Monday, December 24, 2012

Breastfeeding Initiatives: Banning Formula is not the Answer – Kayley Pettoruto

Epidemiologic studies have proven the numerous advantages of breastfeeding over using formula—including health, nutritional, economic, social, immunologic, developmental, social and environmental benefits (1). Breastfeeding reduces a mother’s risk of breast and ovarian cancer and reduces a baby’s risk of ear, respiratory and gastrointestinal infections, reduces rates of hospitalization, asthma, and promotes maternal bonding and optimal growth (2).
Despite these known benefits, breastfeeding rates after six –months and at one year of age are low, compared to public health goals in the United States. The National Immunization Survey of 2001-2002 estimates that more than 71.4% of children nationwide were breastfed at some point; however, that rate drops to 16.1% by one year of age (3). Unfortunately, these rates are lowest among individuals with the greatest risk of poor maternal and child health outcomes: those women of low income, low socioeconomic status, low educational attainment, and non-Hispanic black women (3). With these disparities in mind, New York City developed a hospital-based breastfeeding-only program, namely “Latch On”.
This program is a hospital-based initiative that focuses on reducing distribution of promotional infant formula and a public awareness campaign, to inform women of the benefits of breastfeeding (2). This public health awareness campaign takes form in posters in subways and hospitals (2). The program in New York City also asks that hospitals put away formula, take down formula advertisements, and advertise the health benefits of breastfeeding throughout the hospitals (2). It requires that new mothers ask for formula from the nurses instead of being given promotional material automatically. Nurses are required to discuss the benefits of breastfeeding with new mothers. By reducing formula distribution and increasing knowledge about the benefits of breastfeeding, the “Latch On” program intends to increase exclusive breastfeeding rates. (2).           
Currently 28 hospitals in the area have signed on to participate. The initiative focuses on two main health beliefs—women need accurate information in order to make the right decisions about breastfeeding and through reduction in distribution of promotional formula, breastfeeding initiation and duration rates will improve (2).
While the Latch On approach has many positive aspects to it, which are backed by research and evaluation, the program has received a lot of backlash from the public.
The Latch On Initiative even had to publish a “myths and facts” memo in order to quell some of the many myths that had arisen surrounding the program. Some of the myths included in this publication were: “formula was being put under lock and key”, “formula feeding will be forbidden in some fashion”, and probably most importantly, “Latch on NYC is taking away and/or jeopardizing a woman’s right to choose how to feed her baby” (2).
            In this critique, I will focus on three aspects of the Latch On campaign that failed when considering social and behavioral sciences. Firstly, the campaign assumes individual level factors are sufficient to promote breastfeeding. Secondly, the Latch On campaign ineffectively uses core values. Thirdly, the campaign does not use effective communications strategies, including failure to avert psychological reactance.

Critique 1: Individual Level Factors are Insufficient
Mayor Bloomberg’s Latch On Initiative assumes that individual level factors are sufficient to promote change. This construct led policymakers to create the Latch On Program, which provides information to new mothers about the benefits of breastfeeding through posters, information from hospital nurses and limits access to formula. However, the framework of the social determinants of health explains how social and community influences, living and working conditions, and general socioeconomic, cultural and environmental conditions also influence health behaviors (4).

Interventions that focus entirely on individual behavior change can be ineffective because they fail to consider the cultural, sociopolitical and economic contexts of individual health experience and behavior (5,6).
Even if women leave the hospital without formula and a wealth of knowledge about the benefits of breastfeeding, individual level interventions are not sufficient to promote change, as there are other factors women face once they leave the hospital that may or may not allow them to breastfeed. According to the literature, factors that influence the length and duration of breastfeeding include employment status (7), social support, self-efficacy, and breastfeeding experience (8). Assuming that informing women that they should breastfeed and making formula harder to obtain in the hospital setting does not in any way help women overcome these external factors. The breastfeeding prevalence data reveals that these external factors are not being considered. The major issue in the United States today is the continuation of exclusive breastfeeding, not necessarily initiation. As the data shows, 71.4% of children received breastfeeding initiation, which is a fairly substantial percentile. The problem is the sustainability of breastfeeding—the breastfeeding rate drops to 16.1% by one year of age (3). The American Academy of Pediatrics highly recommends exclusive breastfeeding through the first six months and continued breastfeeding through at least one year of age in order to ensure the health benefits (1).
Ultimately, the flaw in this campaign is assuming that individual level factors are exclusively influencing health behavior—that is, women will breastfeed if they leave the hospital without formula and with knowledge about the benefits. Breastfeeding is a very difficult process and there are many barriers beyond simply those assessed in this intervention.
 By considering only individual level factors, the Latch On program ignores the context beyond the hospital setting; they assume that women choose not to breastfeed because they don’t know the benefits. Stress, lack of social support, and work schedules are just some of the contextual factors that play a role in breastfeeding decisions (7,8). Ultimately, all women need support beyond the day of birth to ensure adequate breastfeeding practices. Simply de-promoting formula use and increasing knowledge are not sufficient.

