National Complete Streets Coalition: Bicycle Policies Revised to Improve Social Equity and Increase Use of Bicycles to Combat Obesity- Jessica Leslie

Introduction

Across America, rising levels of obesity are causing public health concerns. Obesity is a serious threat to health because it increases the risk of developing chronic diseases such as diabetes and cardiovascular disease. There are also numerous psychological and social consequences. Severe obesity is a prevalent public health problem and it disproportionately affects women and minorities[1]. Obesity is caused by a larger intake than output of energy. Therefore, many programs have been developed to encourage adults and children to exercise more.[2]

A missed opportunity for daily physical activity is the commute. The majority of Americans travel by car. The current environment encourages this passive behavior with policy and infrastructure that serves cars over pedestrians and cyclists. Active commuting reduces chances of becoming obese[3]. Bicycling has been shown to be more effective at controlling weight than walking[4]. Therefore, provisions need to be developed to make cycling an attractive and easy form of travel.

In the US, over 30% of citizens are obese; whereas, Germany has a 13% obesity rate and the Netherlands has a 10% obesity rate (a third of US at 10%).[5] This is correlated to bicycle policy and infrastructure. Both Germany and the Netherlands have bike centric policies and infrastructure. In Holland, 25% of trips are made by bicycle and in Germany, its 9%. The US has a meager 1% of all trips made by bicycle. Evidence suggests the average American could lose 13 lbs in the first year of replacing the car for a bike in their daily commute[6] There is a distinct difference of infrastructure; in America the policies are focused on developed shared facilities for bicycles such as bike lanes. In Germany and the Netherlands the policies are bike-centric with separated facilities such as cycle tracks. Cycle tracks are bike paths dedicated for bicycle use and have physical barriers from pedestrians and motorists.

Women have different priorities and concerns when choosing their commute. These concerns must be addressed with policy and infrastructure to provide an environment where women feel bicycle commuting is comfortable and accessible. A higher prevalence of obesity in women than men indicates a need for policies and programs that encourage physical activity targeted at women.

Women make up a very small portion of cyclists in America. The highest users are children and young men. The reasons for this disparity must be addressed if women are going to be able to increase physical activity levels by cycling.

Intervention to critique Complete Streets

The National Complete Streets Coalition is an advocacy group in the US promoting the street designed for all users, not only drivers. It was founded in 2005 as a coalition of advocacy and trade groups. The specific elements of a Complete Streets vary case by case, but include pedestrian infrastructure like sidewalks and crosswalks, traffic calming measures, bicycle facilities, and mass transit accommodations. The Complete Streets policies are recommended to increase the safety, health and economy for citizens of the community. As of 2011, Complete Streets’ policies have been adopted by 175 public agencies and 39 states. Legislation has been introduced into the US Congress that new federally funded road projects must use Complete Streets recommendations[7].

Complete Streets recommends bicycle facilities such as bike lanes and wide shoulders. These recommendations are based on the American Association of State Highway and Transportation Officials guide for the development of bicycle facilities, which does not include cycle tracks[8]. Cycle tracks have been widely ignored by the US reflective of the community of bicycle advocates involved. The policies are based on the belief that cyclists are safest when they act and are treated as drivers of vehicles.

The Complete Streets Coalition has been successful and has had a mostly positive influence on the safety and accessibility of streets. Unfortunately, they encourage cycling on streets with traffic, which alienates large group of riders who are not comfortable in that environment. Frequently, the users most in need of the physical activity opportunity are specifically women. Complete Streets claims to be for everyone. It’s designed and operated to enable safe access for all users, make it easy to cross the street, walk to shops, and bicycle to work.[9] The promoted policy for doing so is flawed and ignores the citizens most in need by encouraging streets designed to include bicycles only with bike lanes.

It is clear from the low rates of bicycle commuters, especially women, that bicycle lanes do not adequately address the needs of the citizens. The program must specifically address the reasons for the lack of female bike commuters with correct infrastructure promotion.

Argument 1: Obstacle of ownership effect

In order to examine how psychology of ownership affects bicycle use on roads, one must understand the roots of the current policies. The basis for classifying bicycles as vehicles comes from a violent beginning. Bicycle law has had a turbulent history. It began in Massachusetts when fist fights between horsemen and cyclists led to laws declaring bicycles ‘carriages’ with all rights to the road, (based in Boston, League of Wheelmen[10]). Conditions continue today with tensions documented by newspapers as “turf wars” between motorists and cyclists[11]. Cyclists have the rights to the road on paper, but the aggressiveness and safety issues of sharing space with cars traveling at high speeds has led to perceptions of cyclists as reckless rogues. Both parties claim ownership to roads, which leads to conflict.[12] This policy was implemented based on the assumption that bicycles would be treated fairly if they had ownership of the roads; however, this is negated by theory of ownership and possessiveness and can explain why cyclists, still, are viewed as second-rate users.

