African American Gender Politics and the AIDS Epidemic: A Critique of Current HIV Intervention Strategy – Tali Schiller

The AIDS epidemic has been an unprecedented medical and public health issue for the last 30 years. Never before has a disease been so difficult to fight medically, socially, and in the public health sphere.  Our national policy has been more than up to the challenge to extend the required effort and financial backing – in fiscal year 2012 alone, the United States earmarked $21 billion for domestic research, prevention, and care and treatment of HIV (1).  Early awareness campaigns, such as SILENCE = DEATH and the Australian Grim Reaper commercial, were instrumental in teaching the public about HIV in the early days of the epidemic; efforts to maintain HIV in the public’s mind, and to educate them about how to prevent transmission, is still very much a priority.  This tremendous effort to prevent the transmission of AIDS through information and awareness is almost unmatched in the field of public health.  Why, then, has the HIV infection rate failed to drop?

The Center for Disease Control and Prevention reports that the domestic new infection rate has remained steady for the last 10 years, with about 50,000 new infections per year.  The African American population makes up a disproportionate percent of these new infections – though only 16% of the total population, African Americans accounted for 44% of new infections in 2009 (2).  Of this population, women of color are the most affected: in 2010, African American women made up two-thirds (64%) of new AIDS diagnoses and 57% of new HIV infections among the entire female population of the United States (2).  These rates show no sign of decreasing, despite millions of dollars spent on education and prevention messages broadcast on every medium. 

African American women are at an especially high risk for contracting HIV.  In 2010, black women were nearly 15 times more likely to be infected with HIV than white women, and nearly 1 in 30 black women will be diagnosed with HIV/AIDS in her lifetime (3).  AIDS is the primary cause of death among African American women aged 25 to 34 (4).  Studies have shown that black women do not engage in riskier behavior than other women, but social dynamics place them at a higher risk.  Factors that increase black women’s risk of contracting HIV include differential access to health information, unequal access to healthcare and prevention materials, low self-esteem and a lack of empowerment, alcohol and drug use, poverty, sex-ratio imbalance, and a number of others (5).  These causes work synergistically to increase HIV transmission in the African American community.  The most important factor to consider is low perceived susceptibility to risk of infection – black women have a significantly lower perceived risk than women of other races, even those who participate in known high-risk behaviors (6). 

The CDC is fighting back against new HIV infections.  They have made a serious commitment to the African American community through a multi-pronged approach targeting different sections of the population.  The Act Against AIDS Leadership Initiative (AAALI) is a $16 million partnership between the CDC and leading organizations that represent the communities hit hardest by HIV.  The Expanded Testing Initiative is a $50 million per year, three-year expanded testing program to increase HIV testing in the African American community.  The CDC provides financial and technical support to community-based testing and prevention organizations, such as the WILLOW program, Sister to Sister, Nia, and Many Men, Many Voices.  The CDC has also created the current Act Against AIDS campaign, which delivers HIV testing information through the “Testing Makes Us Stronger” campaign for black men who have sex with men (MSM) and “Take Charge. Take the Test.” for the black heterosexual female population (7).  These financial commitments, and many more, are inspired by President Obama’s July 2010 National HIV/AIDS Strategy, new policy to address the problem of domestic HIV (8). 

The CDC’s response to steady HIV infection rates among the heterosexual African American female population was to develop the national campaign “Take Charge. Take the Test.” (TCTT), focused on timely testing as a vehicle to increase awareness of HIV status and therefore increase treatment. It combines aspects of several intervention models – Health Belief Model, Theory of Planned Behavior, and the Ecological Model – to create the theoretical framework.  The audience was also segmented; the CDC selected “single, African-American women aged 18–34 years, with some college education or less, who earned US$30,000 or less per year, resigned in certain zip codes of high prevalence for HIV/AIDS, and who were having unprotected sex with men”(9). TCTT is currently the largest and most comprehensive national response to the high incidence of HIV infections in the black female population, launched in ten major US cities where a significant percent of black women are affected.  This comprehensive effort to reach the black female community is larger than any that precedes it.  So why isn’t it working?   

