴱⴱ
1⬍.001
Alcohol/drug use 6 .57 (.43, .69)
ⴱⴱ
53
ⴱⴱ
.19 3 .27 (.13, .40)
ⴱⴱ
5 .97
Healthy eating/weight maintenance 3 .44 (.09, .69)
ⴱ
60
ⴱⴱ
.89 4 .22 (.10, .33)
ⴱⴱ
13
ⴱ
.44
Skin cancer prevention 2 .42 (.13, .65)
ⴱ
22
ⴱⴱ
.78 2 .35 (.04, .60)
ⴱ
21
ⴱⴱ
.61
Other 3 .48 (⫺.08, .81) 110
ⴱⴱ
.93 2 .28 (.12, .42)
ⴱ
2 .98
Note. Analyses combined action and inaction regret, reversing sign for action regret. pvalues compare effect sizes for health behavior category
to vaccination (reference group). Other behaviors included for the intention outcome are looking after one’s health (k⫽1), oral contraception use
(k⫽1), and glaucoma screening (k⫽1). Other behaviors included for the behavior outcome are looking after one’s health (k⫽1) and oral
contraception use (k⫽1).
ⴱ
p⬍.05.
ⴱⴱ
p⬍.001.
Table 3
Pooled Effect Sizes for Anticipated Regret
Predictor
anticipated regret
Outcome intentions Outcome behavior
kr
⫹
(95% CI) Q
Difference in r
⫹
pkr
⫹
(95% CI) Q
Difference in r
⫹
p
Action 28 ⫺.45 (⫺.51, ⫺.38)
ⴱⴱ
562
ⴱⴱ
—19⫺.28 (⫺.36, ⫺.19)
ⴱⴱ
328
ⴱⴱ
—
Inaction 52 .52 (.48, .56)
ⴱⴱ
894
ⴱⴱ
.06 29 .29 (.23, .35)
ⴱⴱ
344
ⴱⴱ
.76
Note. Comparison reverses the sign for action regret. Higher scores indicated more anticipated regret.
ⴱ
p⬍.05.
ⴱⴱ
p⬍.001.
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1268 BREWER, DEFRANK, AND GILKEY
strongly associated with behavior than were perceived severity
(r
⫹
⫽.26 vs. .11) and worry (r
⫹
⫽.35 vs. .26) (both p⬍.05), but
not perceived likelihood.
Meta-Analysis of Means
Ratings of anticipated action regret were lower than ratings of
inaction regret (d⫽⫺1.11, p⬍.001; Q⫽787, p⬍.001;
Hypothesis 2b). This pattern was present in nine of the 10 studies
that examined both anticipated action and inaction regret (all p⬍
.001; see Table 6). All of these studies examined vaccination
behavior.
Discussion
Motivating Health Behavior
Anticipated regret was associated with a broad array of health
behaviors. Anticipated inaction regret was associated with engag-
ing in protective behaviors, whereas action regret showed the
opposite association. The broad pattern of findings was most
consistent with the idea that people minimize anticipated regret
from action. First, mean anticipated regret was lower for action
than inaction, a finding others have hypothesized for regret of
more distal outcomes (Gilovich, Medvec, & Kahneman, 1998).
Table 4
Pooled Effect Sizes for Anticipated Regret by Moderators
Moderator
Predictor
anticipated regret k
Outcome
intentions r
⫹
Difference in r
⫹
pk
Outcome
behavior r
⫹
Difference in r
⫹
p
Consequence
Disease Action 16 ⫺.36
ⴱⴱ
—7⫺.22
ⴱⴱ
—
Death Action 12 ⫺.55
ⴱⴱ
⬍.001 12 ⫺.37
ⴱⴱ
.06
Disease Inaction 42 .52
ⴱⴱ
— 25 .31
ⴱⴱ
—
Death Inaction 11 .53
ⴱⴱ
.82 4 .17 .13
Delay to consequence
Shorter Action 13 ⫺.53
ⴱⴱ
—7⫺.37
ⴱⴱ
—
Longer Action 15 ⫺.37
ⴱⴱ
.003 12 ⫺.22
ⴱⴱ
.06
Shorter Inaction 13 .46
ⴱⴱ
— 3 .22
ⴱⴱ
—
Longer Inaction 40 .54
ⴱⴱ
.15 26 .30
ⴱⴱ
.11
Frequency of behavior
Infrequent Action 9 ⫺.29
ⴱⴱ
—6⫺.18
ⴱ
—
Frequent Action 19 ⫺.52
ⴱⴱ
⬍.001 13 ⫺.32
ⴱⴱ
.09
Infrequent Inaction 26 .56
ⴱⴱ
— 16 .28
ⴱⴱ
—
Frequent Inaction 27 .48
ⴱⴱ
.05 13 .30
ⴱⴱ
.78
Type of behavior
Health behavior Action 9 ⫺.29
ⴱⴱ
—6⫺.18
ⴱ
—
Risk behavior Action 19 ⫺.52
ⴱⴱ
⬍.001 13 ⫺.32
ⴱⴱ
.09
Health behavior Inaction 50 .53
ⴱⴱ
— 28 .30
ⴱⴱ
—
Risk behavior Inaction 3 .31 .41 1 .20
ⴱ
.28
Measurement of AR
Multiple items, AR
o
Action 3 ⫺.64
ⴱⴱ
—3⫺.50
ⴱⴱ
—
Single item, AR
o
Action 9 ⫺.29
ⴱⴱ
⬍.001 7 ⫺.17
ⴱ
⬍.001
Multiple items, AR
⫹
Action 15 ⫺.50
ⴱⴱ
.002 7 ⫺.30
ⴱⴱ
.005
Multiple items, AR
o
Inaction 8 .58
ⴱⴱ
— 4 .36
ⴱ
—
Single item, AR
o
Inaction 12 .45
ⴱⴱ
.04 11 .26
ⴱⴱ
.50
Multiple items, AR
⫹
Inaction 31 .54
ⴱⴱ
.68 13 .32
ⴱⴱ
.78
Note. No studies measured anticipated negative emotion with a single item, as our meta-analysis included only studies that measured anticipated regret.
