Thursday, December 20, 2012

There Are No Good Excuses for Alienating Your Target Audience: A Cautionary Tale in Bicycle Helmet Advocacy – Marisa Castrini

Introduction: Helmet Safety
            According to the CDC, more than 500,000 people in the US are treated in emergency departments, and more than 700 people die as a result of bicycle-related injuries (1).   Of those injured, an estimated 67,000 cyclists visit the emergency rooms with a head injury (2).  In relation to other activities, the annual estimated number of bicycling head injuries requiring hospitalization exceeds the total of all the head injury cases related to baseball, football, skateboards, kick scooters, horseback riding, snowboarding, ice hockey, in-line skating and lacrosse combined (3).   Despite evidence showing that up to 85% of bicycle-related head injuries could be prevented by a helmet, the National Survey of Bicyclist and Pedestrian Attitudes and Behavior reports that only 50% of cyclists wear their helmets occasionally and only 35% wear their helmets at all times (4).  While Massachusetts law requires any person16 years of age or younger to wear a helmet while riding (5), no mandate applies to anyone 17 years of age or older.
To help address this issue, in October 2012, the Boston Public Health Commission launched a new helmet safety campaign, with the slogan “No Excuses Wear a Helmet,” to promote bike safety in the city of Boston. According to the Boston Public Health Commission (6) the campaign features three images that appear on two dozen posters throughout the city in high bike-traffic areas.  Two of the images depict young men with bloodied faces.   The first shows the young man, not wearing a helmet, wiping blood from his chin and reads, “STILL THINK IT’S THE HELMET THAT’S UNATTRACTIVE?  THERE ARE NO GOOD EXCUSES” above.  The second portrays a young man (again, not wearing a helmet) lying down, holding his neck and grimacing into the camera, his face heavily scraped up.  The text above reads “AND YOU THINK A HELMET IS UNCOMFORTABLE?  THERE ARE NO GOOD EXCUSES.”  The final poster in the series features a young woman wearing a helmet, looking disheveled with a very minor contusion across her cheek.  The text above reads, “NOT THINKING ABOUT HELMET HAIR NOW, ARE YOU?  THERE ARE NO GOOD EXCUSES.”
Though a new initiative, the No Excuses campaign has already caused uproar in the cycling community.  The campaign has been charged with relying on scare tactics and putting the sole responsibility of safety in the hands of the cyclists, ignoring other environmental factors that contribute to accidents.  In addition, the campaign has been accused of portraying cycling as dangerous, and cycling advocates fear this will discourage people from riding.  According to various sociological theories, these concerns have merit on a much larger scale than previously discussed in the media.  In this paper, all three concerns will be addressed and potential resolutions will be considered.

Critique #1:  Scare Tactics Are Ineffective Among Teens
            While not overtly stated on their campaign page, one is to assume the targets of these posters are teens and young adults, particularly males.  The individuals highlighted in the campaign are estimated to be around 18 years of age, which would be a sensible target considering the national average has students in grades 9-12 who have ridden a bike in the past 12 months reporting that 87.5% rarely or never had worn a bike helmet (7).  Compared to 72% citywide helmet usage reported in Boston (8), this puts these teens at a much higher risk for head injury than the average cyclist.  However, using scare tactics has proven feeble in many anti-drug and alcohol campaigns for this demographic. 
            The National Youth Anti-Drug Media campaign, which used graphic ads claiming that marijuana use lead to the use of harder drugs, was evaluated in 2002.  The study concluded that the teens that were already planning not to use marijuana were unmoved by the ads, but more importantly, those categorized as “most likely to use” were to actually more likely to disbelieve that regular marijuana use has negative consequences after watching the ads (9).  The attempt to use fear to drive behavior change not only failed to resonate with the teens, but the message actually led teens to feel manipulated an even further reject the cautionary tale.
The No Excuses campaign falls short for similar reasons.  It heavily relies on the Health Belief Model (10), under the assumption that teens don’t fully understand the risk of riding without a helmet.  The presumption that teens simply need to be informed that they are susceptible to serious head injuries in order to change their behavior toward helmet use highly underestimates the role of Psychological Reactance Theory (11).  The images on the posters attempt to shock its audience, which teens will recognize as hyperbole given their own personal experiences.  In addition, by taking such an authoritative tone with its tag line, the audience characterizes the messenger as an authoritative figure, from which they will want to rebel against.  This discredits any further message the campaign may try to get across. 
While the threat of an accident is certainly real, teens often downplay the idea that it could actually happen to them personally.  The Optimism Bias is the theory that person perceives their risk of negative outcomes as less likely than others (12).  It is not that teens do not recognize the threat of risk, but rather they are overconfident in their ability to control potentially hazardous situations.  This belief is strengthened each time they ride their bike without a helmet and remain unscathed.  The Theory of Cognitive Dissonance describes the battle between what the target audience has known as true up until now (riding without a helmet and not becoming seriously injured), and what the No Excuses campaign is outlining (you are going to crash and get hurt).  If the initiative has already lost credibility with its audience, the belief set that has already been established will overtake any new ideas.
Another flaw with depending on the Health Belief Model is that it puts far too much clout in the theory that teens, armed with the right information, will make logical decisions regarding their health and safety.  MRI research has shown that the regions of the brain responsible for governing impulses and exercising judgment are not fully developed during adolescence, and in fact, do not finish developing until the early to mid-20s (9).  People are not rational beings to begin with, and when you consider the substantial physical and emotional changes adolescents and young adults face, the main component of your message can’t rely on reasoned behavior. 
Psychographics of the target audience of the No Excuses campaign did not seem to factor into the delivery of the message.  Teens want to feel that they are in more control of their lives than they really are, and by taking a parental tone and lecturing that there is ‘no good excuse,” the Health Belief Model proves to be completely ineffectual in its approach to helmet safety.  The campaign attempts to connect with its target with the core values of attractiveness and comfort.  While these attitudes hit upon common reasons teens do not wear helmets, using these values to shame the target in the posters evokes a negative reaction and weakens any affinity teens may have felt with the individuals in the poster.