I. Structural Barriers to Care

Considering the creation of an intervention for any disease requires contextualizing it within a socio-cultural framework: no disease exists in a vacuum, but HIV is more susceptible to societal factors than most.  Its stigmatized routes of transmission create a complicated environment in which to create effective public health messages.  Any such message must contend with a 30-year long association with homophobia, drug use, and sexual promiscuity.  In the African American community, these stigmatized activities are additional to the barriers of being black in America – poverty, segregation, and the historical fallout of a 300-year history with slavery.

Research has shown that black women and black gay men, the two populations of color with the highest incidence of HIV, have a similar number of sexual partners and use condoms as often as their white counterparts (10). Individual-level behaviors do not fully explain the racial disparity; in fact, a focus on behavior increases stigma by suggesting that individuals’ bad decisions are solely to blame for their poor health outcomes.  Instead, we must regard health inequalities within the socio-cultural context of race when considering HIV disparity, as with any other health problem that disproportionately affects communities of color.  Some factors that foster health inequalities include segregation in housing, education, employment, and health care, and racially skewed mass incarceration (10). 

Racial segregation by neighborhood increases HIV risk and prevalence. Residents of low-income, minority neighborhoods are also significantly less likely to have access to medical care or prevention methods (11).  Studies show that within a medical practice, black patients are treated differently than their white counterparts and that African Americans are likelier to live or seek care in areas where the healthcare quality is low for all patients (12). Even if they have access to healthcare, African Americans are less likely to have a regular source of primary care and therefore a trusted source of medical care (12).

Geographical segregation also makes communities of color less likely to have access to medical education – important for both seronegative individuals, to maintain their negative status, and seropositive individuals, to maintain their health and make sure transmission stops with them.  Timely diagnosis is an important factor when considering both HIV prognosis and spread in the population.  It is estimated that 1 out of 5 HIV+ individuals don’t know their status (2), affecting both their health and the health of any potential sexual partners; left untreated, HIV is more likely to develop into AIDS more quickly, and is more likely to be transmitted through unprotected sexual contact or intravenous drug use.  Lower rates of medical access, information, and quality have real and quantifiable consequences for the viral load in African American communities.  It is absolutely vital to place any intervention aimed at the African American community in general, and black women in particular, within a context of social determinants and social justice by moving beyond individual-level behavioral risk factors.   The downstream consequence of poor health outcomes should be recognized as the result of upstream factors such as the distribution of wealth.  It may also be worth noting that many health behavior change models depend on the use and spread of health information, in addition to raising self-efficacy, to inspire health change.  Due to the structural problems the African American community faces, behavior-changing information does not spread as widely in their community and therefore does not have the desired effect.

II. Gender Power Imbalance

In the United States, there are approximately 9 African American men for every 10 African American women (13); this creates a sex-ratio imbalance that is frequently cited as a leading cause of relationship insecurity and a fundamental reason for a gender power imbalance.  Since 83% of HIV transmission is through heterosexual contact (14), a dearth of acceptable sexual partners may lead women to choose partners with higher HIV risk.  Therefore, the factors that contribute to a woman’s position within a sexual network may place her at a higher risk of contracting HIV.

The ratio imbalance stems from a number of factors that remove African American males from the community, including higher mortality rates from disease, high violence rates, and high rates of incarceration (15).  Black men are overrepresented in prison systems.  More than 12% of men ages 20-29 are in jail or prison, and black men are more likely to be incarcerated than white men for the same crime (16).  This “sexual network” concept – that a group of individuals are connected directly or indirectly through their sexual contact – has deep ramifications for the African American community.  Many individuals choose sexual partners from within their neighborhoods, so even if they do not engage in high-risk behavior, the systematic segregation will also increase the risk of a high-risk partner (17).  This relatively small network of potential partners allows transmittable sexual diseases to spread more rapidly. In fact, the high viral load of certain inner city segregated communities has been compared to that of third-world countries (18). 

