Tuesday, May 13, 2014

A Critique of the Boston Public Health Commission’s Helmet Campaign – Jacqueline Honerlaw

            The City of Boston has worked to promote bicycling as a method of transportation and recreation since Mayor Thomas Menino established the Boston Bikes initiative in 2007. Since the founding of this program, bicycle ridership has increased by about 82%, with an estimated 56,644 bike trips per day in 2012. (1) The campaign also focuses on developing infrastructure to facilitate bicycle commuting. The bike lanes in the city have increased from a total of 60 yards in 2007 to over 60 miles in 2012. (2)
In addition to increasing ridership and improving infrastructure, promoting safe bicycling practices is also a part of the Boston Bikes initiative. The 2013 Boston Cycling Safety Report issued by the Mayor’s Office described the incidence of crashes and factors associated with crashes. The report revealed a rise in the number of crash incidents between 2010 and 2012, during a period of increased ridership. (1) Due to the findings of the report, Mayor Menino set a goal for the city to reduce the injury rate by 50% by 2020. (1) Efforts to decrease the number of bicycling accidents have been led by numerous branches of city government including Boston Bikes, the Boston Police Department and the Boston Public Health Commission (BPHC).
The helmet campaign was launched by the BPHC in October 2012 as part of the Boston Bikes safety initiatives. According to the BPHC campaign site, “helmets have been shown to reduce the risk of head injury by 85%, the risk of brain injury by 88% and the risk of injury to the upper or mid-face by 65%.” (3) The estimates of helmet use in Boston differ based on the source of the data. The BPHC cites a Boston Bikes survey with 70% of cyclists wearing helmets, while another study from the Annals of Emergency Medicine reports 48% compliance. (3)
The campaign consists of bike lane markings and posters placed in areas frequented by cyclists. Stencils were placed in city bike lanes which show the profile of a person wearing a helmet and read “No Excuses. Wear a Helmet.” Twenty four posters were displayed with three images of young cyclists and a tagline reading “There are No Good Excuses” on each image under a different header. One image in the campaign shows the bloodied face of a man lying on the ground with the header “And you think a helmet is uncomfortable?” Another image shows a man nursing a facial injury with the header “Still think it’s the helmet that’s unattractive?” The final ad shows a woman with a helmet and a minor scrape on her face with the header “Not thinking about helmet hair now, are you?” (3)
            The effort to encourage cycling safety is essential if Boston wants to become the “world-class cycling city” that Mayor Menino envisions for the future. (1) While the BPHC should be commended for creating a campaign to increase helmet use, the execution of the campaign was flawed. The BPHC missed an opportunity to apply methods from social and behavioral sciences to enhance the effectiveness of the campaign. The heavy reliance on the Health Belief Model, the eliciting of psychological reactance and use of a negative frame against cyclists led to an ineffective message.
Problems with Use of the Health Belief Model
            The Health Belief Model (HBM) is a behavioral theory that was developed in the 1950s by social psychologists in the United States Public Health Service (USPHS). It has been widely used in public health campaigns and is the basis for other individual level models. The HBM centers on an individual weighing the costs and benefits involved in making a change in a health behavior. The HBM suggests that an individual will participate in a health promoting activity if
·         they perceive themselves to be susceptible to the disease,
·         they think the disease state would be severe,
·         they perceive the activity to be beneficial and
·         they determine the benefits to outweigh the costs.
The individual is assumed to be a rational decision maker in the HBM and able to understand the factors involved in the process. (4)
            The BPHC helmet campaign relies heavily on the principles of the HBM to deliver its message to Boston cyclists. The intent of the ad is to trigger cyclists to weigh the costs and benefits of helmet use based on the information the image provides them. The BPHC wants a cyclist to see the ad and be able to identify with the injured cyclist pictured. The cyclist would identify the messenger as a peer and determine that they are also susceptible to a bike crash. The graphic image of a bloodied face indicates to the cyclist that a crash without a helmet would yield severe injury. The viewer would then determine that the helmet is beneficial in the event of a crash. The ad points out some of the perceived costs of helmet use to the viewer including discomfort and lack of style. The ad then intends the viewer to compare the graphic images to the minor inconveniences of helmet use and decide that the benefits would outweigh the costs.