AR
o
⫽anticipated regret only; AR
⫹
⫽anticipated regret and other negative emotions.
ⴱ
p⬍.05.
ⴱⴱ
p⬍.001.
Table 5
Comparison of Pooled Effect Sizes for Anticipated Regret and Other Risk Appraisals
Risk belief k
Outcome intentions
r
⫹
(95% CI) Q
Difference in r
⫹
pk
Outcome behavior
r
⫹
(95% CI) Q
Difference in r
⫹
p
Perceived likelihood 15 .15 (⫺.01, .29) 810
ⴱⴱ
— 12 .17 (.03, .30)
ⴱ
399
ⴱⴱ
—
Anticipated regret 15 .47 (.40, .54)
ⴱⴱ
254
ⴱⴱ
.002 12 .28 (.20, .36)
ⴱⴱ
165
ⴱⴱ
.15
Perceived severity 14 .17 (.05, .28)
ⴱ
279
ⴱⴱ
— 11 .11 (.06, .16)
ⴱⴱ
33
ⴱⴱ
—
Anticipated regret 14 .50 (.41, .59)
ⴱⴱ
293
ⴱⴱ
⬍.001 11 .26 (.18, .34)
ⴱⴱ
109
ⴱⴱ
⬍.001
Worry 7 .23 (.12, .34)
ⴱⴱ
81
ⴱⴱ
— 4 .26 (.16, .36)
ⴱⴱ
21
ⴱⴱ
—
Anticipated regret 7 .49 (.36, .61)
ⴱⴱ
162
ⴱⴱ
.004 4 .35 (.20, .48)
ⴱⴱ
42
ⴱⴱ
.04
Note. Analyses only included studies that assessed both anticipated regret and at least one other risk appraisal. Analyses combined action and inaction
regret, reversing sign for action regret.
ⴱ
p⬍.05.
ⴱⴱ
p⬍.001.
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1269
ANTICIPATED REGRET META-ANALYSIS
Second, associations were somewhat smaller for anticipated action
than inaction regret and intentions, though the difference was
marginally reliable, and we found no difference for behavior.
Third, associations of anticipated action regret with intentions
were weaker for less severe behaviors with more distal outcomes;
behavior showed the same pattern, though the behavior findings
were marginally reliable. We did not find these moderation effects
for anticipated inaction regret. Taken together, the findings suggest
that anticipated inaction regret is more strongly felt than action
regret in the domain of health and has more reliable associations
with behavioral intentions and perhaps health behaviors.
A key component of regret management theory is avoiding
self-blame, with less regret anticipated for justifiable decisions
(Zeelenberg & Pieters, 2007). The result was straightforward for
mean levels of anticipated regret: people anticipated less regret of
an action that is widely believed to protect health (getting vacci-
nated) than of an inaction that the medical establishment roundly
condemns (forgoing vaccination). In the context of health behav-
ior, inaction often defies medical authority, thereby leaving the
decision maker more vulnerable to self-blame.
The consequences of avoiding self-blame appear to be more
complex when it comes to anticipated action regret motivating
health behaviors. Although actions may seem more controllable
(Knobe, 2003) and thus more naturally fit the schema of eliciting
self-blame, actions may also elicit the belief that resulting harms
are more controllable (Feldman, Miyamoto, & Loftus, 1999). In
this way, anticipated regret may be less reliably motivating when
it concerns action than inaction, if people perceive consequences
of action to be less preordained and more amenable to remediation.