The act of claiming space instantly induces psychological ownership and possessiveness on the road. The advocates of bike lanes and shared roads believe that the safest form of cycling is as vehicular cyclist. When cyclists behave and are treated as a motorist in traffic. A basic skill taught for vehicular cycling is phrased, ‘take the lane’; when a cyclist must enter the center of the road to make a left-hand turn. This move is difficult for novice cyclists, or when travelling with traffic at high speeds. Simply by being on a shared road with motorists, the choice for car or bike instantly identifies one as an insider and one as an outsider. When a cyclist encroaches on motorists’ space, or even if the mere presence of a bike is on the road, the motorist is set to defend the rights from that outsider. Conflicts between drivers and cyclists; therefore, are based not on reasonable emotion but in possessiveness and subject to the ownership effect.[13]

The possessive self is a barrier to conflict resolution. People value the arguments they are associated with, and place more value on beliefs and values identified with self than even identical arguments identified with others; especially when conflict is anticipated. Negative perceptions and polarization are placed on the person posing the threat[13].

Bike lanes do not provide the necessary boundaries to prevent ownership effect. The drivers experience a form of ‘loss aversion’: seeing their roads narrowed to accommodate an outsider that is an inherent threat to their choices, believes, and attitudes. In the US, cars dominate the infrastructure and dangerously outnumber bicyclists. Therefore, an effect of possessiveness is the belief system common among drivers, in which cars belong and the bikes intrude. As intruders, the cyclists are responsible for any risks associated with sharing the road and should reduce those risks by ‘getting off the road’.[14]

The recommendation for a policy for bike lanes and wide shoulders does not account for the psychology of the American anti-bike culture. Bike lanes are mere markings on the road. Without physical barriers, the ownership effect will always demean cyclists to a second-rate road user. Sharing the road is not an option because cyclists are vulnerable and drivers perceive them as a threat to their self-identity.

Argument 2: Hierarchy of Needs

Physical exposure of cyclists creates dangerous situations; especially when competing for resources with hostile, aggressive drivers at fast speeds. As direct consequence of the laws of biomechanics, and the fragility of the human body, cyclists are vulnerable in traffic[15]. Cyclists have higher crash rates than other road-users due to the nature of cycling: it is easier to fall and lose control of the bicycle. In crashes, cyclists are unprotected (except for perhaps a helmet).

In the US, very few trips are taken by bicycle (1%), and yet each year more than 500,000 people are treated in the emergency room. 700 die from a bicycle related injury per year[16]. Due to the higher percentage of children using bicycles, they are most likely to be injured. Though car crashes causes over 30,000 deaths a year[16], in the US, there is a perception that riding bikes is less safe. This is related to the false security people feel in cars. On a bike, the entire body is exposed making the rider very vulnerable. Cyclists are at much higher risk of injury than motorists if impact occurs. Common types of bicycle crashes involve interactions with motorists, such as ‘dooring’: when a cyclist traveling next to parked cars, hits an opening driver’s door. Motorist-bicycle incidents are most fatal to the cyclists at speeds greater than 20 miles/hour[17] and involve conflicts at intersections or head-on collisions. Clearly in a fatal incident, the motorist is not harmed and only the cyclist is at risk. Vehicular cyclists are defined by the interactions with motorists; however, there is not fair ground since the cyclist must always defer or put his/her life in jeopardy.

Maslow’s Hierarchy of Needs Pyramid depicts his theory of motivation by dividing needs by increasing complexity. The needs are organized into a hierarchy of importance with the most basic and fundamental at the bottom. An individual must satisfy the most basic needs before considering the higher ones. Safety, in the second most fundamental level, must be fulfilled before one can fulfill other needs. Therefore, in choosing an active commute or exercise, which is a need higher in the pyramid, the behavior environment must be safe.

Bicycles are considered vehicles and offered all rights to most roads and expected to follow traffic laws. This does not consider the differences in perspective for a cyclist. A cyclist has different needs than a motorist. The modern road system is designed for cars and does not account for vulnerability, flexibility of behavior, instability on the bike, or different ability levels since there is no standardized bicycle-drivers license. A cyclist makes conscious effort and is highly motivated to minimize energy expenditure that results in unpredictable behavior from the perspective of other road users[15]. The support for riding with traffic as opposed to against traffic is based on the statistics that the most common fatal crashes are from head-on collisions between motorists and bicycles. Therefore riding with traffic is the safest way to cycle in the current environment, but not the best solution to the overall safety problems. As with helmets, these solutions are not primary. They do not prevent the conflict; they merely reduce the injury after the incident. These provisions do not encourage cycling effectively.

Most importantly, the current policies do not reflect the preferences of women, who are in need of more physical activity. Women do not feel safe cycling on shared roads. Studies show women of all skill levels prefer separated paths.[18] This is attributed to characteristics of risk aversion common among women. Women have a different perception of safety and tend to perceive negative consequences of sharing roads with vehicular traffic more than men do.[19] Women are more likely to bicycle if they believe drivers in the community behave safely towards cyclists. All cyclists are most likely to pick routes to avoid high traffic speeds and congestion. Novice cyclists, the ones no doubt most in need of more physical activity, would be unlikely to use a shared road to bicycle on because safety is more important than exercise. Bike lanes and shared roads do not satisfy the basic need for safety and are; therefore, ineffective in nudging people into more physical activity by bicycle use.