            There are several issues with the HBM that make its use problematic in the BPHC helmet ads and other public health campaigns. First, it is inappropriate to assume that individuals are rational in their behavior. Dan Ariely of the Psychology and Behavioral Economics Department at Duke University, argues that humans are in fact predictably irrational. By this phrase, Ariely means that “our irrationality happens the same way, again and again.” (5) Emotions, social norms and other forces outside our control influence our behavior and overtake reasoned thinking. Ariely points out that “while these influences exert a lot of power over our behavior, our natural tendency is to vastly underestimate or completely ignore this power.” (5) The concept of irrational behavior means that there are forces acting upon the cyclist when they view the helmet campaign ads. It is not likely that the viewer is moving through the clean decision making process of the HBM. Instead they may experience emotions or opinions about the ad that prevent them from rationalizing the ad’s message.
            In addition to neglecting the tendency of individuals to act irrationally, the HBM also fails to consider that individuals are influenced by group dynamics. The HBM emphasizes that the individual leads their own decision making process and ultimately makes the decision for themselves. In reality, individuals do not operate in a vacuum – they operate as part of a group. Thaler and Sunstein describe the role of social influence on individual behavior in “Nudge: Improving Decisions About Health, Wealth, and Happiness.” They suggest that the behaviors and opinions of the majority group lead individuals to choose to behave more like the social norm. This conformity can also occur by the individual giving in to peer pressure. (6) The role of social norms and influences cannot be ignored in public health campaigns. The BPHC helmet ads fail to address the group dynamics that may impact the decision to wear a helmet.
Eliciting of Psychological Reactance
            Psychological reactance is experienced by an individual when they perceive that their freedom has been threatened. In the state of reactance, the individual desires to restore their sense of freedom. (7) According to Shen, the theory of psychological reactance “proposes that any persuasive message may constitute a threat to freedom, arouse reactance, and lead to rejection of the message advocacy.” (8) To further restore their freedom, the individual may even actively reject the message by performing the forbidden activity.
            Public health campaigns should aim to reduce the likelihood that the public experiences reactance after hearing their message. Unfortunately, the BPHC did not consider the possibility of reactance while developing their ad campaign. There are two aspects of the campaign that may elicit reactance from the viewer – the language choice and the use of graphic imagery. The language used in the ad campaign is direct and blunt: “There are No Good Excuses.” When these words are accompanied by images of bloodied young men, there is a high risk that the viewer could be offended. A review of smoking campaigns by Shen and colleagues demonstrates this phenomenon. In their study of the use of fear and empathy in anti-smoking campaigns, graphic ads showing pain, suffering or distress elicited psychological reactance in viewers. (8)
            What is most concerning about an ad campaign eliciting reactance in its audience is the risk that the audience will reject the message by acting against it. In the case of the helmet campaign, this could lead cyclists to continue riding without a helmet.  Defying the message of the ad with concrete action is a way for the cyclist to overcome the feeling of reactance and restore freedom. The “freedom” that has been taken away is the freedom for the cyclist to ride the way they want to ride. The very ad that intends to increase helmet use could potentially lead to an opposite effect.
Ineffective Framing: Blaming the Victim
            Risk factors for death and disease have become increasingly important in assessing the health of a community or individual. Though genetic and environmental factors affect risk status, genes cannot be altered and there are limits to what can be done to alter the environment. Thus, most health interventions target behavioral changes executed at the individual level because they are more feasible. The individual is then ultimately responsible for implementing behavioral change. (9)
            Adler and Stewart argue that while increased accountability may be empowering for individuals, it can also have negative effects. This is because “viewing behaviors as freely chosen, as opposed to environmentally constrained, colors the interpretation of responsibility and fault.” (9) The individual is not only responsible for successful behavioral change, but also blamed for failure. Victim blaming is counterproductive because it does not take into account societal factors that affect behavioral change and may even discourage utilization of healthcare. A study of patients with chest pain in the United Kingdom showed that “fear of blame by health professionals appeared to contribute to a reluctance to present to a health professional.” (10)
            A major misstep of the BPHC helmet campaign was that it used victim blaming in the framing of its message. The cyclists in the ads are criticized for not wearing a helmet because they think it is uncomfortable, unattractive or will ruin their hair style. The header of one ad showing an injured man states “Still think it’s the helmet that’s unattractive?” According to the campaign ad, “there are no good excuses” for not wearing a helmet. The wording of the ad and the gruesome image suggests that responsibility for the accident lies with him because he could not change his behavior. The core position of this frame is that there is no one to blame but yourself if you are injured while riding without a helmet.
