Bicycle Helmet Initiative at Boston University 2011--Osnat Glassman

Introduction

Bicycle accidents are a major public health problem in the United States, but particularly in Boston, and at Boston University, where high traffic and sub-optimal helmet use add to both the morbidity and mortality. While bicyclist deaths only represented 2% of all traffic fatalities in 2009, and we are witnessing an overall reduction in deaths of those under 16 in bicycle accidents (down 58% from 2000 to 2009), bicycle deaths of those over age 16 (86% of all bicycle related deaths), representing the population at BU, is rising. Fatal crashes typically were urban (69%) and head injuries accounted for 62.6 percent of bicycle fatalities. Ninety-one percent of bicyclists killed in 2008 reportedly weren't wearing helmets, which is a particularly startling number. And, most of those killed (61%) were on major roads (other than interstates and freeways), (1) which has prompted initiatives around the world and country, but particularly at Boston University—though there is more work to be done as this paper will show.

It is clear that lack of helmet use is directly proportional to injury and death as a result of bicycle accidents. In 2008, only 8% of the 714 bicycle deaths in the US were wearing helmets, where 91% were not. This overwhelming proportion has not changed much since 1994 (2% vs 97% respectively). (ibid.)

These statistics reflect the landmark New England Journal of Medicine study that showed definitively that riders with helmets had an 85 percent reduction in their risk of head injury (odds ratio, 0.15; 95 percent confidence interval, 0.07 to 0.29) and an 88 percent reduction in their risk of brain injury (odds ratio, 0.12; 95 percent confidence interval, 0.04 to 0.40) (2)

In Boston, where bicycle ridership has increased by 122% from 2007 to 2009, citywide helmet usage stands at 72%, (3). While better than national numbers, where only 35% of cyclists use a helmet for all or most trips, (4) it is still not optimal, as it should be to avoid major injuries. In fact, the majority (55%) of Boston EMS calls still include riders without helmets, making a case for more use in Boston. Closer to home, the roads with most bike crashes are Massachusetts Avenue and Commonwealth Avenue, (5), a particularly significant area for the Boston University Undergraduate Campus. In fact, from July through September 2010, 141 bicycle and car accidents—3 deadly—were reported to the Boston Police Department, and 16 since September 2010 (none fatal).

The BU Cycling Safety Survey, sponsored every other year by the BU Bike Safety Committee, found that nearly 48 percent of bicyclists on the Charles River Campus do not always wear helmets. Many quoted inconvenience or lack of style, not the cost, that led to their getting rid of the helmet. (6).

Boston University’s Response

At BU, there have been several initiatives falling under the umbrella of bicycle safety in order to encourage helmet use, given the above statistics.

First, the BU Bike Safety Committee began a new campaign this year called the “Helmet Hair Contest.” This encouraged students to submit pictures of their hair after wearing a bicycle helmet for a chance to win a prize ($150 in Convenience points). (7)

Second, the Committee is planning a Spring Bicycle Safety Day. As a similar event in 2010, representatives from a number of local bike shops will likely be present during the event to offer free tire pressure testing, seat height adjustments, and brake accuracy assessments, offering advice about bike maintenance and tips for those looking to purchase bikes, new and used. Helmet use and info was not mentioned specifically in past school advertising, however.

Staff from the BU Medical Campus, the BU Police Department, Parking and Transportation, and “sustainability@BU” plan to be on hand to offer advice and to promote safe bike practices. All BU students and staff will have a chance to register their bikes with the University, which is encouraged to increase the odds of recovering a bike if it’s stolen and also provides access to indoor bicycle parking on campus. There will be likely be free give-aways as well to attract a crowd, based on last year’s event’s literature. (8)

Third, the most recent initiative has been for the BU bicycle patrol officers to give fake tickets and free bike helmets, since bicycle helmet use over age 16 is not illegal per se, despite it being highly recommended. Stationed along Commonwealth Avenue, the officers handed out orange tickets similar to Boston City tickets, with MassBike’s rules of the road printed on one side and a 20 percent off coupon on locks and helmets at Landry’s Bicycles on the other.

Webb Lancaster’s goal, director of operations for Auxiliary Services at BU, hopes it would encourage both a serious conversation and a memorable meeting. The event was organized by the University’s Bike Safety Committee and the Office of Judicial Affairs to give away free helmets, amongst other safety items like lights, and tire changing kits.

A secondary goal of the initiative was to educate cyclers about Massachusetts law (2009), where bicyclists can be fined $20 for traffic violations, like running a light or biking without proper lighting at night, similar to a motor vehicle. This is something BU Police plan to enforce via its mountain bike unit. The law also requires bikers 16 and younger to wear helmets, but not those of the BU community, the vast majority of whom are over 16. (6).

Why the existing interventions are flawed

There are several recent initiatives to promote helmet use on Boston University campus and I will focus on three of the most obvious and current and examine, using social science theories to analyze the flaws in these approaches.

Helmet Hair Contest.

