Public Health Efforts Regarding Sexual Assault Among College Students:

A Critique Based on Social Ecological Theories – Meaghan McCusker

I.     Introduction

Sexual assault (SA), defined as any form of unwanted sexual contact obtained through violent or nonviolent means, is a critical public health concern within colleges and universities nationwide (1, 2, 3).  SA is the most common violent crime committed on college campuses today (4). Additionally, college women are at a higher risk of SA compared to peers who are not in college (1). One in five college women experience completed or attempted rape during their college experience (1, 5). More than half of college women experience some form of sexual victimization throughout their collegiate career (6). Victims of sexual assault are associated with various negative health outcomes, including increased substance use, depressive symptoms, health risk behaviors, and symptoms of posttraumatic stress disorder. Consequently, the described negative health outcomes have damaging repercussions on academic success (5, 7, 8).

In response to this widespread violence and severe implications, Congress enacted several laws requiring higher education institutions to notify students of sexual assault crime, publicize prevention methods, and ensure SA victims have access to basic legal rights. Despite federal legislation and widespread awareness of sexual violence, campus prevention programs have been slow to take hold. Less than two-thirds of US colleges offer sexual assault prevention programs, and only one-third offer campus wide safety programs (3, 9). Of college campuses that offer prevention programs, such methods include educating women on rates of SA, guidance on how to decrease risk of SA, as well as public health efforts in deterring men as SA perpetrators (10). While the implementation of sexual assault prevention programs has been seen as a positive trend, researchers have begun to question the effectiveness of widely used programs (11). Within this assessment, one will find a critique of three aspects of current SA prevention efforts, based on social ecological theories. Additionally, one will also find a proposed intervention that better addresses sexual assault on college campuses.

II.  First Critique: Use of Health Belief Model in Educating Women of SA Victimization

Many programs aimed at reducing sexual violence across college campuses rely on educating women about the existence of SA. Such educational campaigns include efforts publicizing rates of sexual violence. SA educational campaigns also strive to educate students by providing clear definitions of sexual assault, domestic violence, stalking, and rape (11). Additionally, some colleges also publicize the increased risk of women being SA victims with the use of alcohol and/or drugs (12, 13). Through these educational programs, women are taught to reduce their risk of victimization by avoiding risky situations, such as traveling alone or putting a drink down unattended at a party. Women are taught to travel in pairs, attend parties with friends, and are sometimes offered self-defense classes to physically protect themselves from a potential sexual violence attack.

While educational initiatives are widely used across college campuses that strive to address SA, studies have shown that increased knowledge of sexual violence and safety tips does not translate to a reduction in SA incidences (10). Failure to reduce sexual violence on campus, despite increased knowledge among college students, can be directly related to the over reliance and ineffective use of the Health Belief Model (HBM). The HBM is one of the most widely used behavioral theories in public health that centers around perceived susceptibility and severity of a public health concern, as well as perceived benefits and barriers in addressing a public health concern, that impacts a person’s intention and behavior (14). With this model, one would assume that if college women are educated about the existence of sexual violence, as well as provided safety tips and resources to reduce their risk of sexual violence, then rates of sexual violence would decrease, due to a change in women’s behavior. This assumption is incorrect, however, as the HBM is an individual level model that does not take into account social, environmental, or economics factors in determining behavior. The HBM also assumes rationality and equal access to campaign information (14, 15). As such, providing college campuses with SA information and safety tips do not lead to decreased incidences of sexual violence. Contemporary health prevention and promotion involves more than educating individuals about risks and benefits.

Additionally, educational programs that provide women with safety tips, such as traveling in pairs or avoiding dangerous neighborhoods, are more relevant to sexual assault cases committed by strangers. For example, if a victim were to be sexually attacked walking through an abandoned street, this may be prevented if a friend accompanied the potential victim. These safety recommendations are not typically helpful in preventing sexual assault where the perpetrator is an acquaintance, and when trust is already built between two individuals. As the majority of sexual assault cases within colleges are committed by acquaintances, this further contradicts the benefits of safety tips provided within SA prevention programs (9). Efforts should instead be made at a community level where public health practitioners strive to prevent sexual assault at more of a macro level, rather than though a micro level by educating individuals (16, 17).