             The “blaming the victim” frame used in the ad campaign fails to note that there are other factors outside of individual behavior that contribute to the outcome of injury. If a cyclist is found on the street without a helmet, it is not appropriate to assume that they are responsible for their injury. Another issue is that cyclists who feel they are stigmatized for not wearing a helmet will be put off by the campaign, much like the patients with chest pain who were reluctant to see a physician. The BPHC helmet campaign is telling cyclists who have been injured while riding without a helmet that they deserve their injury.
Proposal for Revised Helmet Campaign
            The BPHC helmet campaign should be revised to address the over reliance on the HBM, the risk of psychological reactance and the ineffective frame using victim blaming. The central tagline of the campaign, “there are no good excuses”, and the images used in ads need to be overhauled. There are several aspects of this campaign that are appropriate to keep in the revision. The placement of ads in areas with high bike traffic is logical in order for the message to reach viewers and should be continued. The BPHC ads also picture cyclists of varied gender and race, which enables a diverse audience to identify with the ads.
            The new helmet campaign centers on the tagline “Bike Safe Boston”. Just as in the BPHC campaign, there are three different images used in the ads. Each ad pictures a young group of cyclists either wearing or holding helmets.  All of the cyclists are interacting with each other, except for one person who is looking at the viewer. This person is handing over a helmet and it appears from the viewer’s perspective that their hand is accepting it. The tagline “Bike Safe Boston” reads at the top of every image. At the bottom of the ad, there is a list of locations where helmets can be obtained around the city.
The only variation in the ads is the setting and target demographic pictured. The makeup of the groups is always diverse in terms of gender and race, but their ages range from 20s-30s. The first ad shows a group of commuters unlocking and docking bikes at a busy Hubway station downtown. This group is dressed in business casual and professional uniforms. The next ad is set at a packed bike rack on a college campus in the city. Students are shown in casual clothes with backpacks and books in tow. The final ad pictures a group of couriers tuning their bikes in front of South Station, with the chaos of the downtown traffic in view. They are wearing full messenger bags and poster tubes in preparation for delivery.
This revised helmet campaign recognizes the influence of society on the individual, positively utilizes labeling theory and re-frames the message into one of empowerment for the cyclist. This campaign addresses the flaws in the original helmet ads and aims to improve the rate of helmet use in Boston.
Recognizing the Role of Society
            While it is true that individuals make choices for themselves, it is essential to address the role of society in shaping personal decision making. Social expectations theory suggests that individuals worry about what other people think and desire to meet the expectations set by their social group. (11) Meeting expectations can provide approval and rewards, but failing expectations can lead to disapproval and punishment. Keeping up with the social norms, or understood rules, is important for group members.      The role of social norms is directly addressed in the new helmet campaign by first identifying a group and then showing helmet use as part of the group norms. The three groups defined in the new health ads are commuters, college students and couriers. One could argue that pleasure bikers and bike tourists were left out of the ad campaign, but these groups do not likely make up a large portion of people who regularly bike in downtown Boston and so they were not targeted. The groups are identifiable by their dress and location, yet the campaign also tries to define them broadly. Commuters appear to have different incomes and occupations, while college students do not wear university specific paraphernalia. When the viewer identifies with the group based on dress and location, they will also see helmet use as a defining characteristic of the group. The image of a group member offering a helmet likens to being offered a place in the group.