Argument 3: Socio-Ecological Model

The socio ecological model examines people’s interactions with their physical and sociocultural environments. This model addresses environmental and social cues that influence behavior. The physical environment and social environment are critical in women’s decisions to use a bicycle. As demonstrated, the physical environment must be safe for women to consider bicycling. But, the socio-ecogical model includes influences at the individual level such as attitudes, preferences, beliefs, and self-efficacy. Social-environment factors include the cultural norms of the community as demonstrated by the collective behaviors of its residents. Communities with higher levels of bicycling tend to have more gender equity, as demonstrated in the Netherlands, where women make 55% of bicycle trips.

Currently women in the US make 0.5% of all bike trips. Men cyclists outnumber women 2:1. This gap leads women to view cycling as abnormal because so few women participate. In terms of social environment, research has shown that those who exercised with one or more significant others were more likely to reach recommended physical activity levels.[20] A positive social environment is likely to influence behavior. Therefore, to increase physical activity levels, more women need to participate with friends in family. Women are unlikely to identify with the bicycle community that is dominated by men. It is integral to change the social environment to increase use of bicycles among women. Since women do not use the established bike lanes, it is unlikely that creating more will increase ridership.

Interplayed with socio-ecological theory is the self efficacy: the confidence one must have that he will be able to do an action and that doing so will have good outcomes. Research shows interventions to increase physical activity are more successful if self-efficacy theory in the development.[21] Most women do not feel confident bicycling with traffic. Complete Streets is not campaigning policies that address this. Building more bike lanes is not going to change how women intrinsically feel about their capabilities.

Proposed Policy Change

Policies are organizational statements or rules that are meant to influence behavior. They may be explicit or implicit and their effects can be intentional or not. Most importantly, they are sociocultural influences because people make them to respond to perceived needs and desires of the larger population (since they are able to encourage or discourage healthy behaviors[22]).

Complete Streets; therefore, must amend its policy guidelines to explicitly state the safest, most attractive forms of bicycle facilities. The emphasis on bike lanes must be changed to cycle tracks and other forms of separated bicycle facilities to develop an environment that is safe and attractive for all levels of cyclists. The default form of infrastructure needs to begin with cycle tracks, as the ideal condition, then work down to shared roads. If building a cycle track is not feasible: design a protected bike lane, move the bike lane to the right side of the street to avoid ‘dooring’, put in traffic calming measures, and ensure that the environment will reflect the needs of the entire population. Since cyclists are vulnerable users of the road, their safety needs to be placed above others.

The policies must encourage bicycling by discouraging cars. The US has not effectively moved away from the car-centric ideals. Only the easiest no-conflict measures have been enacted. With better policies centered on bicycles, the US would drastically increase ridership.

Substantial increases in bicycling require an integrated package of many different, complementary interventions, including infrastructure provision and pro-bicycle programs, supportive land use planning, and restrictions on car use[23]. Bicycle education outreach targeted at women is needed to promote use of bicycles. Direct involvement of women is necessary to change the trend in ridership.

Cycle tracks eliminate ownership effect

First, Complete Streets must change the recommended bicycle facilities from shared to separated. Cycle tracks create a specific, specialized environment for cyclists. This eliminates conflict between users of the roadways. Traffic travels at unsafe speeds. In the US, residential neighborhoods have posted speeds between 25-35 miles per hour. These speeds are much too fast for a bicycle to safely travel along side. [17] The laws are continued because of lack of political support and valid research. Vehicular cycling, biking as a vehicle in the roadway, was the solution for cyclists to make the best out of poor conditions.

Without separation of traffic and bicycle-centered policies, there is natural competition between motorists and cyclists for use of the same roads. As demonstrated by ownership effect, this cannot successfully continue. Motorists are accustomed to owning the streets. Without separate facilities and better policies, the bicycle will never achieve its full capacity as demonstrated by countries that rely on bicycles. Many European cities have implemented policies to directly restrict car use in favor of walking and bicycling[24]. Danish cities give cyclists priority on certain streets and bicyclists are exempt from many turn-restrictions.[25] These measures directly give ownership to cyclists that make the cyclists the main owner of the street.

Conflicts between cyclists and motorists are subject to rapidly increase in severity, since the person owns the vehicle and it represents an extension of the self. The vehicle can become part of the persona and reflect deeper values and beliefs. Though the reasons for using either car or bike are similar (speed, efficiency, convenience), the owner extends the positive values only to his vehicle and deems the others negatively. This contributes to the conflict between them and lack of respect for the opposition.