The theory of concurrent relationships may offer some important insights about the spread of HIV in the African American community.  Previously mentioned factors such as high incarceration and low sex-ratio lead to an especially high number of concurrent relationships, which are “multiple simultaneous sexual relationships or sexual relationships that overlap in time” (19). A study conducted by Morris et al. found that the rates of concurrency in African American male participants between the ages of 20 and 38 were 3.5 times higher than their White counterparts and 1.9 times higher than men of other racial backgrounds. In the same study, African American females had rates of concurrency at 2.1 times higher than their White counterparts and 4.1 times higher than women from other racial backgrounds (19). 

The consequences of these gender inequalities for HIV are clear. Expressed by Newsome et al: “African American women contending with the gender ratio imbalance that exists may relinquish negotiating power in their relationships, be more likely to settle for less desirable partners, accept infidelity, and agree to engage in unprotected sex” (15).

A black woman’s sexual relationships can be informed by concurrency, instability, and an imbalance of power.  These limiting factors often result in disassortative mixing by HIV risk, in which low-risk individuals partner with high-risk individuals due to lack of choice and therefore become high risk themselves.  This system of arrangements puts black women in high-risk situations not of their own making; individual-level risk behavior is meaningless when confronted with a system that puts women at higher risk through no fault of their own.  These gender-based configurations of power stymie traditional behavioral theories’ suggestion that knowledge of risk should result in an increase in self-protective behaviors.  The inherent imbalance of power in sexual relationships naturally leads to an inability to engage in self-protective behaviors – when your sexual options are limited, bargaining for monogamy and condom use is not an option. 

III. Spiritual Worldview and Self-Efficacy

A review of the current literature reveals that by far the most important thing to consider when discussing HIV transmission in black heterosexual females is that they have a much lower perceived risk of infection than comparable populations.  This belief holds the key to understanding their high HIV transmission rates.  Several factors to consider concerning its genesis are the high levels of spirituality and religiosity historically found in the African American community, the optimism and fatalism associated with spirituality, and the power of an entrenched worldview coping mechanism (20).

Spirituality and religiosity have been associated with the African American community as a coping mechanism for systematic oppression (21).  The community depends on religion in times of adversity, and prayer is an important tool in times of need.  African American women in particular report a high level of spirituality and religiosity and “heavily rely on a sense that everything is in the hands of a higher power” (20).  In times of special need or stress, all individuals are known to depend on extant coping mechanisms; this has been shown to be true in cases of extreme illness or disease, such as HIV (20).  However, certain aspects of this religious coping mechanism clash with medically approved prevention or maintenance behaviors recommended for the avoidance of HIV (22). Also, belief in a higher power is associated with higher levels of optimism. This suggests the concurrence of optimism bias, the theory that individuals have an optimistic underestimation of their vulnerability to negative consequences.  Optimism bias has been shown to be a contributing factor to the spread of HIV in the African American community (23).  This is perhaps related to African Americans viewing AIDS as only a gay white male disease (17) and therefore not viewing their risky behavior as risky enough to place them in danger of contracting HIV. 

Belief in a higher power also correlates with the principle of fatalism, or the amount of control people feel they have over their lives and future. Powe (1996) stated, “In addition to poverty, oppressive forces such as the long history of slavery, segregation, discrimination, substandard health care, and the subsequent perceptions of meaninglessness, hopelessness, and social despair provide the environment for the emergence of fatalism [among African Americans]” (24).  People with fatalistic attitudes have been shown to participate less frequently in preventive health behavior (20).  In a study on cancer risk, African Americans and women reported higher levels of fatalism than European Americans and men (25).  This study can easily be extrapolated to HIV; African American women feel as though they have little control over whether or not they contract HIV, and so do not feel as though they need to take precautionary measures, such as condom use or regular HIV testing.  Studies show that although black women are, in fact, in possession of a great deal of knowledge about HIV transmission and prevention (due to years of targeted education), the combined optimistic bias and fatalism inherent in their religion-based coping worldview leads to a lower personal perceived risk of HIV contraction.  This difference in known versus perceived risk may also avoid the cognitive dissonance inherent when pursuing behaviors one knows are risky but does not feel one has the power to avoid.