            Using distinct groups in the ad campaign may also be beneficial in preventing psychological reactance. A study of deflecting reactance by Paul Silva showed that the similarity of the messenger to the recipient was a factor that prevented reactance. The findings of the study showed that “people saw messages from similar communicators as less threatening than message from dissimilar communicators”. (7)
            The BPHC ad campaign tried to induce behavior change using the HBM by telling the viewer why they needed to wear a helmet and that they were doing something wrong. In the revised helmet campaign, the intent is to change behavior by first changing social norms. The viewer is shown that their group is already wearing helmets as part of the social norm and invites them to join.
Positively Utilizing Labeling Theory
Labeling theory suggests that humans have a tendency to categorize individuals into groups and assign them a label based on this categorization. Dara Shifrer of Rice University studied this phenomenon in children with learning disabilities. Her findings showed that “teachers and parents are more likely to perceive disabilities in, and hold lower educational expectations for labeled adolescents than for similarly achieving and behaving adolescents not labeled with disabilities”. (12) Expectations for the children’s performance were based on whether they were considered learning disabled. A label can become a self-fulfilling prophecy, for better or for worse, when used by society to assign social expectations.
The revised helmet campaign makes use of the potential benefits of labeling theory. The audience of the ad is labeled as someone who already knows to wear a helmet. This is achieved by the image of the cyclist in the ad giving a helmet to the viewer. The intent is to label someone as a helmet user so that they continue to wear a helmet. This approach is in contrast to the BPHC helmet campaign which labeled cyclists as forgoing helmets and thus could lead viewers to continue to neglect helmet use.
Re-Framing: From Blame to Power
            The new helmet campaign changes the frame from one of blame to one of empowerment. The individual is still held as responsible, but blame is removed from the campaign. Instead, they are commended for choosing a healthy behavior. The new campaign achieves this by using the image of the group member in the ad handing the helmet to the viewer and the viewer reaching out to take it. Thus, the viewer is already making the health decision to wear a helmet by viewing the ad.
In addition to celebrating individual empowerment, the ad focuses on group responsibility. Whether the viewer relates to the commuters, students or couriers, each group is defined by the fact that they wear helmets. By being offered the helmet, the viewer is invited to become part of the group and participate in one of the activities that defines them.
Removing blame is essential in order to make this campaign effective. The blame frame tells cyclists that they don’t know what they are doing and should listen to the ad. The new frame of empowerment shows cyclists as the authority on helmet use.
            Increasing helmet use by young Bostonians is important in preventing injuries in individual cyclists and in the transformation of Boston into a bike friendly city. The BPHC helmet campaign used a flawed approach in addressing this issue. The ad campaign relied heavily on the problematic HBM, risked the eliciting of psychological reactance and blamed cyclists for their injuries. The revised helmet campaign seeks to address these issues by acknowledging the role of society in health decision making, labeling cyclists as helmet users and framing cyclists as experts on helmet use.
1.       Mayor’s Office. Boston Cyclist Safety Report 2013. Boston, MA: Mayor’s Office. 2013.
2.      Boston Bikes. About Us. Boston, MA: Boston Bikes. http://www.bostonbikes.org/about/overview/
3.      Boston Public Health Commission. Helmet Campaign. Boston, MA: Boston Public Health Commission. http://www.bphc.org/whatwedo/childrens-health/injury-prevention/play-safe-bicycle-sports-safety/Pages/Helmet-Safety.aspx
4.      Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
5.      Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.
6.      Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008, pp. 53-71.
7.      Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
8.     Shen L. The effectiveness of empathy- versus fear-arousing antismoking PSAs. Health Communication 2011 Jul-Aug; 26(5):404-15.
9.      Adler NE, Stewart J. Reducing obesity: Motivating action while not blaming the victim. The Milbank Quarterly 2009 Mar; 87(1):49-70.
10.  Richards H, Reid M, Watt G. Victim-blaming revisited: a qualitative study of beliefs about illness causation, and responses to chest pain. Family Practice 2003 Dec; 20(6):711-6.
11.   DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
12.  Shifrer D. Stigma of a label: educational expectations for high school students labeled with learning disabilities. Journal of Health and Social Behavior 2013; 54(4):462-80.

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