III.         Second Critique: Failure to Follow Psychological Reactance Theory in Targeting Men as SA Perpetrators  

In recent years, public health practitioners striving to prevent sexual violence have shifted the responsibility of prevention by moving away from efforts in educating women about the existence of sexual violence and safety recommendations, and have moved towards efforts in changing men’s behavior. Through a movement aimed at taking away the responsibility of sexual assault from victims, practitioners have intended to decrease victim blaming (18). Such efforts have been supported by research showing the importance of men’s participation in educational programs and social marketing campaigns. A wide variety of programs and campaigns focus on telling men to stop perpetuating sexual violence against women. Common campaigns across college campuses include catch phrases such as “no means no” and “rape is rape”, when striving to deter men from sexually assaulting women (18, 19).

While campaigns aimed at deterring men from perpetuating sexual violence against women on college campuses have sincere intentions, these efforts go against Psychological Reactance Theory. Within this theory, psychologists conclude that when people are told what to do, they are more likely to do the opposite (20). This relates directly to the threat of freedom, an important core value among Americans, and more so among college students who may find their college experience a liberating time period within early adulthood. When applying Psychological Reactance Theory, one can determine that when such campaigns and programs advocate for men to stop perpetuating sexual violence, they may be more likely to conduct such violence. This can certainly be seen when perpetrators may justify sexually violent behavior as normal, especially when alcohol and/or drugs are involved.

In addition to the threat of freedom, SA prevention campaigns that focus on the victimization and perpetration continue stereotypical gender roles, as men are targeted as potential perpetrators and women are targeted as potential victims. There is a lack of research showing the benefits in attitude or behavioral changes in being more aware of stereotypical gender roles (10). This lack of empirical research can be related to both of failure of the HBM, as well as the failure in disregarding Psychological Reactance Theory. More specifically, informing college students about sexual violence, safety tips, stereotypical gender roles, and telling perpetrators what to do can have little impact in preventing incidents of sexual assault on college campuses.

IV.         Third Critique: Failure to Follow Social Expectations Theory in Accepting Sexual Assault as Social Norm

Within sexual violence prevention programs in college communities, public health practitioners have focused on both educating women in how to decrease their risk of victimization, as well as appealing to men to deter them from perpetration. By focusing on educating and changing the behavior of SA victims and perpetrators, there is a lack of effort in changing the social norm regarding the existence of sexual violence on college campuses (21). In other words, in striving to educate victims and change the behavior of perpetrators, it can be seen as socially accepted that sexual violence will exist on college campuses, and efforts are therefore made to reduce the rate of such violence. When efforts are being made to reduce the rate of sexual violence through victims and perpetrators, there is a lack of focus on changing the social acceptance, or the social norm, of sexual violence by all members of the community.

In promoting SA programs that perpetuate this type of violence as a social norm within college communities, public health practitioners are failing to follow the Social Expectations Theory. Within this theory, psychologists and sociologists reflect on the social nature of human beings. People live their lives in webs of complex social interactions and are more than individual organisms responding to stimuli (22). Subsequently, community members do not solely respond to information from public health programs and campaigns. Human behavior is better understood through the reflection of social norms, or general rules that are implied by all members of a group. Therefore, if public health campaigns do not strive to change the social norm of sexual violence on college campuses, then these campaigns may not be effective in changing behavior.

Theorists suggest that sexual violence will only be eliminated when broader social norms are addressed and a broader range of community members is reached (21, 23). Researchers have also noted the increased importance of peer norms, specifically related to the coercion and deterrence of sexual assault (23). Such research and theories call for more of a community level responsibility in changing the social norm of SA on college campuses. Consequently, the American College of Health Association (ACHA) and the Centers for Disease Control and Prevention (CDC) have recently called for the implementation of prevention programs that focus on changing the social norm of sexual violence within college communities (21).

