Monday, December 24, 2012

Analysis and Critique of BPHC Helmet Safety Campaign – Yara Tayeh

        Nationally, bicycle safety is a big concern and may be an even larger concern in the Commonwealth of Massachusetts.  According to the Center for Disease control, the annual rate of bicycle-related emergency visits is over 500,000 people in the US, and more than 700 people die as a result of bicycle-related injuries (1).  In Boston in particular, Commonwealth Avenue and Massachusetts Avenue have the highest rate of bicycle accidents, according to three surveys published by Boston Bikes in 2010 (2). Boston Bikes, a bicycle safety campaign and movement sponsored by Mayor Menino since 2007, reported in its key findings of a survey that citywide helmet usage was up to 72%.  This may seem like a high rate, but the survey also reported that helmet use among EMS calls was only 45% (3). 
Despite these overwhelming statistics, it is evident that cyclists make up a large portion of the population. According to the 2002 National Survey of Pedestrian and Bicyclist Attitudes and Behaviors survey, approximately 57 million people, 27.3 percent of the population age 16 or older, rode a bicycle at least once during the summer of 2002 (4). So how can we protect this large group of cyclists and not only encourage helmet wearing but bicycle safety as a whole?
Mayor Menino has actively been promoting bicycle safety in Boston since 2007 but The Boston Public Health Commission very recently launched a new campaign to promote bicycle safety in the city of Boston in October of this year. The campaign introduces various advertisements across high bicycle-traffic areas in Boston as well as stencils featured on bicycle lanes on major streets in the city.  The advertisements scattered around Boston feature three images of bikers.  In two out of the three advertisements, cyclists without helmets are depicted sustaining serious injuries. In the third advertisement, a helmet-wearing female cyclist is portrayed as dirtied up but virtually injury-free. The posters and stencils on city bike lanes share the same or nearly identical messages stating that there are “No Excuses. Wear a Helmet.” The goal of the bicycle safety campaign is to promote and increase helmet use in the city of Boston, with the central message that it is always safer to ride a bike with a helmet than without a helmet (5)
While the Boston Public Health Commission has just recently released this campaign for helmet safety—thus an insufficient amount of time has passed and proper steps have not been taken in order to evaluate the program—there is evidence to believe that the campaign will not be successful in increasing helmet use in the greater Boston area.  Several problems emerge when analyzing this public health approach to helmet safety and promotion.  This paper will discuss three central flaws in the helmet campaign’s design and will then proceed to explore specific recommendations aimed at improving the approach to helmet safety. 

First Critique of Intervention: Health Belief Model is not appropriate for Helmet Safety Campaign
            The Boston Public Health Commission’s campaign for bicycle and helmet safety follows the well-established and one of the most widely used public health models, the Health Belief Model (HBM), but even the most widely used model can be inappropriate when looking at the context of the issue being addressed.  The Health Belief Model asserts that health behavior is motivated by the following six factors: 1) perceived susceptibility to an issue, 2) perceived severity of an issue, 3) perceived benefits of an action, 4) perceived barriers to taking that action, 5) the presence and experience of a cue to action, and 6) the belief in one’s own self-efficacy related to the behavior in question (6).  Essentially, the HBM suggests that people behave in a rational, predictable manner and that they carefully and thoughtfully weigh susceptibility to, severity of, and barriers to an action against the perceived benefits in order to logically make a decision.  The HBM is a value expectancy model, which refers to the assumption that people will behave in a certain way if they value the outcome and if they believe that this particular behavior is likely to results in that outcome (6).
            Despite these logical assumptions, it is clear that people do not behave as rationally and thoughtfully as expected. According to several studies including a study conducted by Clayton, Cantorrelo, and Johnstone, the Drug Abuse Resistance Education program, which was largely modeled with an HBM approach, was ineffective in reducing the rate of drug use and abuse in elementary and middle school populations (7).  Among other theories, D.A.R.E. program’s entire basis revolved around student education about the severity and susceptibility of drug use and abuse and the benefits of abstaining from this unhealthy behavior, but the program was largely ineffective.  Some studies have even observed an unintended reverse effect; the establishment of the D.A.R.E program may actually have increased the rate of drug use and abuse in evaluated populations and thus the U.S. Department of Education has halted all federal sponsorships for D.A.R.E. programs (8).
            This failure in the HBM has been observed in previous helmet safety campaigns, and the Boston Public Health Commission’s recent campaign has failed to learn from previous shortfalls. Surveys conducted by the Boston Bikes have determined that the target population—mostly consisting of students at universities throughout the Boston area—simply do not wear bicycle helmets because they are uncomfortable, too hot, or result in “helmet hair” (3).  With this invaluable data, the Boston Public Health Commission should not then turn around and attempt to educate the public about bicycle safety and the importance of helmets.  Educating the public about the perceived benefits of helmet use will certainly prove to be ineffective.  Bicycle and helmet safety has been a core element in early health education in Massachusetts, but still students choose not to wear helmets (9).   It is not a matter of self-efficacy—a person’s belief in his/her ability to wear a helmet is not of concern here—but the perceived susceptibility of the individual is simply too low.  Young adult populations have been educated about the dangers of cycling without proper protective headgear, but the perceived costs of wearing the helmet seem to outweigh the benefits through the eyes of the trendy, young college student.  In human development, teenagehood and young adulthood are marked by what is called the “Invincibility theory”, which is the belief that despite perceived dangers, a life-threatening event simply will not occur to the student as they perceive themselves to be invincible (10).  Consequently, it is essential that the Commission step outside of the limiting and inapplicable spectrum of the HBM, dismiss the idea of bicycle education, and instead focus on the idea of immediately changing the behavior, which may potentially instill a change of attitude later on. 
The Diffusion of Innovations theory and the idea of a “tipping point” suggests that past a certain rate of adoption of a particular behavior, the rate of adoption will escalate dramatically (11).  The premises and assertions of this theory may be more useful for the helmet safety campaign.  It is important to convince the population of interest to change the behavior first—in this case the behavior being helmet use—and with that behavior change the adoption of a health-oriented mentality will come.  This new theory will be discussed further on.

