Sunday, December 16, 2012

Why the Boston Public Health Commission’s Helmet Safety Campaign Will Be Ineffective: A Critique And An Alternative Approach - Marlena Sherman

In October, the Boston Public Health Commission (BPHC) launched a campaign to promote helmet safety.  The campaign developed from the results of two different sources.  Survey counts by Boston Bikes found that approximately 70% of the riders they saw wore helmets.  A study published in the Annals of Emergency Medicine found a Boston helmet use rate of 48%.  According to the BPHC, either rate demonstrated that they had to promote and increase helmet use in order to prevent head and brain injuries.   
The overall campaign message is that it is always safer to ride a bike with a helmet than without a helmet.  The campaign features three images, which appear on two dozen posters throughout the city in high bike-traffic areas, and stencils on city bike lanes that remind riders there are “No Excuses. Wear a Helmet.”  In two images, two young adult male bikers not wearing helmets have sustained injuries from a crash.  In one image, the male biker has a brutal bloody face and is holding a tissue to his face.  The following message appears at the top of the poster: “Still think it’s the helmet that’s unattractive?  There are no good excuses.”  In the second image, the male biker has a bloody face, is lying on his back, and is holding his neck.  The following message appears at the top of the poster: “And you think a helmet is uncomfortable?  There are no good excuses.”  In the third image, a young adult female biker wearing a helmet has been in an accident.  Her helmet has been damaged, she has scrapes on her cheek and chin, and she looks dazed and confused.  The following message appears at the top of the poster: “Not thinking about helmet hair now, are you?  There are no good excuses.”  At the bottom of each poster it says, “Wearing a helmet can prevent serious head and face injury. Make it an essential part of biking.”  The stencil of a silhouette wearing a helmet and the message “No Excuses. Wear a Helmet.” is also at the bottom of each poster. 
This paper will provide a critique of this helmet safety campaign arguing that it is flawed in three specific ways, propose an alternative campaign, and explain how the alternative campaign takes into account these flaws.
Flaw #1: Assumes people are rational --- Health Belief Model

The first reason why the intervention is flawed is because it assumes individuals are rational by using the health believe model (HBM) in an attempt to alter individual decision-making.  The HBM, which focuses on individual decisions, was developed in the 1950s to explain why people did not engage in behaviors to prevent or detect disease early (1)The elements of the HBM are: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers (2). Perceived susceptibility is the perception of personal risk for a health problem or the chances of being severely injured while wearing or not wearing a helmet and perceived severity is the degree to which a person believes the consequences of the health problem will be severe or the extent of injuries.  The two graphic images of the young men who are not wearing helmets with bloody faces are trying to increase the perceived severity and susceptibility of the serious consequences of not wearing a helmet if you are in an accident.  The third image of the female biker who is wearing a helmet, is trying to decrease the perceived susceptibility and severity of getting severely injured if you are wearing a helmet and in an accident.  Therefore, the BPHC is attempting to increase helmet usage by increasing bike riders’ perceived susceptibility and severity or decreasing perceived susceptibility and severity.  The campaign also addresses perceived barriers associated with not wearing helmets by incorporating reasons riders choose not to wear helmets, for example, they are uncomfortable, unattractive, or result in helmet hair.

The type of action a person decides to take depends on perceived benefits, which is the combination of perceived susceptibility and severity or the positive outcomes a person believes will result from an action, and perceived costs, which are the barriers or potential negative outcomes a person believes will result from an action.  According to the HBM, people weigh the perceived benefits and perceived costs (1).  Therefore, the HBM assumes that when people are making the decision about whether or not to wear a helmet they will undergo an internal, rational process that assesses their degree of risk and make a cost-benefit calculation.  In spite of this, there is evidence that shows people are irrational and have a tendency to behave irrationally.