 If the elimination of sexual violence was a socially acceptable norm on college campuses, then researchers argue that this new trend would grow within the community and eventually the new social norm of living free from sexual assault on college campuses would take hold. This growth in trend can be related to Malcolm Gladwell’s Tipping Point, when there is one moment when everything can change all at once (24). This tipping point can be related to a change in social norm. If the social norm of SA is changed within a college community, then there is an opportunity where all community members’ acceptance of sexual assault as a social norm can also change. This key element in psychological theory reflects the critical importance of following Social Expectations Theory when creating and implementing public health prevention programs. While previous SA prevention campaigns have failed to follow social expectations theory, one can learn from this oversight when proposing a more effective intervention.

V.  Shift in Public Health Efforts: Community Level Intervention to Promote Bystander Activism

As the CDC and ACHA have called for prevention efforts that focus on changing the social norm of SA at a community level, the role of bystander prevention has become an integral method in doing so. The use of bystander prevention is a community based prevention method that specifically targets the responsibility of the entire community to decrease levels of sexual violence. The term bystander prevention relates to members of the community witnessing sexual violence among themselves and their responsibility in intervening to prevent the act of violence from initially occurring (9). This prevention method relates to a community-based program in publicizing the importance of a bystander and their role in preventing sexual assault within the community.

Bystander activism directly relates to the importance of changing the social norm. Shifting the prevention efforts to the community changes the social norm, in that community members will no longer see acts of SA as socially acceptable. Community-based bystander activism “help(s) all community members become more sensitive to issues of sexual violence and teach them skills to intervene with the intent to prevent assaults from occurring and provide support to survivors who may disclose” (25). The use of bystander prevention reaches a broader community range and promotes a culture free of sexual violence. As bystander activism is a critical method in addressing sexual assault on college campuses, the following section includes a proposed social media campaign to promote bystander activism.

VI.         Proposed Intervention: Know Your Power^TM Campaign

As previous public health interventions have disregarded important behavioral science theories, one can now better propose a SA prevention campaign that follows imperative social ecological theories through the promotion of bystander activism. Researchers at the University of New Hampshire have created, implemented, and analyzed a social media campaign that educates all members of the community to be active bystanders in preventing sexual violence. The social marketing campaign, known as Know Your Power^TM, includes various posters of student actors modeling community-oriented intervention behaviors. These posters were evaluated through focus groups, pilot studies, as well as pretests and posttests. Extensive analysis indicated that students who reported seeing the posters were more aware of bystander intervention behavior and were more willing to partake in bystander intervention to reduce sexual violence (9).

The posters portray typical campus scenarios and model preventive bystander behaviors. One of the posters displays a group of friends discussing how a friend, Joe, took another friend, Anna, into his room after heavily drinking.  The pictured group of friends determine that they should check on Anna, as she’s too drunk to consent. Another poster shows a young man chatting with his friend about how he met a guy online and plans to get that person drunk so they can hook up. The friend interjects and states: “That’s not okay. That’s rape”. A third poster displays a young woman yelling at her girlfriend for speaking to another friend, accusing the girlfriend of flirting with another woman. Bystanders nearby are pictured talking to each other, as they plan to step in and say something about their fear of an abusive relationship (26). Each poster includes the Know Your Power^TM logo and tagline: “Step In, Speak Up: You can Make a Difference”. Each poster provides specific advice about what to do in a situation similar to the one pictured (9). For example, the poster depicting friends intervening between Joe and Anna at the party had the advice of: “Friends watch out for one another…Especially when there is alcohol involved”.