Critique #2: Ineffective Use of Core Values
            The second critique of this campaign is the use of health as the main core value.  When developing a campaign, the core values of the messages must be consistent with American values (9). Powerful American values include individual freedom, freedom speech, and protection against racial discrimination (9) and not health. Framing an issue accurately for public approval is a very important component of public health campaigns (9). In this particular campaign, the interventionists failed at framing Latch On effectively to the public.
            A public health frame is strong if it has a strong core position, utilizes metaphors, catch phrases, symbols, and most importantly, a powerful core value (9). The tobacco industry is one such example of a campaign that has been very successful due to the nature of its core values. Despite the known negative health consequences of smoking, cigarette campaigns have been successful because they appeal to freedom, autonomy, individual rights, and economic opportunity (9). Tobacco control campaigns that have utilized the core value of health have been less successful (9).
To the left is a poster used in the campaign (10). You can see here that the main core value used is health—breast milk reduces a baby’s risk of ear infection, pneumonia, and diarrhea. Throughout reading the promotional materials, I did not come across any metaphors used in the campaign. The main symbol is the baby/infant, and the catch phrases are “Latch On”, and “breast milk is best for you’re your baby”.
            In the press release for this initiative, the State Health Commissioner, Nirav Shah, is quoted as saying, “Mothers who choose to breastfeed their baby are making a healthy choice for their child and themselves” (2). The Latch On initiative is focused solely on health as a core value, which ultimately is ineffective with the public. The framing of this particular initiative created backlash because it did not utilize core values that are important to Americans including freedom, justice, and liberty (9).

Critique 3: Failure of Health Communication Strategies
            Latch On also failed at utilizing effective communication strategies including failure to consider psychological reactance theory and failure to utilize an effective messenger.
This particular initiative took away freedom by limiting new mother’s access to formula. By putting away formula, and requiring that women request it from the nurse, women felt that their individual freedoms were being limited. One particular myth that spread rapidly was that the initiative was “jeopardizing a woman’s right to choose how to feed her baby” (2). This type of reaction is a result of the Psychological Reactance Theory, which states that any pervasive message may cause an individual to feel that their personal freedom or personal choice has been threatened (11,12). There are four main elements to psychological reactance theory: freedom, threat to freedom, reactance and restoration of freedom (11). In this case, the freedom is to receive formula in the hospital; the threat is the removal of the formula; the reactance is the anger that results; and the restoration of the freedom stage is when women go out and buy the formula to reestablish their freedom.
This type of reaction has also been referred to as the Boomerang Effect (12). Warnings, among other types of public health campaigns, sometimes produce opposite effects of those intended (12, 13). One particular example of a public health campaign that produced boomerang, or opposite effects, is the minimum age for alcohol beverages (12). Research has revealed that increasing the legal age for drinking to 21 years of age may actually have increased underage drinking (12).
In public health, policymakers should never limit individual freedoms if they want their interventions to be successful (11). Taking away formula only makes women want formula more, due to Psychological Reactance Theory.
            Psychological reactance also may have occurred because of the lack of similarity of the communicator to the targeted audience. Studies have shown that threats only cause the boomerang effect when the communicator’s similarity was low or unknown (14). When people are similar to the communicator, they agreed with the message of the campaign, regardless of threat to freedom (14). Public health campaigns can avoid reactance if they elect a communicator who is similar to the targeted audience. The Latch On campaign does not employ these communication principles. The messengers for this particular campaign are Mayor Bloomberg, the Health Commissioners, and ultimately nurses and doctors. For pregnant and nursing women, they need a spokesperson of whom is similar to them—another mother or a peer. By using health officials and figureheads, the Latch On program ideology was not relatable to their target audience. As a result, their target audience—new mothers—rejected the program.

Introduction to New Campaign
            I propose a new intervention to replace the Latch On campaign, which I believe will eradicate the three areas where Latch On failed—lack of consideration of factors beyond the individual in determining breastfeeding outcomes, ineffective use of core values, and lack of health communication strategies. Instead of focusing on knowledge and formula access, New York City public health officials should focus on antenatal breastfeeding support. The data shows that the greatest area of need is breastfeeding continuation, with only 16% of women breastfeeding their babies through year one in the United States (3). I propose allocating funding to antenatal breastfeeding peer education and group support in New York City hospitals. This particular intervention will resolve the three failures of the original campaign, by considering the context of breastfeeding, not just individual level factors; by utilizing effective core values including individual freedom; and avoiding psychological reactance through providing choices and a messenger similar to the audience.

Support #1: Breastfeeding Support, Improving the Context
            Instead of focusing on individual level knowledge and access to formula, the Latch On Campaign should improve antenatal breastfeeding support, through both support groups and peer education. Social support is highlighted as one of the most significant predictive factors of breastfeeding initiation and lengthened duration among low-income women (8)—not knowledge or access to formula, as the Latch On Program advocates. In this study on low-income women, breastfeeding experience, self-efficacy, support from the father and support from a grandmother were all statistically significant correlates to lengthened breastfeeding duration and better outcomes (8). Support is imperative to breastfeeding success long term, not simply knowledge.
Social support is powerful in public health. One particular prenatal care intervention, namely the Centering Pregnancy program, is one such example that employs social support as a mechanism to improve outcomes. For Centering Pregnancy, group prenatal care resulted in lengthened gestation and increased birth weight (15). Relationship-centered care empowers women to advocate for themselves and others and gives them a social network of who can serve as a safety net and a sounding board.  The Centering Pregnancy prenatal model of group-centered support groups can be applied to the antenatal period as well. The United Nations Children Fund and the World Health Organization published the 10 steps to successful breastfeeding (16, 19). The tenth step is “foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic” (16). Breastfeeding support groups are an imperative piece to improving breastfeeding outcomes outside of the hospital.
Breastfeeding peer counselors are another component of antenatal support.  Breastfeeding peer counselors are defined as “local community women who have experienced breastfeeding success, have been trained in breastfeeding management, and work with women of similar cultural, demographic, and socio- economic characteristics to promote positive breastfeeding outcomes” (17). Training women to aid other women with breastfeeding practices has been employed and effective in a variety of developing countries, but few in the United States (17, 20, 21). A literature review conducted by the National Institutes of Health revealed that breastfeeding peer counselors improve breastfeeding initiation, duration, and exclusivity and decreased rates of infant diarrhea (22). Studies have also concluded that breastfeeding peer counselors are effective with low income, minority women, who have some of the lowest rates of breastfeeding in the United States (17).
Combining the principles of peer education and group-centered support could help improve breastfeeding outcomes—especially for women who might not have the best context—perhaps without a supportive partner, family, safe neighborhood, among others. The creation of antenatal support groups and peer counselors could help improve breastfeeding outcomes through improving self-efficacy, knowledge, and social support for mothers. Women who are supported in their breastfeeding process will more likely succeed in persevering through the trials and tribulations of parenting and ultimately have a better chance of breastfeeding through the first year of their child’s life. Instead of taking away formula and focusing on knowledge, funding in New York City should be allocated to antenatal breastfeeding support.  Instead of putting away formula, nurses could offer a breastfeeding peer educator and/or group-centered support for women in each hospital in New York City. Immediately from the start, new mothers could have a support system that is offered to them in the hospital immediately when their baby is born. If framed and marketed effectively, this new program could be very effective.

