HIV Prevention among Commercial Sex Workers-Sristi Sharma

Introduction

People who work in the commercial sex industry are more likely to be affected by HIV and AIDS, more so in the developing nations than in the developed nations. The very virtue of their work leads them to be exposed to HIV, as well as many other Sexually Transmitted Diseases. Once they are exposed to these diseases, apart from being ill themselves, they become a continuous source of infection for others. Public health interventions, directed towards sex workers, are mostly aimed at personal prevention as well as prevention of further spread of the disease (1).

Owing to the diverse range of backgrounds and cultures that different Commercial Sex Workers come from, as well as the different lifestyles they lead, it is difficult to generalize sex workers and the interventions that are applicable to them. The levels of risk that they face, in terms of HIV infection, can be vastly different, depending on the country that they live in, where they work (e.g., a brothel or ‘on the street’), and whether they have access to condoms, amongst other factors. So, what are the factors that put a sex worker at a higher risk for contracting and spreading the disease (1)?

1. Multiple partners, inconsistent condom use.

2. Social and economic factors: Sex workers are generally stigmatised and marginalised by the societies that they live in. Around the world there are not adequate laws that protect a sex worker, especially from actions of the client that can put them at an increased risk for diseases.

3. Injecting drug use: Possibly, because of the high stress levels related to the nature of the work that they do, many sex workers are injection drug users.

4. Migration, mobility and sex trafficking: The rise in sex tourism and trafficking, especially in countries in Asia and the Caribbean islands, is just an added factor to the spread of HIV and AIDS.

What are the aims of a successful education programme directed against HIV in Commercial Sex Workers? All the HIV Prevention programs directed against the Commercial Sex Workers, as well as large organizations like World Health Organization have agreed that the goal of a successful HIV program should be the following (1):

1. An increase in the use of condoms among Commercial Sex Workers and their clients.

2. An increase in involvement and control, by the sex workers, of their working environments.

3. A reduction in the number of sexually transmitted diseases in the sex workers.

4. Encouragement to live a healthy and dignified life.

The approach, by the public health workers, to achieve these goals, is through education of sex workers about HIV/AIDS and its prevention. This is done by (1) :

1. Education of the sex workers, by public health personnel.

2. Encouraging peer education (where sex workers inform one another about HIV).

3. Reducing the stigma that communities attach to sex work.

Though major efforts have been put into the education of sex workers for HIV prevention, HIV is still widely prevalent among Commercial Sex Workers in the developing nations, sometimes being as high as 20 times the national average (1). Commercial Sex Workers have been taught almost everything about safe sex practices. However, the use of condoms have not been at par with efforts, thus leading to persistent high levels of HIV and AIDS. This proves that education as a prevention strategy has been unsuccessful among the commercial sex workers in the developing nations.

Criticisms Against The Education Approach For Hiv Prevention Among Commertial Sex Workers

Hierarchy of needs

A Commercial Sex Worker in the Sonargachi Sex District in Kolkata makes about Rs.40, which amounts to less than a dollar. Out of this the sex workers gives half of it to her “owner”, some amount to the policeman as a bribe for letting her work, and some fee for her “room use”. By the time she is done paying off all, she is left with about Rs.10. This barely buys her a single meal. Now consider this. Suppose this lady has not had a single client the whole day and in the evening along comes a man who wants to have unprotected sex. Will she actually go ahead and say no to the client because she has heard and learnt all about AIDS prevention?

The Hierarchy of Needs is also known as Maslow’s Hierarchy of Needs. It’s a psychological model that largely explains, why humans behave the way they do. His model takes the shape of a pyramid, with the most fundamental needs of a human being at the bottom of the pyramid, and the need of self actualization at the top (2). Self actualization is a process by which one expresses oneself in his fullest capability (3).