Posters were displayed during the four weeks immediately following spring break, as studies have shown there is an increase in students drinking behavior during spring breaks and the following weeks. Increased drinking is in turn correlated with an increase in the incidence of sexual assault. Posters were hung throughout residence halls, academic buildings, campus recreation facilities, student centers, dining halls, Greek fraternity and sorority houses, as well as local businesses (9). Posters were also displayed on communal campus computers, as well as bus wraps that traveled around campus and surrounding towns. Additionally, Know Your Power^TM marketing material was distributed throughout campus, including key chains, buttons, water bottles, and bookmarks. Widely distributed posters ensure that member of the college community see these posters on a regular basis (9).

This social media campaign has been in effect for numerous years at the University of New Hampshire. Each year, evaluations are completed to improve current posters, as well as create new posters with varying scenarios that commonly occur within college. Posters are geared towards teaching college community members how to safely intervene when an incident of sexual violence may occur. Posters also provide a link to the campaign’s website, know-your-power.org, where students and community members can find information on bystander intervention and sexual violence resources. Within the following sections, one will find information about how the campaign better addresses sexual assault on college campuses based on three main social ecological theories.

VII.      First Defense: Use of Diffusion of Innovations Theory: Community Responsibility

Within this social media campaign, researchers use the Diffusion of Innovations Theory to prevent SA on a community level, rather than the use of the HBM on an individual level. The Diffusion of Innovations Theory reflects the importance of behavioral changes on a community level, where there are early adapters of behavior, followed by a tipping point where the intended behavior becomes a regular occurrence. Within this campaign, community members are exposed to posters teaching them the importance of bystander prevention, as well as specific ways to intervene to prevent sexual assault. Rather than relying on educating the public on the existence of sexual assault, this campaign specifically teaches students and other members of the community how to safely intervene during a potential sexual assault incident.

Know Your Power^TM is a community-level public health campaign that promotes the adoption of an effective behavior, which community members can mirror to uphold active bystander intervention. Importantly, this campaign is relative to all community members; it does not rely on educating and changing the behavior of SA victims or potential victims, as seen in previous public health efforts that use the HBM. This community level bystander prevention campaign shifts the focus from victim responsibility to community responsibility in preventing sexual assault. Within this campaign, it is more likely for the community to have a critical point where community members become active bystanders. This is because all members of the community are shown the importance and effectiveness of bystander intervention in creating an environment free of sexual violence. Rather than SA campaigns targeting a subset group of SA victims, this campaign reaches the whole community and uses the Diffusions of Innovations Theory in promoting bystander intervention.

VIII.    Second Defense: Use of Psychological Reactance Theory: Empowering Bystanders  

In addition to using the Diffusions of Innovations Theory, Know Your Power^TM also reflects the important findings from Psychological Reactance Theory. As this theory explains, when individuals are told what to do, they were more likely to do the opposite. Rather than tell perpetrators not to sexually assault victims, as previous campaigns have done, this campaign demonstrates the importance of bystander intervention and shows different scenarios in how community members can safely intervene. Within the campaign, all community members are empowered to prevent violence.

Through the use of the Know Your Power^TM campaign, community members receive an empowering message that provides useful and positive messages in how to safely prevent sexual violence, rather than more negative and dominant messages instructing potential perpetrators to not commit a crime. In addition to community level efforts, this campaign demonstrates to the public that there are safe and effective ways to intervene and prevent sexual assault. This campaign reflects the important findings of the Psychological Reactance Theory, and ultimately empowering bystanders within the community to: “Know Your Power^TM: Step In, Speak Up: You can Make a Difference”.

IX.         Third Defense: Use of Social Expectation Theory: Changing Social Norms

As this campaign successfully implements a community level intervention in empowering bystander intervention, the campaign ultimately promotes a critical change in social norm. Through this campaign, the historical social norm of sexual violence as a common occurrence on college campuses shifts to the norm of living free of sexual violence. The campaign follows the Social Expectation Theory in changing social norms to ultimately change behavior on a community level. First, the social norm is changed through the Know Your Power^TM media campaign, leading to a change in behavior in increasing bystander intervention. The powerful tool of bystander activism creates a new norm of intervention and prevention of sexual violence.