Hierarchy of needs, meeting safety

As illustrated, cyclists are unprotected in traffic and travel at low speeds and mass. This makes them vulnerable and they can suffer very severe consequences in crashes with other road users. Preventing crashes between fast and slow traffic is one of the most important requirements for sustainable safe road use. The sought-provisions must be targeted at the physical separation when possible and reduction of impact speeds, if not.[15]

Safety increases with cycle tracks. Countries where women frequently commute by bicycle have cycle tracks. Studies show that separated bicycle facilities are safest by reducing interaction between motorists and cyclists. When two-way cycle tracks are compared to reference streets without bicycle facilities but considered alternative bicycle-routes, the cycle tracks were found to have lower crash rates[26]. One-way cycle tracks may be even safer. The built environment providing purpose-built bicycle-specific facilities reduces crashes and injuries among cyclists. This evidence must be the basis for future engineering guidelines for infrastructure design

Women must perceive the environment as safe if it is going to encourage them to increase levels of physical activity. The separated facilities are safer or as safe as riding in a bike lane, but preference must be shown to separated bike facilities to coincide with the indicated ideal environment for women to increase bicycle use.

Cycle Tracks and the Socio-Ecological Model

A main feature of ecological models is the specification that intrapersonal variables (interpersonal and cultural factors) influence behavior along with the environment. Within this are the theories of social norms and self-efficacy. Pro-bicycle programs should be targeted to women, specifically in low-income social networks/social support theories. Within the community, long-term behavior change depends on the level of participation and ownership felt by those being served[27].

In the US, cycling’s most popular in children and young men, then falls for each age group to just 0.2% of those 65 and older. In Europe, where policy and infrastructure encourage cycling, the full spectrum of ages uses bicycles. In the US, women account for merely 0.5% of cyclists[25]. This is drastically different from those European countries where women make 50% of bike trips (55% in the Netherlands). This exemplifies how the US’s current standards do not consider women. Continuation of the implementation of bike lanes and shoulders as rallied by Complete Streets will only widen this gap. Cycle tracks and bicycle-centered policies with adequate infrastructure are present in the countries with largest age range of riders and female cyclists.

The social norms theory is highlighted in ecological models. For one to choose a behavior, they do so within context of their peers’ views and choices on that behavior. Cyclists do not have preferable image in the US. A renegade image is associated with disobedience of traffic laws, and perceives cyclists as an alien presence on roads intended for cars[25]. Women are not represented in the bicycle community, especially lower socioeconomic levels. These women are at the highest risk of being obese. They are in greatest need of interventions encouraging physical activity, and currently there are few role models to follow in using bicycles for commuting. Bicycles, while affordable, are viewed as an elitist sport and used for transportation only among white, upper class.[28] Women are not being adequately served by the current policies and use of shared facilities. Without separated facilities, the number of women bicycling will never reach the numbers need to change social norms.

Conclusions

The current obesity epidemic presses the issue that our country cannot continue on this path without serious detriment to the majority of citizens. The lack of infrastructure and policy to promote the ease of bicycle commuting for every member of society presents a social equity issue that cannot be denied. The current method of vehicular cycling is not working to engage the majority in bicycle-use for activity. Without reform, the obesity levels will continue to rise, complemented by lack of physical activity.

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[8] “AASHTO_1999_BikeBook.pdf.” .

[9] “Complete Streets » Complete Streets FAQ.” [Online]. Available: http://www.completestreets.org/complete-streets-fundamentals/complete-streets-faq/. [Accessed: 15-Dec-2011].

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[12] Guy buzzes me, then gets out of his car to try to pick a fight. 2011.

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[14] McCarthy, Deborah, “‘I’m a Normal person’: An Examination of How Utilitarian Cyclists in Charleston South Carolina Use an Insider/Outsider Framework to Make Sense of Risks,” Urban Studies Journal Limited, pp. 1-17, Sep. 2010.

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[17] J.-K. Kim, S. Kim, G. F. Ulfarsson, and L. A. Porrello, “Bicyclist injury severities in bicycle–motor vehicle accidents,” Accident Analysis & Prevention, vol. 39, no. 2, pp. 238-251, Mar. 2007.

[18] C. Emond, W. Tang, and S. Handy, “Explaining Gender Difference in Bicycling Behavior,” Transportation Research Record: Journal of the Transportation Research Board, vol. 2125, no. 1, pp. 16-25, Dec. 2009.

[19] C. Emond, W. Tang, and S. Handy, “Explaining Gender Difference in Bicycling Behavior,” Transportation Research Record: Journal of the Transportation Research Board, vol. 2125, no. 1, pp. 16-25, Dec. 2009.

[20] B. Giles-Corti and R. J. Donovan, “Relative Influences of Individual, Social Environmental, and Physical Environmental Correlates of Walking,” American Journal of Public Health, vol. 93, no. 9, pp. 1583-1589, Sep. 2003.

[21] L.-L. Lee, A. Arthur, and M. Avis, “Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: a discussion paper,” International Journal of Nursing Studies, vol. 45, no. 11, pp. 1690-1699, Nov. 2008.

[22] J. Sallis, A. Bauman, and M. Pratt, “Environmental and policy interventions to promote physical activity,” American Journal of Preventive Medicine, vol. 15, no. 4, pp. 379-397, Nov. 1998.

[23] L. Yang, S. Sahlqvist, A. McMinn, S. J. Griffin, and D. Ogilvie, “Interventions to promote cycling: systematic review,” BMJ, vol. 341, p. c5293-c5293, Oct. 2010.