            In Predictably Irrational: The Hidden Forces that Shape Our Decisions, Dan Ariely, presents experiments that demonstrate that people are predictably irrational in the way they make decisions (3).  His experiments provide insight into how we think and how we make decisions.  Specifically, his experiments illustrate that there is a problem with assuming that we are rational and that we compute the value of all the options we face and then follow the best possible path of action.  For example, Ariely and his colleagues set up a table at a large public building and offered two kinds of chocolates¾Lindt truffles, which are irresistible, and Hershey’s Kisses, which are ordinary.  There was a sign above the table that read, “One chocolate per customer.” and the prices of each chocolate.  When they first set the price of a Lindt truffle at 15 cents and a Kiss at one cent, they found that the customers compared the price and quality of the Kiss with the price and quality of the truffle since about 73% chose the truffle and 27% chose a Kiss.  However, when Ariely and his colleagues offered the Lindt truffle for 14 cents and the Kisses free, the Kisses became the favorite even though the customers had the opportunity to get the Lindt truffle for a very good price.  Specifically, about 69% of customers chose the free Kiss and about 31% of customers chose the Lindt truffle.  The results of the experiments exemplify that when people are confronted with something that is free they make decisions that are not in their best interest, which means that people are not exclusively relying on rational cost-benefit analysis.  This experiment and the other experiments Ariely describes illustrate how the pattern of choice digresses from a rational thought process that weighs the costs and benefits. 
The BPHC made the mistake of creating a campaign that warrants people conduct a rational cost-benefit analysis.  The BPHC is attempting to increase the perceived severity and susceptibility of the potential implications of not wearing a helmet by showing that the consequences will result in an injury to the face and neck.  It is also attempting to decrease the perceived severity and susceptibility of the potential implications of wearing a helmet by showing minor bruising to the face.  They also address the perceived barriers by referencing them in the form of a question at the top of the poster.  For example, “And you think a helmet is uncomfortable?”.  Therefore, the content of the posters is trying to get bike riders to weigh the perceived benefits and perceived costs of not wearing a helmet or wearing a helmet.  The BPHC is hoping that bike riders will believe the costs of taking action, such as being uncomfortable or getting helmet hair, are outweighed by the benefits, which means wearing a helmet to reduce their severity and susceptibility. Therefore, the BPHC believes that if the consequences of not wearing a helmet and the benefits of wearing a helmet are disseminated across the city, people will use this information to make their decision and will be more likely to wear a helmet in agreement with the HBM.  However, the HBM assumes people are rational, which is not the case since people are irrational in a predictable way.
Flaw #2: “No Excuses. Wear a Helmet.” Evokes Psychological Reactance
The second reason why the campaign is flawed is because it can evoke psychological reactance.  The campaign maintains that their goal is to get more people to wear helmets every time they ride bikes.  Though, their three posters exclusively feature young adults.  Therefore, it appears that these posters are trying to speak to young adults who do not wear helmets.  It seems feasible that the BPHC would inherently focus on this population since the rates of helmet use among college students are consistently below 25% (4) and there are about 152,000 students at Boston’s institutions of higher learning (5).  Nonetheless, the BPHC failed to take into account how their slogan, “No Excuses. Wear a Helmet.”, would be received by this population.  When delivering a message that is trying to get people to act, such as wear a helmet, it is important to consider psychological reactance in order to decrease the risk of message rejection.     
Psychological reactance theory, coined by Jack Brehm in 1966, evolved in an effort to explain why people often do the opposite of what they are asked to do, and why efforts to persuade people are often ineffectual (6). According to Brehm, reactance theory posits that individuals become psychologically aroused when their perceived behavioral freedoms are threatened or reduced and reactance, a motivational state aimed at restoring the threatened freedom, ensues (7).  Therefore, one way of restoring a threatened freedom is by exercising that freedom.
Research shows that individuals during transitional stages, which include young adults who are considered emerging adults, tend to feel their behaviors are their own business and are inclined to reject persuasive appeals perceived as attempting to control them in any way (7).  As a result, messages that prescribe or prohibit their behaviors can place them at risk for reactance, which can motivate them to perform those behaviors (7). 