Support #2: Effective Framing and Use of Core Values
            Using health as the main core value was entirely ineffective in the Latch On Campaign. As a result, we need to re-frame and re-package the new breastfeeding peer counseling campaign. Public health officials need to frame this campaign as a women’s choice, not a loss of freedom. Freedom and liberty are powerful core values in the United States (9), thus, any such campaign that takes away freedoms (i.e. takes away formula), will be ineffective (11,14). In addition to using powerful core value, public health officials need to employ effective metaphors, symbols, and catch phrases in the new frame.
Core Values
            Instead of framing health as the core value, employing liberty and justice as core values could be effective. Formula companies can be packaged as the enemy—their promotional strategies are infringing upon a mother’s right to choose between breastfeeding and formula. Because every hospital is covered in advertising and mothers are given formula right from the start, women are not given the opportunity to choose whether they want formula or not. Women have the right to reject the promotional strategies of formula corporations, and choose whether they want to breastfeed or not. It is one’s civil liberty to decide how they will feed their children and formula companies, like tobacco companies, are targeting new mothers, without the well being of their babies in mind. Women can make the choice to choose the peer educator and group support over formula. The “the evil formula companies” frame employs the core values of freedom and justice, which are more effective core values than the heath frame used in the Latch On campaign.
Metaphors, Symbols, and Catch Phrases
            In order to make this new frame truly effective, public health officials need to create metaphors, symbols, and catch phrases to support the frame. Metaphors and symbols should be recognizable and important to the American public in order to be effective (9). Some potential catch phrases examples include:
 “Putting mom’s back in charge”
“Taking the profit out of birth”
“It is our civil right to protect our babies”
“Take control of your baby’s outcomes. Work with a breastfeeding peer educator”
“She’s been through it before. She can help you get through it, too.”

            Some important symbols to employ are pictures of all kinds of women who serve as breastfeeding educators—of varying ages, ethnicities and races--in order to appeal to the entire NYC population of women. Posters should be available in multiple languages and focus on women’s rights and self-empowerment.
            This campaign will be more successful than Latch On because of the reframing, use of more effective core values, and appeal to the audience at risk.

Support #3: Using Effective Communications Strategies
The new campaign reduces psychological reactance because women have options. They have the option to choose between formula, or a peer educator and support groups. Giving women the option to choose increases their freedom, instead of decreasing it. By giving women options, psychological reactance is avoided. Women have the option to choose formula, but they also have the option to work with a breastfeeding peer educator and enroll in a breastfeeding support group.
Similarity of the messenger to the audience is an important component of avoiding psychological reactance (14). Breastfeeding peer educators work with women from their own community, who are similar to them in cultural, demographic, and socio- economic characteristics (17).  Because this program utilizes peers, who are similar to the women they serve, psychological reactance is also avoided.
Another pitfall of the Latch On campaign was using the Health Commissioner and Mayor as the spokespeople for the campaign. Given the nature of psychological reactance, the spokesperson for the new campaign should be a mother who breastfeeds, who is relatable to the audience. Having a celebrity endorse a campaign makes it newsworthy and often more effective (18). It could be potentially effective to use a celebrity mother as the spokesperson for this new campaign in New York City.

            The Latch On campaign, although well intentioned and backed with research, did not consider the predictable irrationality of human behavior and social and behavioral sciences. The program fails in three main ways. Firstly, breastfeeding outcomes are not attributed solely to individual level factors. Stress, lack of social support, poverty, working conditions all are factors that influence breastfeeding (8)—not simply knowledge. Secondly, the program uses health as a core value, which is very weak (9). Thirdly, the campaign produces psychological reactance, due to the limiting of access to formula and the dissimilar spokespeople.
            A potentially effective intervention for the low breastfeeding rates at 6 months and one year is breastfeeding peer counselors and group support sessions. Funding should be allocated to training breastfeeding peer counselors and organizing these group sessions. Nurses in hospitals should offer this program to all new mothers in the obstetrics department. This way, women can leave the hospital with a support system that can help them breastfeed. This type of program is backed by a variety research—peer educators and group support sessions are successful at improving initiation and duration of breastfeeding outcomes (16, 17, 20, 21, 22).
This new campaign corrects the errors made by the Latch On Campaign, through the use of social and behavioral sciences. Breastfeeding peer counselors and group support groups will resolve the three failures of the original campaign, by considering the context of breastfeeding, not just individual level factors; utilizing effective core values including individual freedom; and avoiding psychological reactance through providing options and a spokesperson who is similar to the targeted audience. 