The pyramid is as follows (12):

The above picture shows that self actualization, which involves problem solving and acceptance of facts, both of which are vital to the success of intervention programs, is high up in the pyramid. There are many levels in the pyramid that have to be achieved prior to reaching this level. A human being is not usually known to go to a higher level before fulfilling his lower level needs. He is going to take care of his basic needs, which are all the requirements of survival, before he moves to the next level. In the next level, the safety needs of a human being dictate his behaviour. “These needs have to do with people's yearning for a predictable orderly world in which perceived unfairness and inconsistency are under control, the familiar frequent and the unfamiliar rare”(2) . Though in this level we have health and well being, health here involves mostly acute diseases and events, as well as their adverse effects. For example, in the sex worker, fever and Urinary Tract Infections is going to take precedence over AIDS prevention even though AIDS is a health related matter. The perceived severity of a disease, that may not be evident at the moment, takes a back seat. In some ways, the health belief model comes to play here. The chronic nature of HIV and AIDS downplays the sex workers’ perception of severity as well as the perceived susceptibility. The thought of getting AIDS and dying from it is quite farfetched for the sex workers, especially when their daily lives are full of other life threatening situations. No amount of education or prevention programmes can change this perception.

So, in answer to the question in the beginning of the discussion, the sex worker is quietly going to agree to the demands of the client, even though she knows that doing so will put her and her unborn baby at risk for HIV and AIDS. Therefore, education approach for HIV prevention fails because the hierarchy of needs is clearly not addressed in these education programs.

Fundamental Attribution Error

An attribute is an inference about cause of behaviour. There are basically two sources for behaviour-those that are influenced by internal factors and those that are influenced by external factors. Internally caused behaviours are those that we believe are under the personal control of an individual, or those that are done deliberately by him. Externally caused behaviours are those that are seen as resulting from outside causes, that is, the person is seen as having been compelled to behave in a particular way by the force of a situation and not because of his own choice. When we make a fundamental attribution error, we tend to overestimate the internal factors while under estimating the external factors that can explain behaviour (4, 5).

In case of HIV prevention programs, we tend to make a fundamental attribution error when we do not consider the situation that caused a sex worker to choose this type of work. We fail to consider why the sex worker is not using preventive measures in spite of knowing all benefits of doing so. Fundamental attribution error has profound significance. The majority of the common population believe that these diseases, especially HIV and AIDS was “brought onto themselves” by the sex workers; that, it is a voluntary and controllable risk. The population fails to sympathize with their situation. And though this attitude is changing quickly, some work still needs to be done in this area because these social views continue to impact policies, practices for diagnoses, as well as the treatment and the prevention strategies. Social programs and policies that fail to recognize the complex interplay of individuals and social contexts may fail to resolve the problems they are intended to solve. In this situation, Fundamental Attribution Error can also be likened to context minimization error, which is something that eventually leads to the impoverished theory (6).

Fundamental attribution error is made in every level of the intervention for HIV prevention among the Commercial Sex Workers. Policy making, educating the workers, and showing them the harmful effects of risky behaviours; all of these interventions do not take into account the conditions under which a sex worker works. Because of this many of the education programs fail. Intense talks on HIV and AIDS as well as many related conditions may be given, groups of people may be gathered to participate in the education programs, pictures may be shown, even free condoms may be distributed; however at the end of the day it is what the client tells them and what the client pays them, that dictates the behaviour of the sex worker. As long as there is a failure to understand the situation under which the sex worker is working, there will a failure in making an impact at any level; right from the policy making level to the individual level.

Which brings us to the next criticism: What is it that makes the commercial sex worker disregard all warnings?

Theory of Social Stigma and associated Blaming Theory

Social stigma is a severe social disapproval of a person due to his beliefs or work, because they are perceived to be against cultural norms. Erving Goffman defined stigma as 'the process by which the reaction of others spoils normal identity' (7). The attributions of criminality to the work of commercial sex workers stigmatize what they do. Not only do people stigmatize the work that the sex workers do, there is known to be a stigma against HIV/AIDS too. HIV/AIDS related stigma means a real or imagined negative response to a person or persons by individuals, communities or societies that are due to the disease that they have (8).