Critique #2:  Blaming the Victim
            The message coming out of the No Excuses campaign is that if you don’t wear a helmet for foolishly petty reasons (unattractive, uncomfortable, helmet hair), then you are solely responsible for your injuries.  This completely ignores the outside factors that contribute to cycling accidents to begin with, and puts the responsibility squarely on the cyclist.  Despite very little data having been collected nationally on the subject (which is a problem of its own right), some research indicates that the leading cause of cycling accidents is due to a car failing to yield (13).  However, this campaign speaks only to the cyclist, which further fans the flames of a cultural war growing in Boston: drivers versus cyclists. 
            The No Excuses campaign tried to be very careful with their images, opting not to portray a crash scene or a mangled bike, or showing any cars or busses, to avoid fostering any sort of “bikes vs. drivers” sentiment (14).  However, by omitting this factor, the campaign focus shifts too far to the individual level factors associated directly with the cyclist.  The campaign can be interpreted as blaming the cyclist for their injuries because they did not wear a helmet.  This purposely neglects larger factors that need to be considered to make Boston a more bike-friendly city.  Understandably many public health campaigns choose to focus on one aspect of the problem, to better target their message, but in this instance it creates hostility within the cycling community and further alienates the target audience.
            This tactic promotes an atmosphere of self-serving bias for drivers and policy makers.  Cyclists who do not wear helmets are labeled as irresponsible and the negative consequences of Stigma come into play (15).  Attaching this “reckless” label to cyclists who don’t wear helmets disregards the roles played elsewhere.  The driver can blame the cyclist for their injury because they were not wearing a helmet - not because the driver hit them.  Boston newspapers that referenced cyclist fatalities in the past year mentioned every time, without fail, whether or not the rider was wearing a helmet.  While true helmets can save lives, the bigger factor remains that there are particularly dangerous intersections in the city where cyclists get hit by cars, buses or trains – and the takeaway in those instances should not be whether or not the rider was wearing a helmet.  What needs to be addressed is how to avoid these accidents in the first place. 

Critique #3:  Campaign Depicts Cycling as a Dangerous Activity
The second most popular outdoor activity in the US (16), cycling is good for reducing other public health threats such as diabetes, heart disease and obesity.  Research shows adolescents who bicycle are 48% less likely to be overweight as adults (17).  Cycling also has discernible environmental health factors that can cut down on air pollution that is a considerable trigger for asthma sufferers.  However, the No Excuses campaign chose to focus on the negative, which in turn illustrates a direct correlation between cycling and a bloody face.  In a disservice to other public health campaigns which are trying to encourage people, especially adolescents to be more active, this campaign has the potential to scare away existing and future cyclists from riding in Boston by using fear tactics to get its message across.  
Fear-based advertising is a specific type of social marketing that employs scare tactics or other anxiety-producing mechanisms to highlight the dangers of engaging (or not engaging) in a certain practice (18), in this instance, wearing a helmet.  By advertising the imminent likelihood of a gory crash, the No Excuses campaign is promoting a fear of cycling.  As previously mentioned, this tactic will be highly ineffective with its target audience to begin with, but can cause further harm by showcasing cycling as a dangerous activity to the general public.  With Boston putting in a commendable effort towards improving infrastructure and bicycle accessibility, this feels like a step backwards for the overall mission.
Particularly detrimental to the initial public health push for cyclists, research shows there is safety in numbers.  It has been reported that more bikers on the road promote a safer environment for everyone.  Drivers become accustomed to sharing the road with bikers and checking before they turn or change lanes, and bikers can ride more confidently and visibly in groups (14).  The No Excuses campaign had initially reached out to cycling advocacy groups when the initiative was still in the planning stages, and overwhelming response was “anything but a scare campaign.”  It appears as though the campaign started off with good intentions, but then ignored their own research.  Cycling advocacy groups know their market better than public health professionals.  The campaign had a great resource into the psychographics of their target, and went with a stale method in the end.