Second Critique of Intervention: Forceful messages have reverse effects, especially on youth
An important psychological theory that must be considered when developing public health intervention is the Theory of Psychological Reactance.  According to this theory developed by Jack Brehm, when behavioral freedoms are taken away, people will respond in the opposite manner. Brehm writes:
“…people become motivationally aroused by a threat to or elimination of a behavioral freedom. This motivational state is what is called psychological reactance. It impels the individual to restore the particular freedom that was threatened or taken away. It does not impel the individual to acquire just any freedom--only the one threatened or taken away will do” (12).

When a public health campaign begins telling people what to do in a forcible manner, it is likely that the public will respond to this threat to freedom with the opposite behavior.  An example of this dilemma arises in the abstinence-only campaign implemented in several cities and states across the United States.  According to a report published by the Legal Momentum advocacy group and sponsored by Harvard School of Public Health, not only are abstinence-only campaigns wrongly created under the pretext of conservative ideologies and political motivations, they have been proven to be rather ineffective in preventing sexually transmitted diseases and pregnancies (13).  The report states that
[w]hen youth schooled by abstinence-only programs do become sexually active, the programs’ anti-condom messages may actually discourage them from practicing safe sex, making the negative information the programs offer about contraception and disease prevention particularly dangerous. Such messages deny young people the opportunity to receive vital education to protect their health and well-being and, in particular, impede girls’ ability to avoid unwanted pregnancy and STIs to which they are more biologically susceptible” (13).  

Furthermore, the American Public Health association cites that Longitudinal studies find that although abstinence pledgers, when compared to non-pledgers, were more likely to delay initiation of intercourse, they were less likely to use condoms and other contraception after initiation; at six-year follow-up, pledgers experienced similar rates of STIs when compared to non-pledgers (14).
In addition, the efficacy of mandatory helmet laws is under speculation because what may have been perceived as increased helmet use among the population may actually have been due to the fact that a large group of cyclists simply stopped biking altogether as a result of the law.
Like many of these aforementioned interventions, the Boston Public Health Commission’s helmet safety campaign fails to take into account the Theory of Psychological Reactance.  Instead, it relies on strong, forceful language like the slogan “No excuses. Wear a helmet” to promote healthy behavior.  This is likely to be a significant shortcoming of the campaign in the future.  Rather than taking away freedom from the group, the intervention should focus on giving the population something that they desire.  Shifting directions and thinking less about campaigning and more about advertising may be just what this campaign needs (and this will be discussed further along in the paper).