The stigmas faced by the workers are seen at different levels:

v Among the general population. There is a poor understanding and discriminatory practices among the general population, against the sex workers. The general population are usually of the opinion that sex workers work is something that they chose for themselves and that they have the freedom to opt out of it anytime. Due to this, they believe that any health related issues that the sex workers have is because of the choices they have made..

v Among the sex workers: The society’s attitude towards them has a profound impact on the sex worker’s attitude about themselves. The workers tend to think of themselves as being inferior to the general population. The level of self esteem that these individuals have is quite low too. They feel suppressed and thus they rarely raise their voice against any of the injustice, including violence, which may be done to them. They usually have no say over their client’s demands, even if the demands put them at a risk for HIV/AIDS. If the sex worker is addicted to drugs, this compounds the problem because the worker will be more in need of money and she will be more easily exploited. Overall, because of this attitude, where the sex worker thinks of herself as a victim, , make them more vulnerable to diseases. However, do they hold themselves responsible for the disease when they actually get them? No. Their low self esteem always makes them think of themselves as a “victim” and thus the blame is put on the client.

v Among the “clients”: Clients usually thinks of a sex worker to be someone whom he has complete power over. They are looked upon by the clients as someone they go to when they have to escape the realities and responsibilities of life, just like people using alcohol and drugs. These are beliefs that are quite deeply embedded and are difficult to change. The health of the sex workers is usually the last thing on a man’s mind when he uses her “services” (9). However, in event of a disease which they get from their risky sexual behaviour, they usually blame the sex worker.

How does all this fit into the education against HIV/AIDS approach? The social stigma attached to the work that the commercial sex workers do is so strong, that no amount of education of the sex workers will change the attitudes of people, clients as well as the workers themselves. As mentioned above, the illusion of control that a client has over a sex worker can lead him to demand unsafe sexual practices from the sex worker. The illusion of being “inferior to the common man” makes the sex worker agree to the demands that their clients make on them and finally the very fact that the entire society looks down on the work that the sex workers do, makes the society opposed to the idea of supporting the interventions that could make a difference. The education approach does not take the social stigma and the blame theory into account. The stigma makes it look like the “nice” and “decent” people of the society preaching the sex workers who are looked down upon. And the very fact that none take responsibility to their actions and the resulting consequences, makes them non responsive to the messages that we give the workers or their clients.

The above 3 reasons could be among the many others that this approach to reducing HIV and AIDS among sexual workers has failed. This in turn has lead to the failure of prevention of spread of the disease, not just among the clients and their networks, but also among the children of the sex workers themselves. The HIV/AIDS situation among the sex workers have been subtly acknowledged as one of the reasons of the pandemic that is taking over the world. Unless some major changes are undertaken to improve the methods of education of the sex workers, there will not be a significant difference in the way HIV and AIDS is spreading around the world.

Interventions Proposed To Counteract The Above Criticisms.

The biggest criticism to the education theory is that the public health workers preach and then expect the sex workers to follow their advice because “that would bring them good health”. The hierarchy of needs is largely ignored. Before the health problems of the sex workers are addressed, their basic needs need to be addressed. This could be done by making them self sufficient. Vocational programs would be one of the most effective interventions here. These programs would teach the sex workers some work that they are capable of doing. As I mentioned earlier, the sex workers live a secluded life in their districts. Though these districts are quite self-sufficient, much work needs to be done here. So, right from simple things like tailoring and knitting, to something as important as the education of children of the sex workers, could “jobs” that the sex workers do to feed themselves. Of course, the job would be based on the skills that the sex workers possess. The fact that they have the financial support to address their basic requirements of food and water, among others, would then make the workers think of the higher level of needs in the hierarchy. The next level is related to security. Security is a big issue with the sex workers. They are often victims of abuse, from the clients as well as the society. At the most basic level, this can be addressed by teaching the workers basic methods of self defence. Special laws that would cater just to the protection of sex workers could be passed. Then there is the next level of the need, where a human needs social support. Fulfilment of this requirement needs participation of the sex workers themselves. Forming peer groups, counselling groups as well as close circle of friends would be one way of addressing this need. The groups would be effective in providing support to those who are victims of abuse, addiction or just stress. Something as simple as having someone to talk to, can be a huge support to these women. Project Saheli (10), based in India, has a hugely successful counselling program for the sex workers in Mumbai. The program addressed the social level of hierarchy.