IV. Proposed Intervention

What lessons can be learned from this social and psychological profile?  First of all, the real source of many issues of public health can be found upstream.  The health problems of the African America community extend far beyond the prevalence of HIV, and the underlying cause is the systematic racism, poverty, and segregation endemic in the community. Interventions geared toward changing individual behaviors are useless without considering the socio-cultural framework that the individual is part of.  It’s impossible to understand a black woman without also understanding how her gender, history, value system, and sexual network affect her behavior, and how they interact to create seemingly irrational behavior patterns.

Second, accurate knowledge is the vital center of many health interventions, yet knowledge alone is not enough to warrant substantive change.  Many models address this disparity between knowledge and behavior through the addition of self-efficacy; raising an individual’s efficacy is the theoretical answer.  The problem with behavioral models is that black women already know they are at a higher risk of HIV and they know safe sex will protect them.  Educational interventions have taught them all about HIV.  The problem is, all of the other factors that create the worldview of a black American woman combine to decrease her perceived risk.   This occurs in order to avoid the cognitive dissonance inherent in participating in the risky behaviors known to be associated with HIV transmission while not feeling like she has the power to avoid these risky behaviors.  Behavioral interventions may teach safe sex and regular HIV testing, but women will continue to ignore them as long as that is the sacrifice they must make for the comfort of feeling protected by their heterosexual relationship.  But if the HIV incidence rates in the black female population are to be reversed and eventually stopped, the first goal must be prevention through engaging people’s existing worldviews on a societal scale. 

The components of the proposed intervention are as follows:

a.) There is no simple solution for the root cause of health inequality. The best way to address the important HIV implications of skewed incarceration statistics, wealth inequality, racism, and segregation is to eliminate these systematic inequalities.  This is easier said than done.  The Obama administration’s National HIV/AIDS Strategy and Implementation Plan makes great strides in this area by focusing not only on HIV testing and education, but by also addressing disparities as the root cause of high HIV transmission rates.  Some action items suggested by this plan include making HIV tests available to low-income populations, promoting a holistic approach to health, and adopting community-level approaches to reduce HIV infection rates (8).  Still, it’s clear that tackling the root causes of poor health outcomes will take generations, and may only be addressed on a national level by increasing social funding.

b.) Increasing HIV testing in the African American community, the primary goal of the CDC’s “Take Charge. Take the Test.” campaign, is an important way to improve health outcomes for HIV+ individuals, but the main message of any HIV intervention should be to avoid infection in the first place.  Decreasing HIV infection must be the primary message if HIV rates are ever to decrease, in any population.  If you test positive, it’s already too late.

c.) Black women are doubly disenfranchised by their race and their gender.  These factors combine to increase their powerlessness in many situations, including HIV prevention, because most prevention techniques depending on changing male behavior.  Women may not feel empowered to ask their partners to use a condom or ensure monogamy, two of the most important HIV prevention behaviors.  Any intervention aimed at the black female population would acknowledge that telling women to always use a male condom is problematic and instead turn to other options. An answer may be to create new or popularize existing prevention techniques in which the woman is empowered to practice safe sex on her own terms.  One such existing technique is the female condom, a tool that allows women to dictate their own safety.  Leaving women’s safety from sexually transmitted infections in men’s hands just because affordable, comfortable female-controlled safe sex tools are unavailable is ridiculous and untenable.

d.) The cognitive dissonance created by the struggle between safe sex knowledge and core values is a powerful psychological force.  Additional HIV transmission education is not the answer, and HIV testing comes too late.  The fatalism and optimism inherent in spirituality are too firmly entrenched within the African American worldview to be denied; the only response is to use cultural values of similar importance as a fundamental building block of HIV prevention campaigns.  One potentially powerful appeal may be to Family.  Familial relationships, and keeping the family together, would act as a significant existing cultural touchstone to draw from.  If HIV prevention were framed as a duty to protect family and community rather than just a duty to individual health it may resonate more with the target audience.  This reframing would align the goals of the target audience with the goals of health promotion, reducing cognitive dissonance and psychological reactance, and would allow women to act on their health knowledge. 