[24] J. Pucher and R. Buehler, “Making Cycling Irresistible: Lessons from The Netherlands, Denmark and Germany,” Transport Reviews, vol. 28, no. 4, pp. 495-528, 2008.

[25] R. S. Tolley, Sustainable transport: planning for walking and cycling in urban environments. Woodhead Publishing, 2003.

[26] A. C. Lusk, P. G. Furth, P. Morency, L. F. Miranda-Moreno, W. C. Willett, and J. T. Dennerlein, “Risk of injury for bicycling on cycle tracks versus in the street,” Injury Prevention, Feb. 2011.

[27] D. S. Morrison, M. Petticrew, and H. Thomson, “What are the most effective ways of improving population health through transport interventions? Evidence from systematic reviews,” Journal of Epidemiology and Community Health, vol. 57, no. 5, pp. 327 -333, May 2003.

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Canning Indoor Tanning: Evaluating The Current Public Health Approach And Offering Advantageous Changes To Be Made -Tara LePage

Introduction:

“Kiss by the Sun,” “Desert Sun,” and “Bermuda Bronze” are three clever names of tanning salons in south eastern Massachusetts, advertising to consumers a guaranteed healthy glow. What these consumers are not getting from these salon titles is the FDA’s perspective; advising that sunlamps and tanning beds promising consumers the bronzed body year-round, are posing serious health risks from the exposure to ultraviolet (UV) radiation (1). In addition to skin cancer, the most common of all cancers in the United States (2), the FDA warns about the associations of tanning with premature aging, immune suppression, eye damage, and allergic reactions (1). Despite empirical reports denouncing the use of indoor tanning beds, the indoor tanning industry continues to flourish. An article by Denise Woo and Melody Eide, “ Tanning beds, skin cancer, and vitamin D: an examination of the scientific evidence and public health implications” reports that as one of the fastest growing industries in the United States, indoor tanning businesses are accruing an estimated 5 billion dollars in annual revenue (2). The Skin Cancer Foundation estimates that nearly 30 million Americans tan annually at 50,000 U.S. tanning facilities; while the American Cancer Society estimates that there will be about 70,000 new cases of melanoma and about 9,000 melanoma related deaths this year (3). With projections like these, it is clear that tanning salons have successfully warranted demand across the country; however, unless meaningful intervention is in place soon, the latter of the above statistics will also continue rising, ultimately resulting in severe negative health consequences for the public.

Honing in on defining the scope of the problem of indoor tanning is rather alarming. While all age groups are victim to the advertisements and pressures of keeping up with a tan, vulnerable populations have been found as the most frequent users of the indoor tanning salons. “Persistent use of tanning facilities has become especially apparent within adolescent female populations” (4). Girls as young as eight years old are exposing their developing bodies to the dangers of indoor tanning, and according to some physicians, the risks are especially high for this population whose skin cells are both dividing and changing rapidly (4). The Center for Disease Control (CDC) reports that, “nearly 9% of teens aged 14-17 years old have used indoor tanning facilities, and girls aged 14 -17 years old were seven times more likely than boys within that age group to use the devices” (5). As part of the Healthy People 2020 cancer objectives, the goals include reducing the 14% of adolescents grades 9-12 who report using artificial sources of UV light for tanning as well as reducing the 13.7% of adults aged 18 or older who report using artificial sources of UV light for tanning (5). The statistics could not be more clear.

What does this mean for public health officials? Intervention is needed. Over the past decade, a variety of Public Health Campaigns have begun efforts to challenge the epidemic of indoor tanning. The general approach to combating indoor tanning has currently been derived from the traditional public health education of groups at risk, along with proposed legislative bans and misled ignorance of impactful social learning and modeling in today’s culture. It is clear from the numbers above, many of which have been reported within just the past two years, that these current approaches of intervention against the negative impacts of the indoor tanning industry have failed. Analyzing this public health problem with a more progressive perspective on social and behavioral health will yield great benefits towards the creation of new intervention approaches.

Flaw #1: Misuse of the Traditional Health Belief Model

The Health Belief Model has been a longstanding, traditional foundation for public health interventions, originating in the 1950’s from the work of social psychologists, Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels (6). Basing its mechanism on the understanding that people weigh the scale of perceived benefits of practicing a behavior versus the opposing costs, there are six main principles influencing people’s decisions about whether or not to take action under the health belief model, including: “perceived susceptibility, are they at risk; perceived severity, are the consequences serious; perceived benefits, will taking action reduce risk and consequences; perceived barriers, are costs outweighed by benefits; cue to action, will intention prompt action; and self efficacy, is one confident in his or her ability to take action” (7). Assuming that individuals are rational in their evaluation of costs and benefits is a major limitation of the health belief model that directly ignores elements of external and social influence as well as disparities in knowledge among individuals (6).