Another possibility is that feeling culpable for action may make
feelings about those actions especially subject to defensive pro-
cessing to protect one’s sense of self-worth (Croyle, Sun, & Hart,
1997;Kessels, Ruiter, & Jansma, 2010;Kunda, 1987). The result
would be a greater minimizing of the anticipated regret of action
than of inaction. Future research can help to tease apart these
accounts that rely on perceived responsibility.
Emphasizing the consequences of inaction may benefit inter-
ventions that focus on anticipated regret as a way to change health
behavior. In our own intervention work, we have used anticipated
regret of harms from not vaccinating to prompt HPV vaccination
(Golden et al., 2014). However, as initial pilot work suggested
direct appeals to anticipated regret might elicit reactance, we
developed education materials with a quote from a local parent that
allowed us to incorporate the construct indirectly (“And I’d feel
awful if [my kids] got sick because I didn’t get them vaccinated”).
Other regret-based interventions include so-called regret lotteries
in which people learn whether they would have won a prize in the
lottery, whether or not they sign up for it (Zeelenberg & Pieters,
2004). In the health context, people have used variants of regret
lotteries to encourage health risk assessments among employees
(Haisley, Volpp, Pellathy, & Loewenstein, 2012). Similar regret-
based interventions encourage weight loss (Volpp et al., 2008) and
may increase medication adherence in some patients (Kimmel et
al., 2012). Others have suggested leveraging anticipated regret to
encourage appropriate use of mammography screening (Rosen-
baum, 2014). Finally, some studies have shown that merely asking
anticipated regret questions can increase health behaviors such as
cervical cancer screening (Sandberg & Conner, 2009).
Other Risk Appraisals and Anticipated
Negative Emotions
Anticipated regret generally yielded larger associations than
other anticipated negative emotions and risk appraisals. Sub-
stantial interest has built for adding emotion to supplement the
largely cognitive expectancy value models of behavior (Mellers,
Schwartz, & Ritov, 1999;Loewenstein et al., 2001). Expectancy
value models have their roots in utility theories that posit that the
expected chance and value of future outcomes guide behavior
(Edwards, 1954). Arguing that anticipated emotions are already
included in utility theories (Over, 2004) may be an oversimplifi-
cation. One descriptive approach has been to note the similarity of
anticipated regret to constructs already in models, such as the idea
of loss aversion in prospect theory (Anderson, 2003;Kahneman &
Tversky, 1979). Another approach has been to build descriptive
evidence for adding the construct to the models, such as to the
theory of reasoned action/planned behavior, as anticipated regret is
conceptually distinct from other model components and explains
additional variance in behavior above and beyond them (Sandberg
& Conner, 2008;Sheeran & Orbell, 1999). Unfortunately, efforts
to add anticipated regret, for example, to the these models do not
appear to have changed the way that many researchers use them or
teach them in training programs (e.g., Glanz, Rimer, & Viswanath,
2008). The research findings also did not prompt the inclusion of
anticipated regret in updates to the reasoned action approach
(Fishbein & Ajzen, 2010).
Our findings suggest that anticipated regret of action may be
different than other anticipated negative emotions, perhaps be-
cause regret is specific to decisions or because it has an explicit
cognitive component. We found stronger associations of intentions
and behavior with anticipated regret of action when measured
without other anticipated emotions. This finding is important be-
cause more than half of the studies in our review, especially those
informed by the theories of planned behavior or reasoned action,
named the construct anticipated regret, but they often used mea-
sures that incorporate this construct along with other anticipated
negative emotions. Past research suggests that different emotions
have different functions and impacts (Keltner, Ellsworth, & Ed-
wards, 1993;Lerner, Gonzalez, Small, & Fischhoff, 2003), and
Table 6
Mean Anticipated Regret of Action and Inaction
Study nAction M(SD) Inaction M(SD)p
Brewer, 2011 567 2.8 (1.2) 3.6 (1.8) ⬍.001
Chapman, 2006 428 2.3 (1.4) 3.1 (1.5) ⬍.001
Liao, 2013 507 2.0 (1.0) 1.7 (.8) ⬍.001
McRee, 2014 543 2.0 (.9) 3.4 (.9) ⬍.001
Morison, 2010 243 3.6 (1.4) 5.4 (1.0) ⬍.001
Reiter, 2011 (parents) 535 2.7 (1.1) 3.2 (1.0) ⬍.001
Reiter, 2011 (sons) 412 2.8 (1.1) 3.1 (1.0) ⬍.001
Reiter, 2015 428 2.1 (.9) 3.4 (.8) ⬍.001
Wroe, 2004 190 42.3 (32.5) 89.5 (25.1) ⬍.001
Wroe, 2005 108 44.2 (29.0) 84.4 (24.5) ⬍.001
Ziarnowski, 2009 783 2.7 (1.2) 3.6 (.8) ⬍.001
Note. Ten studies assessed both anticipated regret of action and inaction;
all studies concerned vaccination. Higher scores indicated more anticipated
regret. Studies used 5-point response scales, except for Morison (6-point
response scale) and Wroe et al. (100-point response scale).