How the message prescribes or prohibits behavior is extremely important because the strength or intensity of the language used is known to affect whether an individual will respond favorably toward an advocated behavior (7).  Language intensity can be defined in terms of explicitness where explicit messages tend to convey a single meaning and explicit commands tell a person clearly and directly what to do by using forceful language (7). According to Lanceley (1985), highly explicit, directive language is viewed as controlling (7) and has been found to increase reactance and message rejection among young adults.  For example, studies surrounding excess drinking on college campuses found that messages radiating controlling language led to negative ratings of the message and more drinking intentions, and participants consumed a third more beer than participants exposed to a low-controlling message (8).  Quick and Considine (2008) found that an adult sample responds unfavorably to forceful persuasive messages advocating exercise activities. Messages that contained forceful language such as “You have to do it” or “Stop the denial” were associated with reactance and decreased persuasiveness (9).  Therefore, limiting or threatening freedoms through controlling or forceful messages, have the potential to evoke reactance and, as a result, lead individuals to attempt to restore their threatened freedom by disregarding the message or performing the opposite of the behavior advocated.
No Excuses. Wear a Helmet.” is explicitly telling people what they should do.  As a result, it has the potential to be perceived as controlling and coercive, thus reducing the message’s effectiveness since controlling language can lead to psychological reactance and consequently, message rejection.  Therefore, it is likely that this promotional health message fails to motivate young adults who do not wear a helmet to wear a helmet.     
Flaw #3: Unrealistic optimism
The third reason why the campaign is flawed is because it does not account for Neil Weinstein’s unrealistic optimism, which is also known as optimistic bias.  Unrealistic optimism developed from the ideas that people tend to think they are invulnerable and they expect others to be victims of misfortune, not themselves (10).  According to Weinstein, these ideas imply a hopeful outlook on life and an error in judgment (11).  The error in judgment is what he refers to as unrealistic optimism.  Research shows that beliefs about personal vulnerability are often systematically in error (10). 
According to Baric (1969), getting people to acknowledge their vulnerability, especially getting them to admit that they may be at greater risk than most others around them, is not an easy task (10).  Furthermore, for many health and safety threats, people tend to think they are less at risk than other people (10).  For that reason, featuring posters that pose a safety threat can result in people thinking that their chances of getting into a bike accident are less than average so why wear a helmet.
         Surveys concerning automobile accidents and disease find many people who say their risk is less than average and a few who say their risk is greater than average (11).  A study using the HBM to predict helmet use among undergraduates examined their personal vulnerability as part of a 57-item Bicycle Helmet Attitude Scale.  The researchers did this by exploring the undergraduate’s perceived exemption from harm, which has been shown to play a significant role in helmet attitude (12).  The following items were posed under the heading perceived exemption from harm: I do not go fast enough to need head protection in a crash; I feel that helmets are unnecessary for very short rides; Being an adult who has been riding for years, I can easily avoid an accident when riding; Bicycle helmets are less important for those who ride their bikes infrequently; Bicycle helmets are more important for those who ride their bikes long distances; and Since I’m not racing or doing any bike stunts, I don’t really need a helmet.  Scores ranged from 0.59 to 0.75 and higher scores indicate more agreement with reasons for not needing to wear a helmet.  Also The BHAS differentiated helmet wearers from nonwearers and found that nonwearers report less perceived vulnerability than wearers (12).
         Since nonwearers report less perceived vulnerability than wearers it is likely that these posters, which illustrate a safety threat, will not increase nonwearers’ vulnerability as the BPHC had intended by using the HBM as a model for their campaign.  Therefore, it is possible that the posters will have a insignificant or no effect on bike riders who do not wear helmets and they will continue to be nonwearers since many of them find their risk of being in an accident is less than average.    