The next level of hierarchy is according to me, the level that public health workers and the community as a whole can make the most difference. At this level not only do is the next level of need in the hierarchy pyramid addressed, the problem of social segregation is also addressed simultaneously. Respect is important for anyone, most importantly the sex workers. Dignity and acknowledgement of the work that they are doing is important. Once the sex workers are looked upon as someone who is not an outcast, they will know that they don’t have to agree to everything that the client demands. The power will be in their hands, and we know from various social and behavioural studies that restoring power in the hands would have the most impact on any intervention and approach that we may undertake. The attitude of entire society should be changed. The education programs should be directed not just to the commercial sex workers but also to the population at large. This can be done through media like television and radios, print media as well as something more cultural like street theatre. Programs like the RHANI program utilize the local forms of communication to get the message across to the population in question (11). Similar approaches can be used. Though, in many parts of the world, sex and sexuality is not a taboo subject any more, however there are many regions where the subject is still a source of embarrassment. Education of the society through the means mentioned above, is known to have a positive impact. In countries, like Brazil, which has much lower prevalence of HIV and AIDS among sex workers, sex and sexuality is such a “taboo-less” subject that not just is the topic freely discussed, but even sex work is legal. The government, by legalising the industry, has put the power right back into the hands of the sex workers. Many projects in Brazil have emphasized the self esteem and dignity of the sex workers. An excerpt “Sex work is not illegal in Brazil and the government has taken an unprejudiced approach to preventing HIV infection among this group. A number of schemes have been carried out, including a high profile campaign based around a cartoon character called ‘Maria without Shame’. Advertised on posters, leaflets and stickers placed in women’s toilets, this character was shown with the message “You need have no shame, girl. You have a profession”. A radio advert featuring a famous Brazilian singer was also broadcast. The aim of this campaign was to improve the self-esteem of sex workers and to encourage them to take care of their health, with an emphasis on using condoms. It was found, in a 2009 study, that almost half of sex workers are reached by prevention programmes and 60 percent know where they can take a free HIV test” (12) . There are many lessons to be learnt from Brazil’s approach to the problem:

· A strong relationship between the government, civil society groups and NGOs to fight against discrimination of the sex workers is usually the first step in any HIV/AIDS related program targeted at the commercial sex workers.

• The educators and the teaching methods should be non judgemental and tolerant while educating the sex workers about HIV and AIDS and their prevention.
• A strong focus on condom promotion.
• A commitment to fighting stigma and discrimination, and encouraging a culture where people who are sex workers are not looked down upon, but instead they themselves are actively involved in helping respond to the epidemic and promote the prevention methods.

This is one of the biggest methods which can impact the education for prevention approach. Recognising the fact that the work sex workers do is nothing for them to be ashamed of, legalising sex work and treating sex workers with dignity is very important in making sure that the stigma faced by them is erased. This way they will gain self esteem and confidence. This in turn will help them move to the next level of hierarchy where they will be more responsive to acceptance of facts, about themselves and their health, and thus will be an integral part in the problem solving process.