1.       American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human milk, section on breastfeeding. Pediatrics 2005; 115(2): 496-506.
2.       New York City Department of Health and Mental Hygiene. Latch On New York City.
3.      Li R, Darling N, Maurice E, et al. Breastfeeding rates in the United States by characteristics of the child, mother, or family. Pediatrics 2005; 115(1): e31-e37.
4.      Dahlgren G., Whitehead M. Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Futures Studies, 1991.
5.      Marks, D. Health psychology in context. Journal of Health Psychology 1996; 1(1): 7-21.
6.      McKinlay, JB, Marceau, L.D. Upstream health public policy: lessons from the battle of tobacco. International Journal of Health Services 2000; 30(1): 49-69.
7.      Anderson-Kosmala, J. Breastfeeding works: the role of employers in supporting women who who wish to breastfeed and work in four organizations in England. Oxford Journal of Public Health 2006; 28(3): 183-191.
8.     Mitra AK, Khoury AJ, et. all. Predictors of breastfeeding intention among low-income women. Maternal and Child Health Journal 2004; 8(2): 65-70.
9.      Menashe, C. & Siegel, M. The power of a frame: an analysis of newspaper coverage of tobacco issues—United States, 1985-1996. Journal of Health Communication 1998; 3(4):307-25.
10.  Oh, I. Bloomberg's breastfeeding program, 'Latch On NYC,' wants hospitals to change baby formula protocol. Huffington Post, 2012.
11.   Dillard, JP & Shen, L. On the nature of reactance and its role in health communication.” Communication Monographs 2007; 72(2): 144-168.
12.  Ringold, DJ. Boomerang effects in response to public health interventions: some unintended consequences in the alcoholic beverage market. Journal of Consumer Policy 2002; 25: 27-63.
13.  Stewart, D. W., & Martin, I. M. Intended and unintended consequences of warning messages: A review and synthesis of empirical research. Journal of Public Policy and Marketing 1994; 13: 1–19.
14.  Silvia, P. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance.” Basic and Applied Psychology 27(3): 277-84.
15.   Zohar M, Schindler Rising S, Ickovics J. Centering pregnancy group prenatal care: promoting relationship-centered care. Journal of Obstetric, Gynecologic, & Neonatal Nursing 2006; 35: 286-294.
16.  Nickel, N., Labbok, M., Hudgens, M., et all. The extent that noncompliance with the 10 steps to successful breastfeeding influences breastfeeding duration. Journal of Human Lactation 2012; XX(X): 1-12.
17.   Chapman, DJ, Morel, K, Burmudez-Millan, Young, S. et all. Breastfeeding education and support trial for overweight and obese women: A randomized trial. Pediatrics, 2012.
18.  Aschermann-Witzel, J., Perez-Cueto, F., et all. Lessons for public health campaigns from analyzing commercial food marketing success factors: a case study. BMC Public Health 2012; 12:139.
19.  Merewood A, Heinig J. Efforts to promote breastfeeding in the United States: development of a national breastfeeding awareness campaign. J Hum Lact 2004; 20(2): 1405.  
20. Leit, AJ, Puccini, RF, Atalah, AN, et all. Effectiveness of home-based peer counseling to promote breastfeeding in the northeast of Brazil: a randomized control trial. Acta Paedrics 2005; 94(6): 741-746.
21.  Aidam, B., Perez-Escamillia, R., & Lartey, A. Lactation counseling increases exclusive breast-feeding rates in Ghana. Community and International Nutrition 2004: 1691-1695.
22. National Institutes of Health. Breastfeeding peer counseling: From efficacy through scale up. Journal of Human Lactation 2010; 26(3): 314-326.

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Just Say No to Abstinence-Only Sex Education - Hasti Mehta

Teen sexual activity continues to remain a prevalent problem for the United States (U.S). Although the proportion of high school students who reported ever having sexual intercourse has remained steady since 2001, it is still nearly half population (47%) (1). Approximately 47% of adolescents aged 14-18 are sexually active, defined as having sex in the past three months (1). Early sexual activity is associated with teen pregnancy, increased risk of sexually transmitted infections (STIs) and a multitude of other physical and mental problems. The U.S. still has the highest teen birth rate amongst comparable countries even though teen pregnancy rates are at the lowest levels since the National Center for Health Statistics (NCHS) began tracking them in the 1940s (2,3). Despite these unnerving statistics, the majority of states continue to implement abstinence-only education and the U.S. continues to predominantly fund abstinence-only education.

Abstinence-Only Education
    For a program to be considered an abstinence-only education program, it must accomplish specific goals as put forth by section 510 (b) of Title V of the Social Security Act (4). The goal of abstinence-only education is to create a social environment in which abstinence from sexual activity before marriage is the norm. Abstinence-only sex education also aims to teach students the importance of healthy, monogamous relationships (namely marriage), the negative psychological impacts of sexual activity prior to marriage, and the importance of being self-sufficient before engaging in sexual activity. Overall, the program is designed as a way for youths to learn how to make sound decisions regarding sexual activity and long-term relationships. This paper seeks to address what are believed to be the primary flaws of the dominant, abstinence-only education program approach to sexual health education; namely, 1) the lack of proper communication between educators and students; 2) the role of individual level health belief models to account for context; 3) the perceived lack of control caused by abstinence-only education programs. Additionally, this paper will offer suggestions for how to improve upon current public health practices, specifically addressing each of the three criticisms outlined above.