Proposed Campaign 
The new helmet safety campaign images will feature people who are involved in professional sports and professions that require wearing head protection.  Hockey players, football players, baseball players, lacrosse players, horseback riders, boxers, snowboarders, soldiers, and firefighters wear helmets.  Why?  These sports and professions present a risk of head, brain, and upper face injury.  Since it is routine to see athletes, soldiers, and firefighters wearing helmets, the goal of this campaign is to encourage bike riders who do not wear helmets to follow their lead because they too are at an increased risk for head, brain, and upper face injury.  For example, one poster will have a hockey player, young adult bike rider, soldier, and snowboarder standing tall and confident wearing their particular uniform and helmet with a smaller image of a person on a bike who is not wearing a helmet looking up at them.  The message on the poster says, “We wear helmets because we’re at risk of head injury. Just like you.”  Another poster will have a firefighter, football player, young adult bike rider, and lacrosse player wearing their specific uniforms and helmet with a smaller image of a person on a bike who is not wearing a helmet looking up at them.  The message on the poster says, “They wear helmets.  Why don’t you?”  The slogan for this campaign will be “Helmets! They help keep you safe.”  The posters’ job is to present a message that is clear, appealing, and stimulates the viewer to think about the content of the message (13). 
This part of the paper will describe and provide evidence that supports how this proposed campaign corrects for the flaws in the original campaign. 
Solution #1: People are predictably irrational
Rather than using the HBM, an individual behavior change model that makes the assumption that people are rational, the BPHC could have used a model that has the power to affect the masses and posits that people are irrational.  Therefore, using the social organization theory, which is an extension of the social expectations theory, as a model might prove to be more effective because it takes into account human beings’ irrationality and strong social nature.  This theory developed from the fact that when people choose what course of action to follow, their primary considerations tend to be the expectations of others and their probable responses (14).  Or rather, people worry about what other people will think.  A major concept of social organization theory is norms, which are general rules that are understood and followed by all members of a group (14). 
The intention of the new posters is to remind bike riders who do not wear helmets that athletes, professionals, and fellow bike riders wear helmets because it is safer than not wearing one.  It highlights that wearing a helmet is a norm that is understood and followed by people at risk for a head injury.  The benefits of promoting norm information was examined in a study that posted signs near two elevators, which stated either that most people used the stairs or that taking the stairs was a good way to get some exercise.  In the location with the norm information sign, which says most people used the stairs, the number of individuals who used the elevator versus the stairs dropped by 46%.  This study’s findings suggest that drawing attention to readily available norm information can be an effective strategy for changing behavior (e.g., pointing out that the vast majority of people do not talk during the movie) (15).  Therefore, posting norm information around the city can help increase the number of people who wear helmets. 
Solution #2: Implicit Slogan
Instead of using the explicit slogan, “No Excuses. Wear a Helmet.”, the BPHC should have used the following implicit slogan, “Helmets! They help keep you safe.”   Implicit speech is indirect, less controlling, less forceful, and more polite compared to explicit speech (7).  Furthermore, implicit speech has been referred to as autonomy-supportive language, which emphasizes self-initiation and choice (7). 
Many young adults do not like being told what to do.  Therefore, using a slogan that implies choice is important since research examining the effects of explicit health messages targeting young adults confirms that their reactance increases and they are likely to reject the messages. Since the new slogan is not controlling it will not lead to higher levels of psychological reactance, anger, more negative cognitive evaluations of the message, less positive assessments of the message topic, less intention to behave in the advocated way, and more negative perception of source credibility (7).
Solution #3: Minimize the magnitude of Unrealistic optimism
Instead of featuring the aftermaths of biking accidents, which can be perceived as safety threats, the BPHC should have featured more positive images such as professionals wearing helmets.  When people are asked to assess their risk of experiencing a safety threat or negative event they are inclined to think that they are less at risk than other people.  Thus, optimistic bias can arise.  When optimistic bias develops it may affect self-protective behaviors like wearing a helmet, the risk-taking behavior of individuals like not wearing a helmet, and their response to health promotion messages (16).  Also if people do not recognize their vulnerability to harm, then this helmet safety campaign is likely to be ineffective in getting people to wear helmets.  According to Kos and Clarke (2001), the effectiveness of health promotion campaigns may be improved if they emphasize that although people may have the ability to control the risks of negative events, the risks of experiencing such events can only be decreased if this control is exerted.  Therefore, it seems that it would be more beneficial to have a campaign that promotes wearing a helmet in a positive way in order to reduce the risk of optimistic bias and increase helmet use.        

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