Although a significant and vital amount of resources have recently been dedicated to eliminating HIV transmission in the African American community and specifically in women, certain fatal social science errors permeate current health interventions.  Recognizing the flaws in individual-level, behavioral interventions when applied to racial minorities is the first step to creating socially sensitive and appropriate health campaigns.  Any health campaign created to address the problem of HIV prevalence in the African American female population should include elements of social funding, should focus on HIV prevention rather than testing as an outcome, should empower women to demand safe sex by popularizing a female-based safe sex tool, and should reframe staying HIV-free using the core value of Family or an equally powerful value for the African American community.  The sooner this is implemented, the sooner we will have an AIDS-free generation. 

REFERENCES

1.     U.S. Federal Funding for HIV/AIDS: The President’s FY 2012 Budget Request. (October 2011).

              http://www.kff.org/hivaids/upload/7029-07.pdf.

2.     The HIV/AIDS Epidemic in the United States. (December 2012). http://www.kff.org/hivaids/upload/3029-13.pdf.

3.     Center for Disease Control and Prevention. HIV in the United States: An Overview. (March 2012). http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/pdf/HIV_overview_2012.pdf.

4.     Center for Disease Control and Prevention. CDC - HIV Among Women.  (August 2011).

 http://www.cdc.gov/hiv/topics/women/pdf/women.pdf.

5.     Arya, Monisha, Heidi Behforouz, and Kasisomayajula Viswanath. (March  2009). African American Women and HIV/AIDS: A National Call for Targeted Health Communication Strategies to Address a Disparity.

http://member.ubmmedica.com/verify.php?referrer=http://www.theaidsreader.com/display/article/1145619/1385623&parentreferrer=null

6.     Nunn, et al. (March 2011). Low Perceived Risk and High HIV Prevalence Among a Predominantly African American Population Participating in Philadelphia’s Rapid HIV Testing Program. http://www.hivdent.org/_medical_/2011/Nunn_2011_AIDS_Pt_Care_STD_Low_perceived_risk_and_high_HIV1.pdf.

7.     Center for Disease Control and Prevention . HIV/AIDS and African Americans | Topics | CDC HIV/AIDS. (February 27, 2012).

            http://www.cdc.gov/hiv/topics/aa/.

8.     NATIONAL HIV/AIDS STRATEGY (July 2010).  Retrieved from http://www.whitehouse.gov/files/documents/nhas-implementation.pdf.

9.     Fraze, J. ., Uhrig, J. D., Davis, K. C., Taylor, M. K., & Lee, N. R. (September 2009). Applying core principles to the design and evaluation of the “Take Charge. Take the Test” campaign: What worked and lessons learned. http://ezproxy.bu.edu/login?url=http://www.sciencedirect.com/science/article/pii/S0033350609002352

10. Robinson, Russell, and Aisha Moodie-Mills. (July 2012). HIV/AIDS Inequality: Structural Barriers to Prevention, Treatment, and Care in Communities of Color | Center for American Progress. http://www.americanprogress.org/issues/lgbt/report/2012/07/27/11834/hivaids-inequality-structural-barriers-to-prevention-treatment-and-care-in-communities-of-color/.

11. Elimination of Health Disparities: National Prevention Strategy. Retrieved from http://www.healthcare.gov/prevention/nphpphc/strategy/health-disparities.pdf.

12. The National Bureau of Economics Research. GEOGRAPHY AND RACIAL HEALTH DISPARITIES.  (February 2003). http://www.centerforurbanstudies.com/documents/electronic_library/cuba/healthcare/geography_and_racial_disparities.pdf.