Critique 1: Lack of Relatable Educators
            A significant obstacle in the success of the abstinence-only education programs is the difficulty that students have in connecting with the individuals conveying the message. In 2005, 42 percent of teachers in the United States were aged 50 or older compared to 11 percent of teachers who were under the age of thirty (5). In 2011, 31 percent of teachers were aged 50 or older compared to 22 percent of teachers who were under the age of thirty (5). Although the average age of teachers has been on the decline, the problem on connecting with the educator still remains. A message being delivered by someone who is liked, similar, and familiar greatly increases the chance that the message will be taken more positively (6).  Research has shown that a liked source can be more persuasive at times when the message is difficult to process (7). This concept of “liking” is an easy way for individuals to get others to comply with their requests (6). When the person delivering the message is a friend or a known person, it induces feelings of warmth and security and there is a smaller likelihood that the individual will reject the request (8). Liking the person who delivers a message increases the chances that those receiving the message will also agree with the message (9).
            Similarity is another important factor that influences an individual’s decisions. The effects of similarity, however superficial, can create an instant bond between two people (10). When presenters are similar to the audience, their credibility is increased and they have an easier time connecting with the audience. Experiments conducted by Paul J. Silvia about the effect of similarity and likeability on compliance and reducing resistance found that when the presenter’s level of similarity was low or unknown, there was a boomerang effect (9). However, when the presenter was highly similar to the audience the audience agreed with the presenter regardless of the message being delivered (9). The strength of similarity and its effects on persuasion can easily be seen in an experiment conducted at a fundraiser on a college campus where the contributions more than doubled when the phrase “I’m a student” was added to the request (11).
            The last characteristic, familiarity, is also a large influence on whether a message will be well accepted. Normally, individuals are fond of things that are familiar to them (12). Prior experiments have found that merely being exposed to the image of an individual in the past can increase the likelihood that a person will remember the individual and be more likely to be influenced by their statements (8). Although the abstinence-only message being delivered in schools is targeted towards teens, it can be difficult for them to be persuaded because they feel no connection with the teachers delivering the message.
Critique 2: Individual Level Health Models Failure to Account for Context
            The second significant obstacle in the success of abstinence-only education programs is that they do not consider context. The health belief model was developed to explain behavior at the individual level (13). According to the health belief model, individual behavior is influenced by four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (13). Based on this model, an individual weighs the perceived benefits and the perceived costs of an action and makes a rational decision based on the given facts. The health belief model fails to factor in social or environmental influences. It also assumes that all individuals are rational and nothing will influence their decision once they have made it. This model treats individuals as though they are living in a vacuum, not in the real world. While the health belief model would work for one time quick decisions where the behavior will follow the reasoned thought process, it is unlikely to work in situations where the action must be sustained (14). Since the health belief model does not consider context, it is unable to effectively influence behavior. Sexual activity among adolescents has frequently been characterized as unplanned and impulsive (15), but these models are still used to insufficiently influence change amongst them.
            Recent research has shown that there is a definite difference in how individuals, specifically students, make decisions when they are aroused and when they are not. Ariely and colleagues conducted an experiment where they asked male undergraduate students to answer questions in a “cold state” (where they were not aroused) and a “hot state” (where they were aroused) (16). The research found that while in the “cold state” the students were very rational, always took the moral high ground, and predicted that they would use a condom during sexual activity (16). However, when the students were in the “hot state”, they themselves did not know what they would actually do and completely underestimated their actions (16). All thoughts of prevention, rationality, and morality disappeared and they were 25 percent more likely in the aroused state than in the cold state to predict that they would not use condoms (16). The research by Ariely et al. showed that the students who could recite all the risks and negative consequences of sexual activity in the cold state were simply irrational and unpredictable in the face of passion. Teens know the risks that sexual activity can lead to while they are in school or at home, but when it comes to an intimate setting, their perceived benefits and risks can drastically change, thus leading to the very behavior the programs are trying to prevent.