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1270 BREWER, DEFRANK, AND GILKEY
now our meta-analysis shows that in some circumstances antici-
pated regret shows stronger associations than other anticipated
emotions. By including studies that assessed other anticipated
emotions, some of our effect sizes likely underestimate the true
effect of anticipated regret on health behavior. Future studies
should more directly by compare measures of anticipated regret
alone to measures of anticipated negative emotions excluding
regret. Future studies should also better characterize and distin-
guish between the expectation of regret and emotions such an
appraisal generates.
Limitations
The literature that we reviewed had several limitations. Analy-
ses identified several moderators of the association of anticipated
regret and behavior or intentions, but stratified pooled effect sizes
remained heterogeneous suggesting the presence of moderators
that remain to be identified. Although moderator analyses in meta-
analysis can yield spurious findings, we are encouraged by the
consistency of findings across our analyses. The correlational
designs widely used in the studies precludes strong causal infer-
ence (Brewer, Weinstein, Cuite, & Herrington, 2004;Weinstein &
Nicolich, 1993). Longitudinal studies yielded similar associations
to (or in one case larger than) cross-sectional studies, which
increased our confidence that anticipated regret precedes behavior.
With the exception of the vaccination literature, studies of health
promotion typically only measured inaction regret, whereas studies
of risk behaviors typically only measured action regret. Antici-
pated action regret was absent in the medical screening literature;
studies on screening only measured inaction regret. With rising
attention to the potential harms of medical screening (Harris et al.,
2014;Rosenbaum, 2014), examining both anticipated action and
inaction regret in this context may be fruitful.
Limitations of our meta-analysis are that we did not examine
studies of solely other risk appraisals or anticipated negative
emotions other than regret; the generalizability of our findings to
studies not included in our meta-analysis remains to be established.
Few studies were available to test certain hypotheses. For example,
only four studies examined influence of both anticipated regret and
worry on behavioral outcomes. Also, some moderation analyses
were limited by small cell sizes when stratifying by action and
inaction regret. Our comparison of mean anticipated regret of
action and inaction relied solely on studies of vaccination; the
generalizability of these finding beyond vaccination is unknown.
Implications for Measurement and Health
Behavior Models
The field should consider adopting common methods for mea-
suring anticipated regret. We propose that standard measures of
anticipated regret (a) specify a negative consequence of the action
or inaction; (b) assess regret of the action or inaction but not the
health consequence; (c) examine only anticipated regret without
also assessing other expected negative emotions; (d) have separate
subscales for action and inaction; and (e) include multiple items in
each subscale, if possible. Here is an example of an item that meets
the first three criteria: “Imagine that you had an abnormal Pap test,
but the HPV vaccine might have prevented it. How much would
you regret that you did not get the HPV vaccine?” Identifying
multiple negative consequences of action or of inaction can facil-
itate developing multiple item scales. Using multi-item scales that
mix various negative emotions but incorrectly label them as an-
ticipated regret, and using single item measures, underestimates
the impact of anticipated regret.
Although interest in anticipated regret has accelerated in past
years, none of the leading theories of health behavior yet include
this important construct. We believe it is now time for anticipated
regret to be a standard variable assessed in studies of health
behavior (Bell, 1983). The literature on anticipated regret and the
theories of planned behavior and reasoned action have supported
such action for at least 15 years (Sandberg & Conner, 2008;
Sheeran & Orbell, 1999), though debate continues (Fishbein &
Ajzen, 2010). Other expectancy value models, such as the health
belief model (Janz & Becker, 1984), may benefit similarly from
including anticipated regret (Bell, 1983). At the very least, studies
relying on these models should also assess and make use of
anticipated regret in their conceptualization of the health behavior.
Anticipated regret had stronger associations with health behaviors
and intentions than several other risk appraisals including per-
ceived severity, which is central to most expectancy value models.
Including anticipated regret in these models would raise several
interesting questions, such as whether anticipated regret acts only
through intentions, whether it could mediate or precede more
cognitive constructs such as perceived severity, or whether it
moderates the intentions-behavior association (Sheeran & Orbell,
1999). Answering questions like these represents a next stage of
maturation in research on anticipated regret and health behavior
models.
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Received November 13, 2014
Revision received August 15, 2015
Accepted August 18, 2015 䡲
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