Evidence of this model is manifested throughout the current approach working to defeat indoor tanning use. The Skin Cancer Foundation’s, “Go With Your Own Glow” campaign, published a variety of PSA announcements through the use of cartoon color print advertisements, along with libraries of educational videos explaining the process of UV radiation developing skin cancer (8). The CDC has supplemented their “Choose Your Cover” campaign with published educational brochures, posters, and print advertisements with the intention of emphasizing the statistics to stake their message (9). With these types of initiatives, public health officials from pristine agencies such as the CDC and The Skin Cancer Foundation are incorrectly assuming that by providing and explaining the risks and ultimate costs of exposure to indoor tanning UV radiation, that their target audiences, often young adolescent females, will rationally conclude with similar analysis of data that they should eliminate indoor tanning from their behavior cycle. Countering irrational mindsets with educated information alone has proven unlikely to be successful in many prior campaigns, and again in the case of diminishing the use of indoor tanning facilities.

Flaw #2: Legislative Bans Represent Heavy Hand Authority

Another major focus of anti-tanning campaigns has been their association with government intervention. A number of campaigns have teamed up with state lawmaking bodies, to propose and pass legislation concerning tanning restrictions for minors; the target audience for intervention. California is now banning the use of tanning beds for all minors under the age of 18; at least thirty one states regulate the use of tanning facilities by minors; and some counties are also involved in regulating the use of specific tanning devices (10). The International Agency for Research on Cancer has openly encouraged policy makers to “consider enacting measures, such as prohibiting minors and discouraging young adults from using indoor tanning facilities, to protect the general population from possible additional risk for melanoma” (10). While intervening on the macro level shows great initiative and responsibility, heavy handed authority is not always a successful route through which to take public health intervention, especially with a target audience at the adolescent development stage.

Turning to behavioral science for analysis of this approach, “psychological reactance was first defined in 1966 by Brehm, as the motivational state directed toward the reestablishment of a threatened or eliminated freedom” (11). The four elements that are fundamental to psychological reactance theory include freedom, threat to freedom, reactance, and restoration; which have each been researched extensively concerning their association with message rejection.

Described in the article by Rains and Turner, “Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined Model”, interventions such as educational efforts, warnings, and legal restrictions have all produced boomerang effects largely consistent with the conditions necessary to, and responses predicted by, psychological reactance theory. Through limiting or threatening freedoms, health messages have the potential to elicit reactance and, as a result, lead individuals to ignore the message, perform the opposite of the behavior advocated, or otherwise attempt to restore their threatened or lost freedom (9).

As we concluded from the previously mentioned statistics, adolescents under the age of 18 were those most likely to be frequent consumers at indoor tanning facilities. Evaluating the restrictive bans in terms of Brehm’s theory, the passed legislation inadvertently added to the increasing profits of the tanning industry, as opposed to decreasing the number of individuals dangerously exposed to UV radiation through indoor tanning, the intended goal. While their health and well being were at the foundation of the age restrictive bans, the legislation directly threatens the freedom of this particular population. Taking psychological reactance into account before intervening on behalf of the public’s health is an important component for any intervention. In doing so, the challenge for public health officials is to initiate interventions that will avoid threatening individual freedoms. If the intervention fails, psychological reactance becomes an additional risk factor for the unhealthy behavior, specifically indoor tanning.

Flaw #3: Ignoring Social Learning and Modeling as a Major Impact of Current Society

It is interesting to uncover that the desirability of associating a tan with attractiveness was not adopted until early in the twentieth century. Historically, suntanned skin represented working-class farmers and outdoor laborers, whereas fair skin represented nobility and wealth. Shortly after sun tanned skin was utilized by clothing designers as a new fashion statement, the American culture also adopted the appearance as a popular beauty trend. Extending beyond physical appearance, a suntan was considered a sign of good health, wealth, and prestige. (12) These messages did not end with fashion shows. “The mass media is constantly changing and evolving, and over the last twenty years, different media has emerged including music videos, computer games, and the internet; thriving in popularity amongst adolescents” (13). Today, a suntan is advertised in magazines, television shows, movies, and more. “Effects of Media Images on Attitudes Toward Tanning,” a paper written by Mahler, Beckerley, Vogel, described experiments determining whether exposure to images in these types of media showing attractive models who do not have a tan, relative to those who do, might result in less favorable attitudes towards tanning (12). Ultimately, the results concluded, that as popular media revealed attractive models with a suntan, the favorability towards a tan increased (12).

What can be pulled from these data is that many decisions made by adolescents incorporate influence from the environment around them, often times media exposure. Overwhelmingly in the current approach to reach adolescents concerning the danger of indoor tanning, public health officials and organizations are targeting the individual for change. This approach misses a significant impact of the vulnerable adolescent lifestyle, their models. In understanding the Social Learning Theory/Social Cognitive Theory, individual behavior is part of a triangle; an interaction between an individual, his or her behaviors, and the environment (14). As one of the first traditional health belief models to include group level factors, “Bandura emphasizes, in the social learning theory, the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others. He states that, “learning would be exceedingly laborious, if people had to rely solely on the effects of their own actions to inform them what to do;” (15) therefore they proceed by the examples of others. When creating interventions targeting adolescent behavior, it is important to take into consideration the impact of models on this specific population.