This marketing technique to encourage helmet use relies on human vanity and self-perceived importance of the student hair-do to encourage helmet use. As prior BU surveys have shown, students tend not to use helmets due to the negative impact that the helmet might have on their coiffure, as opposed to the price of the helmet itself. If one were to perhaps analyze this approach by means of the “Diffusion of Innovations (DOI)” theory, one would find that the approach does not stand on its own. The DOI consists of an innovation being communicated through certain channels over time among a social system’s members. (9) The Helmet Hair Contest relies on several competitors and a final single winner to show that a ‘helmet head’ is actually an innovation, rather than a detractor. Yet while, in this model, the innovation (the helmet head due to helmet use) may be perceived as something ‘novel’, the communication channels are essentially halted once the contest is over. This lack of use of communication channels (other than perhaps the winner talking about her prize for a day or so) will lead to a very shortened innovation-decision period for others in the social system (i.e. BU student body) to even consider adapting to. Once there is no contest, there is no further incentive to promulgate the ‘helmet head’ (and bicycle helmet by extension) in order to continue making that ‘look’ a novel approach. In addition, the five-stage process in the DOI (knowledge, persuasion, decision, implementation, confirmation) is dramatically cut short due to a rapid and non-repeating culmination of having one winner. The knowledge of the innovation limited to brief period, there leaves only room for persuasion before the winning of the prize. Decisions to wear the helmet for the prize will be fleeting, implementation will be slim and confirmation would likely be non-existent given the inherent need for adequate time. (ibid.)

Bicycle Safety Day

There are some elements that are related to bicycle safety in the description of the Safety Day, but, interestingly, there is no mention of helmet use in either the BU Today article or the Spring 2010 advertisement (10) which featured a man standing on a bike’s handlebars and seat without a helmet. Using the premise of the Health Belief Model, which addresses perceptions of individuals of a threat posed by a health problem (in this case, not wearing a helmet and getting a head injury), the advertising for the Safety Day reinforces the common health belief of youth that there will, in fact, be no injury or consequence of not wearing a helmet. The fact that there is no mention of helmets in the ad, nor in the BU Today article promoting last year’s Bicycle Safety Day skirts the importance of the issue of helmets and doesn’t present helmetlessness as a potential health problem; in addition, it proposes no perceived severity of the issue, and essential component of the Health Belief Model. In addition, the poster proposes no perceived benefits of helmet use, and provides no cues for action. The promotion of the Day for forfeits any encouragement of confidence in student’s ability to take action and wear a helmet, since it almost ignores the item completely (except in the accompanying student video link showing one student wearing a helmet, but doesn’t explicitly mention anything about it). If a student actually decides to purchase and use a helmet as a result of Bicycle Safety Day, it is not due to any cues to action provided by the 2 modes of advertising seen here. If the advertising were to employ aspects of the Health Belief Model, it would have to propose some sort of susceptibility and severity of non-use, and provide benefits, cues to action and self-efficacy (confidence) to use a helmet, none of which past advertising has done. If anything, it has done the opposite. (11)

In addition, the event is framed improperly, since safety consciousness is not first and foremost on people’s mind, especially students at this age, who do not think about health risks. The framing of the event by calling it “Bicycle Safety Day” paints a bland picture that puts bicycle use in a boring light. Framing the “Day” in a new way may make it more effective. (12)

Faux violation tickets with coupons for helmets

This approach, while novel, still doesn’t change one’s perceived behavioral control, nor one’s attitude toward the behavior, two essential components to the Theory of Planned Action. The Theory of Planned Action states that intention and ultimate behaviors are affected by attitude toward the behavior, subjective norms and perceived behavioral control. (13) If there is no real consequence presented by the BU authorities, rather simply a coupon, there is no real obstacle or prevention of their lack of use, thus no true behavioral control. The attitude toward the behavior of not wearing the helmet is not influenced, since it has no real effect. While giving out a coupon may raise a financial interest buy a helmet, the only compelling reason to buy the helmet appears to be the discount, as opposed to the health threat. It would be important to influence attitude toward the behavior and perceived behavioral control, according to the TPA, in order to affect intention to use. Certainly, the subjective norm is ‘non-use’ of helmets, which is also a potent factor, not necessarily affected by this intervention. The current subjective norm seems to say that wearing a helmet is not ‘in style,’ can ruin one’s hair and is cumbersome and bulky to carry from class to class. This intervention does not attempt to change that subjective norm.

Interventions addressing the flaws, using social science theories

Helmet Hair Contest

In order to improve the contest using the “Diffusion of Innovations (DOI)” theory, there needs to be communication through social channels over. (14). In order to aid in the diffusion, I would recommend that there be 2 winners, a male and a female, in two different competitions. The novel ‘helmet head’ would then not necessarily stop once one winner is found; if there are 2 contests between the sexes, there will be enhanced communication, due to the interplay of the sexes and the greater attention each might give each other. In addition, I would add an interim contest for the helmet with the best design, where contestants would design a theme on their helmet with an eco-friendly message. An eco-message might appeal to the people who ride bicycles who may be more environmentally conscious. More contests surrounding the helmet would lengthen the innovation-decision period for others in the social system to consider adopting—helmet wearing. In addition, by making perpetual contests of different sorts, throughout the year, room for persuasion exists even after the prize is won, in preparation for the next helmet contest.