13. U.S. Census Bureau. (2000). Male-female ratio by race alone or in combination and Hispanic or Latino origin for the United States: 2000 (PHC-T-11). http://www.census.gov/population/www/cen2000/briefs/phc-t11/index.html

14. Chen, N., Meyer, J., & Springer, S. (February 2011). Advances in the prevention of heterosexual transmission of HIV/AIDS among women in the United States. http://www.pagepress.org/journals/index.php/idr/article/view/idr.2011.e6/2966

15. Newsome, V., & Airhihenbuwa, C. (October 2012). Gender Ratio Imbalance Effects on HIV Risk Behaviors in African American Women. http://ezproxy.bu.edu/login?url=http://hpp.sagepub.com/content/early/2012/10/04/1524839912460869.long

16. The Sentencing Project. Comparative International Rates of Incarceration: An Examination of Causes and Trends. (June 2003). http://www.sentencingproject.org/doc/publications/inc_comparative_intl.pdf.

17. Aral, S., Adimora, A., & Fenton, Kevin. (August 2008). Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. http://ezproxy.bu.edu/login?url=http://www.sciencedirect.com/science/article/pii/S0140673608611186

18. Gallo, R. (2008, November 16). Inner Cities Need an AIDS Relief Program. http://www.washingtonpost.com/wpdyn/content/article/2008/11/14/AR2008111403132.html

19. Morris M., Kurth A. E., Hamilton D. T., Moody J., Wakefield S. (2009). Concurrent partnerships and HIV prevalence disparities by race: Linking science and public health practice. American Journal of Public Health, 99, 1023-1031.

20. Younge, Sinead. (2008). Risk Revisited: The Perception of HIV Risk in a Community Sample of Low-Income African American Women. http://ezproxy.bu.edu/login?url=http://jbp.sagepub.com/content/36/1/49.full.pdf+html.

21. Jagers, R. J. (2000). Work notes on communalism. African American Research Perspectives, 6(1), 69-78.

22. Franklin, M. D., Schlundt, D. G., McClellan, L. H., Kinebrew, T., Sheats, J., Belue, R., et al. (2007). Religious fatalism and its association with health behaviors and outcomes. American Journal of Health Behavior, 31, 563-572.

23. Kalichman, S. C., & Cain, D. (2005). Perceptions of local HIV/AIDS prevalence and risks for HIV/AIDS and other sexually transmitted infections: Preliminary study of intuitive epi- demiology. Annals of Behavioral Medicine, 29, 100-105.

24. Powe, Barbara. (1996). Cancer Fatalism Among African-americans: A Review of the Literature. http://ezproxy.bu.edu/login?url=http://www.sciencedirect.com/science/article/pii/S0029655496800200.

25. Conrad, M., Brown, P., & Conrad, M. (1996). Fatalism and breast cancer in Black women. Annals of Internal Medicine, 125, 941-942.

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.

REFERENCES

(1) Center for Disease Control and Prevention. Bicycle Related Injuries. Atlanta, GA: Home and Recreational Safety, 2009. http://www.cdc.gov/homeandrecreationalsafety/bikeinjuries.html
            (2) The Daily Free Press. Bike initiatives aim to increase cyclist’s safety. Boston, September 2012. http://dailyfreepress.com/2012/09/20/bike-initiatives-aim-to-increase-cyclists-safety/
            (3) City of Boston. Bike Statistics. Boston, MA: Parks and Recreation Department, 2010. http://www.cityofboston.gov/bikes/statistics.asp
            (4) Pedestrian and Bicycle Information Center. General Bicycling Statistics. North Carolina: University of North Carolina Highway Safety Research Center. http://www.bicyclinginfo.org/facts/statistics.cfm
            (5) Boston Public Health Commision. Helmet Safety Campaign. Boston, MA: Injury Prevention, 2012. http://www.bphc.org/programs/cib/healthyhomescommunitysupports/injuryprevention/Pages/HelmetSafety.aspx
            (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.
            (7) 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.  http://www.alcoholfacts.org/DARE.html
            (9). Mass Ride. Safe Routes to School Funding in Massachusetts. Massachusetts: Safe Routes to School National Partnership, 2012. http://www.saferoutespartnership.org/state/srts-in-your-state/massachusetts.
            (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.