Changing the Approach:

From the examples provided above, it is clear that there is significant support behind the efforts put forward to decrease the danger of indoor tanning. That being said, the methods through which they have focused their approach have been ineffective. Altering the current approach will result in a world of difference concerning both the public’s perception and well being, as it is associated with indoor tanning. A more meaningful intervention will move away from dependence on the rational education of the traditional health belief model, and will divulge deeper than just statistics, to show the public impactful stories of individuals suffering from their decisions to choose to expose themselves to the dangers of indoor tanning. In addition, the intervention will also separate itself from the adoption of legislative bans, thus avoiding common psychological reactance occurrence in the target population. Lastly, this new approach will appreciate and incorporate the impact of social norms on societal decisions; selling the movement at a group intervention level will yield much more successful results. The role of communicating this public health message will be complex, and understanding these advances from the traditional approaches will only progress the success of public health initiatives in years to come.

Intervention #1: Moving Education away from Statistics

Educating the public on their health has been, and will continue to be an important role of public health officials and those who work on behalf of public health interventions. However, the traditional manner of presenting statistics is not always as successful as we would hope. In using the health belief model, the law of small numbers and optimistic bias are more progressive social behavioral principles addressing human irrationality that are directly ignored. The law of small numbers explains that humans have a distorted view of probability and without a proper perspective on statistics relating to risk, it is impossible to expect humans to be able to relate to the numbers. In public health, the truth is often used as support, highlighting statistics and probabilities, in an effort to convince the masses to change their behavior; however, the masses have this distorted understanding of numbers so much so that they are not impacted by the numbers provided. (16) Complementing this idea, “Optimistic bias means that people have the tendency to judge their own susceptibility for a disease or other negative outcome as lower than other’s susceptibility. People in general expect positive events in their futures even if there is no reason to assume this outcome” (17). Interestingly, while they underestimate risk and probability of negative outcomes in their own lives, individuals commonly overestimate risk and probability of negative outcomes in the lives of the general population.

Smoking studies have been another area of public health in which these phenomenons have been apparent. Smokers are able to define the negative health risks of smoking as much greater than the actual numbers in discussion of the smoking population overall. However, when asked about their personal risk, smokers feel inferior to those negative health outcomes, underestimating the personal probability (16). Specifically targeting adolescents, Richard Branstrom and Yvonne Brandberg concluded in their study “that adolescents have strong positive optimistic bias for several of the most important health risks, diminishing the importance of their individual health behavioral risk, while identifying these same risks as the most dangerous to other people’s health in the general population”(17). It is clear that this irrationality is programmed in humans; most likely a technique for avoiding depression, building self esteem, and coping.

Learning from the aforementioned studies, these concepts present a much different understanding of the impact of statistics; these biases are in effect and they simply are not acceptable. Rethinking the strategies of facts and statistics moves education in a new direction. Approaches that take advantage of this human quality of irrationality will likely result in positive change for the indoor tanning efforts. How to proceed? A new intervention will target one or two powerful examples of the negative effects of indoor tanning exposure rather than discuss the probabilities of hundreds in a mathematical format. Those at risk already understand the danger of the masses; we need a message that will strike the individual much more personally. Finding ways to utilize the media, the television, radio, and internet, to share the narrative of an individual suffering from skin cancer caused by excessive exposure to indoor tanning radiation, will be much more relatable for the adolescent population than numbers. This one compelling story, if employed in a manner that reaches the masses, will have a disproportionate effect on those targeted, one that is much different than their original inclinations of inferiority. Controlling for these factors, as well as understanding the need for and implications of this change, will be the first positive step in changing the intervention.

Intervention #2: Avoiding Psychological Reactance

Health communication researchers and practitioners are becoming increasingly aware of the risk of activating psychological reactance in the process of translating health awareness resulting in less effective or even counterproductive results (18). From what we have learned about the reactions to threatened freedom, it is necessary for public health officials to take caution in creating intervention approaches that avoid reactance from the target adolescent population. Three key techniques to focus on in avoiding psychological reactance are explicitness, dominance, and reason. In order to enhance persuasion over the developing adolescents, the message needs to be clear to the point where it does not make use of obvious manipulation. The message should also minimize the tone of dominance, or extent of highlighting that the source of the message is in control; and lastly, should strategize for significant support behind it’s reasoning in order to soften the perceptions of intrusiveness observed from the target population (19).