Final Critique of Intervention: Inappropriate use of marketing images
The helmet safety campaign puts too grand of an emphasis on fear.  Catch phrases like “No excuses” and displaying images of bloodied and severely injured peers only strives to scare the population. Instilling fear in this target population does not seem like it will be a very effective mechanism for promoting a healthy behavior.  A study was published in the Journal of Psychology and Health that explored the use of fear arousal in health education.  It found no solid evidence that fear as a central message in campaigns and health education is an effective means to promote behavior change (15).  The study states that “fear control processes may interfere with precautionary motivation, recommends cautious and limited use of fear appeals in health promotion. It seems likely that fear arousal is less important in motivating precautionary action than perceptions of action effectiveness and self-efficacy” (15).  The authors of the study recommend cautious use of fear appeals for health educational campaigns, suggesting that campaigns may profit more from highlighting the personal relevance of threats to health and the feasibility of preventative action rather than “frightening people about the severity of outcomes following risk behavior by showing images of death and injury” (15).
By contrast, a meta-analysis performed by the Department of Communication at Michigan State University that reviewed the use of fear appeals in public health campaigns found intriguing results (16).  The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, which confirms the efficacy of the Health Belief Model for certain public health campaigns. It appears that strong fear appeals followed by high-efficacy messages are most successful in producing behavior change, whereas strong fear appeals with low-efficacy messages are met with higher levels of defensive responses (16).  In what realm does the Boston Public Health Commission’s helmet safety campaign lay?  While wearing a helmet requires little effort, perhaps this meta-analysis did not take into account the age group and the behavior in question.  It is likely that the target population is immune to strong appeals to fear because of the aforementioned Invincibility theory.  Because the population of interest has such little perception of susceptibility, then a strong fear appeal will only lead to defensive reactions and overcompensated behaviors.
Rather than relying on fear appeals, the Boston Public Health Commission should focus on marketing and appealing to the aspirations of youth. Marketing theory has been very effective in all different fields, including business, product promotion, and public health, which will be further discussed below.

A New Proposal: Redefining helmet safety in Massachusetts
Although the helmet safety campaign sponsored by the Boston Public Health Commission uses traditional designs to promote healthy behavior, there is evidence to suggest that this campaign will not be entirely successful in increasing helmet use in Boston, Massachusetts.  The following sections will propose an alternative approach to this helmet campaign, building off of and improving upon the design of the current campaign.
I propose three modifications to the campaign: 1) focus on immediate behavior change rather than trying to educate the public by providing discounted helmets to the public, 2) instead of taking the freedom away from cyclists by forcing them to obey the law with “No excuses”, promise freedom to the cyclists and give them something instead, and lastly 3) employ marketing techniques to inspire helmet use and change the face of the posters scattered around Boston.  Let us begin by individually examining each of these modifications and try to understand the social and behavioral theories that support these changes to the campaign.

First Defense of New Intervention: Change behavior, change a mind
The helmet safety campaign is largely based off of the Health Belief Model, where educating the public about the severity and susceptibility of bicycle accidents in order to promote helmet use is significantly stressed.  But we have seen how in more than one case, the Health Belief Model just does not seem to work out as well as expected, especially when dealing with youth who do not feel especially susceptible to the dangers of the road.  The Diffusion of Innovations Theory explains the pattern and rate of behavior adoption in society, which is usually portrayed by a sigmoidal curve (17).  Along the curve range people we call Innovators, then Early Adopters, then the Early Majority, the Late Majority, and finally at the very end of the curve are the Laggards (in order of early to late adopters of the behavior of interest).  In a study conducted by James Dearing, Edward Maibach, and David Buller, the Diffusion of Innovations theoretical approach was explored in promoting physical activity (18).  Among other results, the study found that in order to be effective, interventions should focus on tailoring messages according to each individual’s degree of readiness (where he/she is on the sigmoidal curve) and employ change agents to interact with potential adopters (18).  
In his book, The Tipping Point, Malcolm Gladwell writes about the phenomenon called the “tipping point”, which is the idea that explains change as not a gradual occurrence but something that happens at one dramatic moment of time; little changes can have big effects (11).  So how can we combine both the Diffusion of Innovations Theory and this “tipping point” concept to promote helmet use?
The Boston Public Health Commission should focus on providing discounted helmets to the target population, and past a certain point of behavior adoption, the use of helmets should escalate dramatically. When just a small subset of people potentially adopts helmet safety, they, in turn, will influence the vast majority of other potential adopters to use a helmet while cycling.
            The Boston Public Health Commission’s agenda has included providing $5 bicycle helmets to cyclists in the past, but students do not want cheap and unstylish headgear (5).  These helmets should be stylish and have a slightly aerodynamic shape so as to be more aesthetically appealing.  It is important that the helmets are fun and sleek, but still of the highest and safest quality. The helmets can even be designed to have built in compartments made of breathable material—perhaps built in headphones—that does not jeopardize the safety of the rider.  If the Boston Public Health Commission focuses on making the helmets more fashionable and appealing, then perhaps more people will begin wearing the helmets.  Another strategy could be to pay public health professionals to cycle around Boston while sporting these fashionable helmets.  The more these helmets are sighted, the more likely observers will be to begin wearing helmets until the number of peoples wearing the helmets will pass the “tipping point” and escalate dramatically.