Critique 3: Perceived Threat to Personal Freedom
            The third significant obstacle in the success of abstinence-only education programs is that it specifically urges students to abstain from sex entirely rather than teach them safe-sex alternatives (4). It is common knowledge that freedom of behavior is an important part of human life. In order to make decisions, people normally weigh their wants and needs with the dangers and benefits and decide on ways to get what they want (17). When a person’s behavioral freedom is reduced or threatened, the person will begin to get agitated and look for ways to rebel (17). This need to recover their lost freedom and ensure loss of further freedom is known as psychological reactance (17). This is the problem plaguing the abstinence-only education programs. Research conducted by Sharon Brehm has indicated that children as young as two understand that their freedom is being threatened and will try to restore that freedom (18). Brehm’s study concluded that this behavior demonstrates psychological reactance because the children could not accept that they were not in control and they had to assert their control even though it was not physically possible (18).
            Another example of psychological reactance and its effects can be seen in the experiment conducted on the effect on couples relationships based on negative parental interference (19). The study found that the more the parents had a negative impact, the more the couple stayed together (19). This experiment proves that the more individuals are told not to do something, the more they crave the opposite in order to assert their control. People are very intuitive and can figure out when individuals who approach them do not agree with their point of view. Kevin Hogan, author of “Covert Persuasion” states in his book that “People are quickly receptive to information and attitudes that agree with their point of view. People will formulate arguments on the spot against any point of view that disagrees with their currently held belief” (20). The concepts taught in abstinence-only education programs are stated in a way that causes students to feel as though their personal freedom of choice is being threatened.
Proposed Intervention
            As public health professionals continue to devise different interventions to combat high teen pregnancy birth rates, it is critical they realize the importance of implementing a program to which students can relate. The proposed intervention will consist of three major changes to the current model.
The first major change will be a shift from teachers to peer educators as the main individuals who will convey the message of abstinence-only education programs. Many studies have proven the importance of having someone who is relatable when intending to convey a message. In order to increase the chances of getting the message of abstinence-only being the best way to prevent teen pregnancy across, peer educators will be likeable, similar, and familiar (6,7). It will be important to find students who are familiar with the student body and are well known.
The second change will include implementing group level health models to introduce new behavior and encourage change. Current individual level health models do not address societal factors and the notion that individuals are inherently irrational when making decisions (13,16). In order to reach the student body more widely, it is important to implement alternative models that have the ability to affect change in large groups of people and account for factors such as irrationality and social norms (21). By implementing a group level health model it will be easier to change the social norms and get a greater group of students to practice abstinence.
The third change consists of changing the way the abstinence-only model is currently framed and turning it into a comprehensive sex education model to reach more students and create a more effective program. With the current model threatening the students’ control, it is important to develop a model that allows students to understand that they have choices and it is up to them how they choose to be safe when it comes to sexual activity. By creating a comprehensive sexual health education program, the goal is to frame abstinence in a way that it shows the students that they have more control when they abstain than when they have safe sex.

Solution 1: Shift from Teachers to Peer Educators
            To be able to create an effective campaign that will be able to spread the message of abstinence-only education programs it is imperative to have likeable, similar, and familiar individuals presenting the information to their peers. By placing peers who are well liked and familiar in the role of educators, the students will be more likely to listen and accept the message the students are putting forth. This concept of liking and its positive effects in terms of influencing people was documented in Cialdini’s book, in reference to the Tupperware party. He believes the Tupperware party is the “quintessential American compliance setting” because it uses the idea of liking to sell products (8). Simply because the request to buy the Tupperware does not come from a stranger, the attendees are more likely to actually buy the products (8). This proves that if the student educating his or her peers is well liked, they will have the power to influence the thoughts of their peers.
            Another characteristic that must be present in the peer educators is that they must be similar to the group they are trying to teach. Similarities do not have to be glaringly obvious, but something as trivial as having the same style of clothing as their peers can place a positive spin on the message being delivered (8). This theory was tested out at an antiwar campaign in the 1970s where one female volunteer was dressed as a “hippie” and the other was dressed “straight” and it was found that each of the women attracted more signatures for their petitions from similarly dressed individuals (22). This example proves that dressing the same way and being able to blend in with the crowd that you are trying to persuade can play a huge role in how the message you deliver is perceived. Peer educators would be at much higher advantage than teachers when informing students about abstinence-only education because they are very similar to their peers.
            The final characteristic that is beneficial in efficiently persuading the students to understand the importance of abstinence is to ensure the peer educator’s familiarity. From the first two requirements we understand that the peer educator should be well-liked and similar to the target audience. Guaranteeing that the peer educators are also familiar to a majority of the study body is the last step. It would be beneficial to choose an individual who is involved with student government or an accomplished athlete that is well-known and liked by the students. An experiment conducted during an Ohio election in which a man with little chance of winning changed his last name to “Brown”, a family name of much of Ohio’s political tradition, ended up victorious (8). From the previous examples it is evident that choosing a well-liked, similar, and familiar student to educate his or her peers, the acceptance of abstinence-only message amongst teens can go up significantly.  