Working from these recommendations, it is clear why current interventions supporting the legislative bans against miners using indoor tanning facilities have backfired. Because adolescents are extremely perceptive in defending their freedom, it is important to frame any intervention goals at invoking their most prized core value of freedom, as opposed to taking it away. For a most effective approach, a message needs to project affirmation rather than contradiction towards individuals’ beliefs and attitudes in order to encourage behavior change. Incorporating similarities between the source and the recipient of the message is a common tool used to significantly decrease reactance. Also, in acknowledging these tendencies of young people, another study suggests that “health campaigns utilize slick production effects, hip music, lively camera work, and sharp editing techniques to produce messages effective at capturing the attention of the highly at risk target audiences” (20). Culminating these suggestions encourages an approach that emphasizes representativeness to the adolescent in the message we project. Of great importance will be choosing the right messengers to capture the attention of the target population in addition to investing creativity that matches the creativity and technology so familiar to today’s youth. Rather than telling them what choices to make, our message needs to covertly persuade them to believe our mission is already engrained in their own belief systems. Similar to smoking cessation programs, perhaps we can frame the tanning industry as the “bad guys” who are eliminating their future freedoms of life. In doing so, we can join forces with the target population to restore the threatened value and ultimately make advances in their health. Despite public health support of legislative actions targeted to protect the health of adolescents, it will be important to separate those initiatives from employed interventions. Adolescents need to know that our mission shares commonalities with their deepest values and beliefs, and each of these changes will develop relatable characteristics. We’re about what they’re about, and together we will continue to preserve their freedom to be healthy-- not destroy their freedom to make choices.

Intervention #3: Realizing the Group versus the Individual

Lastly, moving beyond the traditional Social Learning Theory, and progressing towards group level approaches can be much more impactful. Three basic premises of alternative models highlight the power of group level thinking that are not accounted for in traditional models of public health intervention. First, a group is more than just the sum of individuals; therefore, group behavior cannot be explained by models at the individual level because mob mentality takes over and negates the individual decision making. Second, groups of individuals can be affected at the same time, specifically influencing behavior change; and thirdly, behavior is in fact, often unplanned, out of our control and dynamic including visceral drives and aspects of environmental context that take a significant amount of human decisions out of immediate control. (21)

Components from the Social Expectations Theory, Social Network Theory, and the Diffusions of Innovation Theory all contribute a unique new twist of new ideas and the ability of understanding the parts of the current intervention that have been left out, until now. Social expectations theory states that much of people’s behavior is explained and dictated by their perception of how members of their social group behave; therefore, if harmful behavior is perceived as the standard in a social group, the social urge to conform will ultimately rule the decision making process of the individual group members (22). This message mirrors behaviors from inside the classroom to relationships across the country. Once the idea of social norms is grasped, diffusions of innovations theory models how behavior is picked up in a pattern overtime and eventually results in the change of those social norms. Tracking the percentage of the population adopting specific intervention practices overtime gives light to the period, also known as the point of inflection or tipping point, in which the ideas of the intervention take off and influence the population’s conformity (23). Lastly, social network theory, similar to the concepts of social norms, considers the specific network of family and friends that individuals associate and identify themselves with as the target for intervention. For adolescents this could be groups such as sports teams, extracurricular activity groups, student government, or simply just best friends.

Turning to our specific health focus, the dangers of indoor tanning, the current approaches have targeted individuals to motivate change. They have simply been missing a huge factor in the influence of the adolescent lifestyle; social norms and networks. Aside from the media impact mentioned earlier, direct environmental factors are also in effect on this population’s decision making. Perhaps the most powerful change of the new approach to this public health issue will result from the understanding of the dictation of social norms. We will be able to reframe the new intervention with an environmental approach that seeks to impact both social and cultural environments as the way to then influence individuals (22).

From the current numbers, we know that the practice of indoor tanning, especially among adolescents, is socially acceptable and even desirable. The job of the new approach is to change the social norm. We are surrounded by historic successes of this approach every day including the elimination of the deviant behavior of spitting in public, the acquired use of seatbelts in automobiles, all the way to the adoption of smoke free bars and restaurants across the country! It works. Without much studying, we know the peer effects that occur in the adolescent developmental stage. Rather than targeting each teen as before, it will be more beneficial to intervene at the group level, targeting the teen through his or her whole social network to relay our message. If this intervention has succeeded, behavior will begin to increasingly change in the direction of the intervention message across the population over time. Once the majority of the population has adopted the new norm, we too will reach the tipping point in popularity. With the technological advances of today’s world, there are a number of ways to target social networks including campaigns utilizing Facebook and Twitter, as well as professional networking sites such as Linked In. In these domains, our message not only reaches the masses, but the groups of those specific individuals who are at risk; influencing the herd mentality that ultimately negates individual decision making in a new way.

Conclusion:

Identified in this analysis are three of the major flaws in the current approach to the dangers of indoor tanning facilities, specifically targeting the adolescent population. Highlighting the imperfections has turned up the volume on the call for new intervention. It is clear that the support is present to fight for the health of this population. However, change is needed. Addressing each of these flaws with progressive theories and concepts of social and behavioral science will only lead to success. In this new intervention, the focus will control for the misuse of traditional health belief model’s educational use of statistics and rational decisions, reactance against threatened freedom, as well as the influence of social norms and networks on the developing adolescent. Powerful stories, invoking the core value of freedom, as well as taking a group level approach will combine together to steer the campaign against indoor tanning facilities in a new and more successful direction --ultimately attracting the adolescent population to join the movement against the use of indoor tanning facilities. Using this evaluation, the public health message will find a way to shine brighter in the eyes of the growing adolescents than the “Bermuda Bronze” and “Desert Sun” advertisements for unhealthy behavior.

References:

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