Intervention – Know How to Approach Your Audience
            The overall flaw with the No Excuses campaign is that it alienates the very groups it is reaching out to.  The primary target of the campaign is teens and the secondary audience is a much broader reach of cyclists in general.  Sadly, both groups were mishandled by this campaign.  The general tone of the message was condescending to teens, which will trigger a rebellious response.  In addition, the execution laid blame squarely on the shoulders of the cyclists, causing many riders to react aggressively toward the campaign as they felt the need to defend themselves.   Overall, the effort elicited an immediate knee-jerk reaction and was neither persuasive nor valued by its intended audiences.

Addressing Critique #1:  Talk to Teens as Their Peer, Not Their Superior
            Ideally the focus of the next potential campaign will shift to positive approaches.  Giving young adults a sense of ownership, making them part of a community is important.  Currently, Bikes Not Bombs does a remarkable job at reaching out Boston youth and getting them actively involved.  Their website asserts: “We believe that the best youth programs are ones that involve young people not only as participants but also as consultants and ones that give young people the opportunity to self-manage and become leaders.” (19) This is exactly how this age group needs to treated.  In order to breed life-long habits of safety and respect, these kids need to feel like they are contributing to a project and that they are important.
            For a shorter-term, more general approach, I would recommend developing a media campaign that appeals to teen’s sense of humor.  Most importantly, this message needs to be available where teens spend their time.  According to Nielsen, teens are the heaviest mobile video viewers and more receptive to mobile advertising than older generations.  They spend less time watching television or to browse the Internet.  They know where they want to go, and get there through their phone.  Social media sites and YouTube are the best places to catch this demographics’ attention.
The main component behind the campaign would be a series of short 30-second videos.  These clips would exist on a social media site such as Facebook, as well as on YouTube.  In terms of style, parodies are a great format for this age group.  At the adolescent stage in life, it is cool to mock anything that takes itself too seriously, such as a public health message.  But if the message itself is poking fun at an existing campaign, teens feel like they are in on the joke, and are more likely to identify with the core value of rebellion. 
The clips, either two or three in total, would play on safe sex messages.  In one, the camera shows a teen boy is getting ready for a date.  You see him put several condoms into his backpack and he heads out the door.  His phone vibrates and when he looks down there is a text message that reads, “Don’t forget the protection <3.”  You see him head back in the house and grab his helmet on the counter before hoping on his bike and riding away.  Another clip would open on a shot of two teens making out.  For the sake of perpetuating gender stereotypes in this example, the boy will pull back and ask the girl “Are you sure you’re ready?” to which she will reply “Did you bring protection?”  The boy smiles, hands her a helmet, and camera pans out to show them getting on a tandem bike.  The scene fades to black as they ride off into the sunset.

Addressing Critique #2:  Involve Cyclists and Motorists Alike
            A collaboration between MassBike, the Massachusetts Department of Transportation, Executive Office of Public Safety and Security, Department of Public Health, Department of Conservation and Recreation (I just love it when organizations work together), the website  “Same Roads.  Same Rules” does a good job of speaking to the community as a whole.  The mission is to reach out to both cyclists and motorists and debunk common misconceptions.  While there are the typical “safety tip” sheets that advocate helmet use and proper signaling, the main goal of the initiative is to foster a truce between cyclist and motorist.
The website provides information two both parties and holds each responsible for their actions.  There is an almost playful tone in the “Myths Vs Reality” section, where the site lays out common complaints from each side, and provides solutions in a calm manner, while subtly drawing attention to how self-entitled the complaints on either side can be. It is important to note that the message is not explicitly promoting health; rather it tasks citizens with the responsibility of keeping one another safe.  It forces a sense of ownership for someone else’s safety.    The “us versus them” mentality gets reframed to an all-inclusive label of “people” - everyone is in this together.  While this tactic does not spread a wide net (Bostonians are known for their cynicism, after all), it is certainly a step in the right direction.
What the No Excuses campaign could learn from this is that just one group can’t shoulder the responsibility of public health.  The most off-putting aspect of the campaign is that by leaving motorists out of the equation, cyclists feel ganged up on by the very commission that is claiming to support them.  This fundamental attribution error by the campaign has been interpreted as outwardly hostile towards cyclists, and therefore any message that follows is met with disdain and defiance.  The conversation needs to be shift from individual responsibility to policy change.
Part of what is hindering further safety analysis is the lack of data available to advocacy groups.  Sadly, most often thorough action is not taken until a high-profile tragedy hits the media.  In the wake of last week’s terrible accident on Commonwealth Avenue, a bike safety hearing produced a significant victory for health and safety advocates promising a long-term bike crash data improvement.  The Menino Administration is commissioning the first thorough analysis of Boston Police narrative reports for bike crashes in the city, covering 2009-2011, and will be made available to transportation planners and others involved in the public health and safety initiative (20).  The key to successfully presenting these results is to refrain from pointing the finger at neither cyclist nor motorist.