Solution 2: Institute Group Level Alternative Models
            In order to combat the flaws the individual model, which include not accounting for social norms, context, and irrational behavior, it is recommended that an alternative model be used. The alternative model will account for the group dynamic, unplanned behavior, visceral drives, and irrational behavior (21). The idea of the “tipping point” as outlined by Malcolm Gladwell would be effective in creating the intended effects. The implementation of the group-level changes in a “hot state” rather than a “cold state” would be another change that would bring about the intended effects of abstinence-only education.
             By creating situations in which students are placed in a “hot state” of mind as mentioned before, the message of abstinence may translate better when the students are in a situation where they must make a sound decision (16). In order to make sure that students are in a “hot state” of mind which can consist of fear, jealousy, anger, or arousal, if would be important to invoke those feelings when the message of abstinence-only education is being presented (16). In order to invoke these feelings, several strategies can be used, including giving the students reading exercises, having them watch videos, or having conversations that invoke the feelings associated to the “hot state”. By giving the message to the student when they are in the “hot state”, it is more likely that they will remember the message when they are engaging in sexual activity.
Gladwell has written about “tipping point”, which is the moment of critical mass, the inflection point, the boiling point at which widespread change occurs (22) and this tipping point is applicable to the diffusion of innovations theory. His book uses the example of Hush Puppies, the well-known American shoe, which were dying out in early 1994 (22). The process by which they became a popular accessory again emphasizes the approach to be taken in order to make abstinence-only more socially accepted. In early 1994, Hush Puppies were dying out and the manufacturers were planning on discontinuing the shoes, but they found that Hush Puppies were beginning to become a fashion statement again in the clubs and bars in downtown Manhattan (22). Soon fashion designers were asking the company to use the Hush Puppies in fashion shoots and other high profile individuals were asking for a pair as well (22). Soon after there was a huge increase in sales and the Hush Puppies once again became a hot trend (22). This example demonstrates that there was a time when only a few people wore the Hush Puppies, precisely because no one else was wearing them, but after the shoe was picked up by two fashion designers, there came a certain point where the shoes became a fashion statement unintentionally (22). By applying the concept of the tipping point to abstinence-only education, a few early adopters can fuel the trend, which will eventually be adopted by the rest of their peers. In this way, abstinence will become the norm rather than something students are resistant to.
Solution 3: Emphasizes Freedom of Choice  
Abstinence-only programs are very difficult to frame in a way that does not intrude on the students’ personal freedom of choice, thus the proposed intervention should include resources for students who choose to engage in sexual activity to do so safely.
Applying advertising theory to the abstinence program is another way to enact change in teens and frame the idea in a way that is appealing to the intended audience. The three main components of advertising theory are the promise, the support, and the core value (23). The idea of advertising theory is to speak to the deepest aspirations that people possess and deliver a message that addresses those aspirations. The promise will be adequately supported by images, sounds, and stories that invoke certain core values that the intended audience holds dear to them (23). Advertising theory emphasizes the desired behavioral change rather than the individual’s current action (23). Advertising theory touches on the idea that people are irrational and can be easily persuaded to change their opinion if the right techniques are employed. In order to induce change by using advertising theory, it is important to create a promise that the teen population can relate to and may actually want. Once the promise is created, it would be important to support the promise with related music and images that speak to teens. It is imperative to ensure that the advertisement speaks to the core values that teens hold dear, one of the main ones being freedom. By emphasizing the promise of freedom of choice or freedom from burden at such a young age, advertising theory can be effectively used to convey the message of abstinence-only to a larger audience.
The next piece would be to market and brand the idea in a way that would be appealing to teens. Appropriate use of marketing theory includes researching what people want and applying those findings to create and package the message in a way that fulfills the needs and wants of the target population (24). From the Florida “truth” campaign it was found that students wanted “the facts” and then they wanted to be left alone to make their own decisions (25). The “truth” campaign found that if they wanted to be successful they would have to give alternate options instead of just “don’t” (25). By defining freedom as one of the most prevalent core values in teens, the abstinence-only education programs need to be replaced by comprehensive safe-sex education programs that give teens the freedom of choice and the chance to make an educated decision if they choose to engage in sexual activity. In order to reach teens effectively, they need to receive honest, effective sex education which helps them understand the options available to them should they choose to engage in sexual activity, thus the intervention should be amended to include a comprehensive sex education component.

In summary, although there are good intentions behind the abstinence-only education programs, research has shown that they are not effective at producing favorable results when it comes to delaying early sexual activity and decreasing teen pregnancy rates. The most obvious flaws include the lack of familiarity and similarity between the educators and teens learning about abstinence, the lack of a group level intervention that accounts for irrational behavior, and the threat to teens’ freedom of choice at such a rebellious age. Through this intervention, the flaws of the abstinence-only program can be seen and the proposed solutions of adding a group-level, peer educated abstinence program with a comprehensive sex education component can gain support.