The next problem that needs to be addressed is the problem of fundamental attribution error. The circumstance under which the sex worker is working is never taken into account. We just assume that they are not responsive to our messages because they have a choice and they choose not to. But that is not always the case. Here individual approach to the problem is necessary. Each sex worker’s situation must be understood. This can be done by getting someone from the community or some public health worker who is close to the community to visit the workers regularly and to see what conditions that the worker works in. If this is not possible, then the members of the community themselves could themselves be involved in the lives of the workers and then could come back to the public health workers to learn to deal with the situation and teach the other members to deal with it too. Another way of dealing with fundamental attribution is by putting the power right back to the hand of someone who knows the situation and deals with it daily, i.e., the sex workers themselves. Engaging the members of the community, right from research to policy making, gives the members the power to control and modify their situation. For example, if we want to make a rule where all sex workers are required to use condoms, then instead of ordering them, we could involve them in the law making process so that they are more acceptable to the law. This way, not only do the policymakers understand the situation from the sex workers’ perspective, but the workers themselves will become more involved with the implementation. Also, the laws should not just apply to the sex workers. It should also monitor the clients. The creation of a situation where the sex worker is cornered into accepting “demands” from the clients should be avoided. The client himself should feel responsible, or should be “forced” by the law to use protective methods. He should also be instructed about the health benefits of practicing sex safe. He should be taught about the dignity of the sex workers. Another very important step in avoiding fundamental attribution error by the health workers is by periodic training sessions in which the tendency to "blame the victim" and the tendency to commit the fundamental attribution error are openly discussed. This can lead to the better acceptance and better understanding among the healthcare workers themselves.

Conclusion

HIV/ AIDS among the commercial sex workers are a major issue that needs to be tackled by the health care professionals. Not only are the sex workers one of the largest continual sources of infection, they are also the most disregarded source. The public health interventions that are directed towards the sex workers are mainly aimed at educating the sex workers about HIV and AIDS and how to prevent it. The education approach to the problem, is flawed in many ways. However some changes can be made and incorporated into the approach, so that maximum impact is seen from the interventions.

REFERENCES

(1) "Sex Workers and HIV Prevention." Averting HIV and AIDS. International HIV and AIDS charity, 9/4/2011. Web. 9 Apr 2011. .

(2) "Maslow's Hierarchy of Needs." Wikipedia. Wikipedia, 13th April, 2011. Web. 19 Apr 2011. .

(3) "Self-actualization." Wikipedia. Wikipedia, 17th March, 2011. Web. 19 Apr 2011. .

(4) "Perception and Person Perception." RU. RU, 9/9/2004. Web. 11 Apr 2011. .

(5) "Social Psychology." AllPSYCH Online-The Virtual Psychology Website. AllPsych and Heffner Media Group, Inc, 18/1/2008. Web. 11 Apr 2011.

(6) Shinn, Marybeth, and Shioban M Toohey . " Community Contexts of Human Welfare." Annual Review of Psychology. Vol. 54: 427-459 . 2003. Web. .

(7) "Social Stigma." Wikipedia. Wikipedia, 13th April, 2011. Web. 14 Apr 2011.

(8) Wilson, Makgahlela Mpsanyana. "The effect of stigma on HIV and AIDS testing uptake among pregnant women in Limpopo province." university of Limpopo, 2010. Web. 23 Apr 2011. http://ul.netd.ac.za/jspui/bitstream/10386/291/1/The%20effect%20of%20stigma%20on%20HIV%20and%20AIDS%20testing%20uptake%20among%20pregnant%20women%20in%20Limpopo%20Province..pdf>

(9) Bader, Michael. "Why Men Do Stupid Things: The Psychological Appeal of Prostitutes." AlterNet. The Independent Media Institute, Web. 23 Apr 2011. http://www.alternet.org/sex/79635/>

(10) Gilada, Dr I. S. "Indian Health Organisation's 'Project Saheli' for Sex Workers ." Aarogya-AIDS Support. Aarogya, Web. 5 May 2011. .

(11) "Reducing HIV Among At-risk Wives in India (RHANI Wives Project)." Population Council-Research that Makes a Difference. The Population Council, Inc, Web. 5 May 2011.

(12) "HIV and AIDS in Brazil." AVERT- Averting HIV and AIDS. AVERT, 15/04/2011. Web. 23 Apr 2011. .

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