Bicycle Safety Day

The Health Belief Model requires integration into adverting for a Bicycle Safety Day in order to re-enforces the health belief that there could very well be injury or irreversible damage if one does not wear a helmet. One approach could be to advertise the event with a startling picture of a watermelon smashed on the sidewalk next to a bicycle tire. This would have the effect of reminding a rider that his or her head is a delicate object, yet would do so with an indirect symbol. While the smashed watermelon is not the actual head, it gives the impression of a head and the damage of non-helmet use. To advertise bicycle safety, the central theme has to include helmets, which is a crucial piece of preventing death and injury as shown in the introduction of this paper. The smashed watermelon provides a cue for action, an essential component of the Health Belief Model. Also the watermelon image implies susceptibility and severity of non-use. It is both humorous and serious at same time, and makes a strong statement about the delicate nature of the human head. The posters should be placed strategically in places where there is direct eye contact of bicycle riders, and not on the sides of the dormitories and convenient stores, where only pedestrians might look (which is where most BU ads are currently).

In addition, as mentioned earlier, the framing of the day as “Bicycle Safety Day” is quite dry and likely unexciting to students; it would behoove the committee to change the event to another name, like “Tour de Boston,” implying an exciting event, related to bicycles. This day will provide information, not only about safety equipment and promote helmet use, but will also feature a competition to find a treasure in the Boston area using bicycle paths; the condition for participating in the treasure hunt would be to fully equip oneself with a helmet, and perform fully bicycle maintenance prior to the competition. Framing the day properly can help to change people’s attitude and behavior regarding helmet use. (15)

Faux violation tickets with coupons for helmets

As mentioned earlier, this approach had no true affect on one’s perceived behavioral control as per the Theory of Planned Action. (Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley) In order to truly affect behavioral control, the author proposes that one give out real tickets of consequence that make it truly ‘illegal’ to ride helmetless, at least on the Boston University Campus. While not truly illegal in Boston, wearing a helmet on campus could be a BU ‘law’ that could be truly reinforced. Giving the coupons is effective but only in the context of real consequences for not wearing the helmet. The attitude toward the behavior would then be affected and social norms could be changed, according to the Theory of Reasoned Action. In order to change the subjective norm of using a helmet as being ‘in style,’ I would defer to the intervention proposed above, using several contests, as opposed to just one. In addition, positive reinforcement could be used for those who did wear a helmet, in the form of extra meal points on meal cards.

In conclusion, since the Charles River Campus area has the highest rate of bicycle accidents in the city, it is important that BU takes an active role in approaching the issue of helmet use with cyclists. It is clear that encouraging and enforcing helmet use could have a direct impact on morbidity and mortality as a result of bicycle accidents based on the evidence. In addition the more students perceive their peers using a helmet and the less they perceive them not using a helmet, they too will use them as well. Students tend to exaggerate their peers’ lack of use of helmets, according to the “social norms theory.” If active steps like the one’s proposed above are taken, people’s behavior can be influenced and a new ‘norm’ can be formed. Students will form a new perception of how other members of their social group behave, and if they think that wearing helmets is typical, they are more likely to wear the helmet, (16) which in the end will achieve the final public health safety goal.

References

1. Bicycle Helmet Safety Institute, http://www.bhsi.org/stats.htm)

2. Thompson, Robert, et al. A Case-Control Study of the Effectiveness of Bicycle Safety Helmets, New England Journal of Medicine 1969;320:1361-7.

3. Boston Bikes Annual Counts, Boston, MA http://www.cityofboston.gov/bikes/statistics.asp

4. National Survey of Bicyclist and Pedestrian Attitudes, http://www.nhtsa.gov/

5. Boston Bikes Accident Survey, http://www.cityofboston.gov/bikes/statistics.asp

6. BU Cycling Safety Survey, Boston University, Boston, http://www.bu.edu/today/node/12769

7. Helmet Hair Contest, http://www.bu.edu/bikesafety/

8. Bike Safety Day Today 2010, http://www.bu.edu/today/node/11455

9. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press

10. Bicycle Safety Day, Boston University, Boston, http://www.bu.edu/today/files/images/v_bikesafety.jpg

11. Janz, Nancy and Marshall Becker, The Health Belief Model: A Decade Later, Health Education Quarterly, Spring 1984; 11 (1): 1-47.

12. Tversky, Amos and Daniel Kahneman, The Framing of Decisions and the Psychology of Choice. Science, 1981; 211: 453-458.

13. Fishbein, M., & I. Ajzen, Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley, 1975.

14. Rogers, E. M. Diffusion of Innovations (5th ed.). New York, NY: Free Press, 2003.

15. Dorfman, Lori, Lawrence Wallack, and Katie Woodruff, More Than a Message: Framing Public Health Advocacy to Change Corporate Practices, Health Education & Behavior June 2005; 32 (3): 320-336.

16. Best Practices, Social Norms, Wisconsin Clearinghouse for Prevention Resources, http://wch.uhs.wisc.edu/13-Eval/Tools/Resources/Social%20Norms.pdf