  1. The National Campaign to Prevent Teen and Unplanned Pregnancy (2012, July). Teen Sexual Behavior and Contraceptive Use: Data from the Youth Risk Behavior Survey, 2011. The National Campaign to Prevent Teen and Unplanned Pregnancy. Retrieved December 8, 2012, from
  2. The National Campaign to Prevent Teen and Unplanned Pregnancy (2012, October). Summary of 2011 Preliminary Birth Data from the National Center for Health Statistics (NCHS). The National Campaign to Prevent Teen and Unplanned Pregnancy. Retrieved December 8, 2012, from http://(2)
  3. The National Campaign to Prevent Teen and Unplanned Pregnancy (2012, March). Teen Birth Rates: How Does the United States Compare? The National Campaign to Prevent Teen and Unplanned Pregnancy. Retrieved December 8, 2012, from
  4. Advocates for Youth (n.d.). 8-Point Definition of Abstinence-Only Education. Advocates for Youth. Retrieved December 8, 2012, from
  5. Emily Feistritzer, C., Griffin, S., & Linnajarvi, A. (2011). Profile of Teachers in the U.S. 2011. National Center for Education Information. Retrieved December 8, 2012, from
  6. MajorLeagueBusiness (2011, September 20). Robert Cialdini - The 6 Principles of Influence [Video File]. Retrieved from
  7. Knowles, E. S., & Linn, J. A. (2004). 9: Narrative Persuasion and Overcoming Resistance. In Resistance and Persuasion (p. 179). Mahwah, N.J: Lawrence Erlbaum Associates.
  8. Cialdini, R. B. (2007). Liking: The Friendly Thief. In Influence: The psychology of persuasion. New York, NY: Collins.
  9. Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 27, 277-284. Retrieved from
  10. Cialdini, R. B., & Goldstein, N. J. (2002). The Science and Practice of Persuasion. Cornell Hotel and Restaurant Administration Quarterly, 43(2), 40-50. Retrieved from
  11. Aune, K. R., & Basil, M. D. (1994). A Relational Obligations Approach to the Foot-in-the-mouth Effect. Journal of Applied Social Psychology, 24(6), 554-556. Retrieved from
  12. Bornstein, R. F. (1989). Exposure and affect: Overview and meta-analysis of research, 1968-1987 . Psychological Bulletin, 106(2), 265-289. Retrieved from
  13. Edberg, M. C. (2007). Individual health behavior theories. In Essentials of health behavior: Social and behavioral theory in public health (1st ed., pp. 35-49). Sudbury, Mass: Jones and Bartlett.
  14. Siegel, Michael. “Health Belief Model.” SB721. Boston University, Boston. 11 Oct. 2012. Lecture.
  15. Moore, K. A., Miller, B. C., Glei, D., & Morrison, D. R. (1995, June). Adolescent Sex, Contraception, and Childbearing: A Review of Recent Data. Child Trends. Retrieved December 9, 2012, from
  16. Ariely, D. (2008). The Influence of Arousal. In Predictably irrational: The hidden forces that shape our decisions. New York, N.Y: HarperCollins Publishers.
  17. Burke, W. W., Lake, D. G., & Paine, J. W. (2009). A Theory of Psychological Reactance. In Organization change: A comprehensive reader. San Francisco, CA: Jossey-Bass.
  18. Brehm, S. S., & Weinraub, M. (1977). Physical barriers and psychological reactance: 2-yr-olds' responses to threats to freedom. Journal of Personality and Social Psychology, 35(11), 830-836. doi:10.1037/0022-3514.35.11.830.
  19. Driscoll, R., Davis, K. E., & Lipetz, M. E. (1972). Parental interference and romantic love: The Romeo and Juliet effect. Journal of Personality and Social Psychology, 24(1), 1-10. Retrieved from
  20. Hogan, K., & Speakman, J. (2006). Covert Persuasion Begins in the Mind. In Covert persuasion: Psychological tactics and tricks to win the game (p. 6). Hoboken, N.J: John Wiley & Sons.
  21. Siegel, Michael. “5 Premises of the Alternative Model.” SB721. Boston University, Boston.  25 Oct. 2012. Lecture.
  22. Gladwell, M. (2000). Introduction. In The tipping point: How little things can make a big difference (pp. 3-14). Boston, MA: Little, Brown.
  23. Siegel, Michael. “Advertising Theory.” SB721. Boston University, Boston. 1 Nov. 2012. Lecture.
  24. Siegel, Michael. “Marketing Paradigm.” SB721. Boston University, Boston. 29 Nov. 2012. Lecture.
  25. Hicks, J. J. (2001). The strategy behind Florida's “truth” campaign. Tobacco Control, 10(1), 3-5. Retrieved from

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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.


(1) Center for Disease Control and Prevention. Bicycle Related Injuries. Atlanta, GA: Home and Recreational Safety, 2009.
            (2) The Daily Free Press. Bike initiatives aim to increase cyclist’s safety. Boston, September 2012.
            (3) City of Boston. Bike Statistics. Boston, MA: Parks and Recreation Department, 2010.
            (4) Pedestrian and Bicycle Information Center. General Bicycling Statistics. North Carolina: University of North Carolina Highway Safety Research Center.
            (5) Boston Public Health Commision. Helmet Safety Campaign. Boston, MA: Injury Prevention, 2012.
            (6) 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.
Clayton RR, Cattarello AM, Johnstone BM. The effectiveness of Drug Abuse Resistance Education (project DARE): 5-year follow-up results. Preventative Medicine, 1996; 3: 307-318.
            (8) Hanson, D.J. Alcohol Abuse Prevention. Drug Abuse Resistance Education: The Effectiveness of DARE. Potsdam, NY, 2007.
            (9). Mass Ride. Safe Routes to School Funding in Massachusetts. Massachusetts: Safe Routes to School National Partnership, 2012.
            (10) Jack, M.S. Personal fable: a potential explanation for risk-taking behavior in adolescents. Journal of Pediatric Nursing, 1989; 5:334-338.
            (11) Introduction. In: Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown and Company, 2000, pp.3-14.
            (12) Brehm, J.W. Psychological Reactance: Theory and Applications. Advances in Consumer Research, 1989; 16, 72-75.
            (13) Legal Momentum: Advancing Women’s Rights. Sex, Lies, & Stereotypes: How Abstinence-Only Programs Harm Women and Girls. New York: Committee on Oversight and Government Reform, 2008.
            (14) American Public Health Association. Abstinence and U.S. Abstinence-Only Education Policies: Ethical and Human Rights Concerns. Washington, DC: Advocacy and Policy, 2006.
            (15) Ruiter, R., Abraham, C., Kok, G. Scary warnings and rational precautions: A review of the psychology of fear appeals. Psychology and Health, 2001; 16:6.
            (16) Witte, K. and Allen, M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education and Behavior, 2000; 27:591.
            (17) Dearing, J. Applying Diffusion of Innovation Theory to Intervention Development. Research on Social Work Practice, 2009: 19:503.
            (18) Dearing, J., Maibach, E. and Buller, D. A Convergent Diffusion and Social Marketing Approach for Disseminating Proven Approaches to Physical Activity Promotion. American Journal of Preventative Medicine, 2006; 31:4.
            (19) Grier, S. and Bryant, C. Social marketing in public health. Annual Review of Public Health, 2005; 26:319-339.
            (20) Andreasen, A. Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. Jossey-Bass, 1995.
(21) Cardeno, A. et al. Marketing HIV Prevention for Heterosexually Identified Latino Men Who Have Sex with Men and Women: The Hombres Sanos Campaign. Journal of Health Communication: Health Perspectives, 2012; 17:6.

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