Addressing Critique #3: Promote Cycling as a Community Activity
            The goal of the following is to once again create an environment for people to identify with wearing helmets.  Earlier we focused on a teen target demographic, but there is also a need to reach the broader population. Boston hosts bike events throughout the year and these are great opportunities to promote helmet use for all cyclists.  This is an atmosphere where it is appropriate to hand out fact sheets; all the better if they also include vouchers for helmets.  For younger attendees, or those who are simply young at heart, a booth could be available where crafty helmet decorations are available.  Items that will not compromise safety, such as pipe cleaners, stickers, or fake flowers, can create a playful atmosphere where if you don’t have a helmet, you are left out of the fun.
Much more structured programs like Roll it Forward reach out to low-income communities by distributing bicycles and providing proper bike safety education.  Every recipient of a bicycle from this program is fitted with a helmet and is required to complete a bike safety education workshop and must demonstrate safe riding skills.  They also must agree to ride courteously and with a helmet.  Similar to how Bikes Not Bombs approaches the initiative, the focus is on providing a sense of identity as a cyclist.  Part of that identity involves wearing a helmet and expands even further to groom responsible cyclists.
This next proposal focuses more on taking advantage of convenience rather than identifying with helmet culture.  Currently inexpensive helmets are available for purchase near Hubway stations, the bike-share program, but the idea of buying a helmet when only renting a bike for a short ride does not connect with members.  A possible solution is to have each bike come equipped with a helmet per rental.  There currently do not exist rental helmets that can be quickly sanitized between uses, but that is a challenge I ask anyone who reads this paper to explore.  If we could have Helmets on hand and ready to go with a rental bike it could help foster the normalization of helmet use in the city.

Boston is currently in the process of transforming into a community of cyclists.  Helmet use is only a part of what contributes to the overall public health mission for cyclists, but with the right strategy and collaborations, a difference can be made.  Communication between advocacy groups is necessary before the launch of any new campaign in order to gather as much research from community peers.  Boston is fortunate to have a number of dedicated organizations focused on the same overall goal and much can be learned from their experience.  The biggest mistake the No Excuses campaign made was not listening to the suggestions of fellow advocates.  What resulted was an unimaginative attempt at curbing irrational behavior that fell flat with its target.  As more alternatives to the Health Belief Model are implemented across the system, the public health community will start to see more creative approaches to tackle growing epidemics. 

1.    Centers for Disease Control and Prevention (2009).  Bicycle Related Injuries
2.   Lewis & Tompkins, P.C.  National Bicycle Accident Statistics
3.   Snell Safety Education Center, Inc.  (2009).  Use Your Head, Wear a Helmet '09  [Brochure].
4.   National Survey of Bicyclist and Pedestrian Attitudes,
6.   Boston Public Health Commission (2012).  Helmet Safety Campaign.
7.   Centers for Disease Control and Prevention.  Youth Risk Behavior Surveillance. MMWR 2012;61(No. SS-#).
8.   City of Boston. (2010). 2010 Boston Bikes Annual Summary
9.   National Institute of Mental Health. (2001).  The Teen Brain: Still Under Construction.  NIH Publication No. 01-4929.
10.          Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
11. Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008; 98:2229-2236.
12.          The National Academies Press. (2007). Preventing Teen Motor Crashes: Contributions from the Behavioral and Social Sciences: Workshop Report. Washington, DC
13.          Network of Employers for Traffic Safety (2012). Bicycle Related Injuries and Fatalities.
14.          Bike Safe Boston Blog. (2012).  The Helmet Dilemma
15. HealthKnowledge. (2007). Concepts of Health and Illness: Section 3. Labeling and Stigma.
16.          Outdoor Industry Association.  (2011).  2011 Outdoor Recreation Participation Topline Report 2011.
17.          Menschik D, Ahmed S, Alexander MH, Blum RW. (2008). Adolescent physical activities as predictors of young adult weight. Arch Pediatr Adolesc Med. Jan;162(1):29-33. doi: 10.1001/archpediatrics.2007.14. PubMed PMID: 18180409.
18.          Bradley, Ishmeal. (2011).  Ethical Considerations on the Use of Fear in Public Health Campaigns. The NYU Langone Online Journal of Medicine.
19.          Bikes Not Bombs.
20.         Boston Cyclists Union

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