Second Defense of New Intervention: Advertising for freedom
The Advertising Theory can take the idea of providing discounted helmets one step further.  Not only should these helmets be stylish, they should display one single word on them—a word that the bicyclists themselves can choose.  For example, a bicyclist can either custom-make the helmet by selecting a word that holds great meaning for him/her (such as “hope” or “freedom” or “courage” or the name of a significant other or perhaps a loved one who has passed) or he/she can choose from a range of helmets with a range of statements.  Imagine how these helmets can immediately transform from unstylish and annoying to equipment that symbolizes the ideals and system of beliefs of the wearer.  The helmets can become symbols of youth, independence, originality, and most of all freedom.  Students will want to wear their helmets in order to proclaim to the world what they stand for and compare their symbols with others.  Imagine if one cyclist reads the word on another’s helmet and this ends up striking up a wonderful conversation between two strangers.  The helmets can come to symbolize and expand the social lives of those who wear them.
Advertising Theory focuses on meeting the needs and desires of the intended audience, promising the audience that they will be or feel a certain way if they adopt this particular product or behavior (19).  These helmets potentially make promises of freedom, uniqueness, and expression to consumers.  Relying more on Advertising Theory quickly bypasses any sort of psychological reactance that may occur as a result of strong, forceful messages (“No excuses. Wear a Helmet”) and instead empowers bicyclists to take control of their own lives.  This change in campaign design may significantly improve rates of helmet usage in Boston.

Final Defense of New Intervention:  Appealing to aspirations
Lastly, let us take a look at Social Marketing Theory and see how it can apply to and support the modified helmet safety campaign.  Social Marketing Theory is based on the idea that the behavioral and social change of interest should be reframed and repackaged in such a way so as to make it more appealing and more tailored to the target beneficiaries (20).  Public health professionals must focus on tailoring the message according to the needs and values of the audience, as well as appealing to the population’s preferred channels of communication (20). 
Social Marketing Theory has been found to be the most effective model used to influence behavior change, specifically in regards to sexual health (21).  The Hombres Sanos, a social marketing campaign aimed at the promotion of condom use and HIV testing for Latino men and women, was well-received and showed promising results.  This campaign employed social marketing techniques—which involved consumer-centered, culturally sensitive communication, branding and catchy slogans, as well as visual media such as appealing and humorous posters—in order to promote condom use and HIV testing (20).  The campaign really focused on the population’s interests and aspirations, molding its message and tone to fit the needs and values of Latino men and women.
So how can we employ social marketing techniques in order to increase helmet safety in Boston? The helmet safety campaign should appeal to the aspirations of the youth that are not wearing helmets via various media used by youth.  What do young, college-level adults aspire for?  What do cyclists aspire for?  Let us return to the idea of freedom and fun introduced earlier in this paper.  College students usually strive for independence, fashion, and a good time, and we know that helmets do not necessarily evoke any of these values.  How can we transform perceptions of bicycle helmets?  Building upon the proposals mentioned earlier, public health professionals should focus on advertising for the new, trendy bicycle helmets using empowering and stylish posters scattered around Boston as well as utilize social media as a means of communication.  These posters and advertisements should be catchy and appeal to the motivations of freedom and independence, branding these helmets as tools for expression. All materials for the campaign should be consistently branded under the concepts of independence, strength, and empowerment.  The helmet brand could be called ‘Xpression’, which emphasizes that these helmets are not just for safety but mainly for the freedom of expression.  Envision an electric poster that shows the silhouette of a man or woman on a bike with the words “strength” or “fierce” or the catch phrases “I am my own person” or “keep smiling” imprinted on his/her helmet.  The poster will display a single phrase on it “Xpression: what defines you?”  This poster would strike the average college student more than an image of a young adult male covered in blood after a bicycle accident.
            Overall, the Boston Public Health Commission’s helmet safety campaign can be improved by using and modeling after theories such as the Diffusion of Innovations Theory, Advertising Theory, and Social Marketing Theory.  “No Excuses. Wear a helmet” just does not sit well on the tongue, but a campaign that revolves around empowering youth while still remaining fashionable and easily adoptable may just be what Boston has been waiting for all this time.


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