This campaign creates a change in social norms of sexual assault, and therefore promotes a change in behavior through bystander intervention. Through the shift in social norms, the campaign builds a broader sense of community. The bystander model provides each community member with an active role; each role can then be adopted to prevent sexual violence within that community, and eventually each community can reach a broader range of people with the increase of bystander activism.

The campaign is a community-level approach in preventing and ultimately terminating sexual assault on college campuses. Efforts through this group-level campaign to change this social norm relates directly to Malcolm Gladwell’s tipping point theory, where the change in social norm can lead to a relatively quick change in bystander intervention behavior. Through this intervention, resources can be used productively through shifting the social norm of preventing SA on college campuses. With the change in social norm and increase in bystander intervention behavior, each community member has an opportunity to become active bystanders, as well as build sense of trust and belonging with community members, specifically regarding the prevention of sexual assault.

X.  Conclusion

Sexual violence on college campuses is a critical public health concern (1, 2, 3). Various efforts have been implemented to educate the community about the existence and risk of sexual violence. While these programs may have increased awareness, sexual assault continues to be the most common violent crime committed on college campuses today (4). Recent efforts centered on changing the social norm and increasing bystander intervention has led to a new public health approach that prevents SA through the use of a group-level prevention methods. Such recent efforts should be implemented through various college campuses across the country to assess effectiveness in preventing SA. If effective across various campsues, the Know Your Power^TM should be widely used to prevent and ultimately eliminate sexual violence on college campuses.

XI.         Citation of References

1.    Young A., Grey M., Abbey A., Boyd C.J., & Esteban McCabe, S. (2008). Alcohol-Related Sexual Assault Victimization Among Adolescents: Prevalence, Characteristics, and Correlates. Journal of Studies on Alcohol and Drugs. Vol. 69, No. 1

2.   Shifting the Paradigm: Primary Prevention of Sexual Violence. (2008). American College Health Association

3.   Karjane, H. M., Fisher, B. S., Cullen, F. T. (2005). Sexual Assault on Campus: What Colleges and Universities Are Doing About It. U.S. Department of Justice: Research for Practice

4.   Fisher, B. S., Cullen, F. T., & Turner, M. G. (2000). The sexual victimization of college women: Findings from two national-level studies. Washington, DC: National Institute of Justice and Bureau of Justice Statistics.

5.    Crawford E., O'Dougherty Wright, M., & Birchmeier, Z. (2008). Drug-facilitated sexual assault: college women's risk perception and behavioral choices. Journal of American College Health. Vol. 57, No. 3

6.   Messman-Moore, T.L., Coates A.A., Gaffey K.J., & Johnson, C.F. (2008). Sexuality, Substance Use, and Susceptibility to Victimization: Risk for Rape and Sexual Coercion in a Prospective Study of College Women. Journal of Interpersonal Violence. Vol. 23, No. 12

7.   Banyard, V. L., Moynihan, M. M., & Crossman, M. T. (2009). Reducing Sexual Violence on Campus: The Role of Student Leaders as Empowered Bystanders. Journal of College Student Development, 50(4), Pg. 446

8.   Ullman, S.E. Starzynski, L.L., Long, S.M., Mason, G.E., & Long L.M. (2008). Exploring the Relationships of Women’s Sexual Assault Disclosure, Social Reactions, and Problem Drinking. Journal of International Violence. Vol. 23, No. 9

9.   Potter S. J., Moynihan, M. M., Stapleton, J.G., Banyard, V. L. (2009), Empowering Bystanders to Prevent Campus Violence Against Women: A Prelimiary Evaluation of a Poster Campaign. Violence Against Women. Vol. 15, No. 106

10.                  Sochting, I., Fairbrother N., Kock, W. (2004). Sexual Assault of Women: Prevention Efforts and Risk Factors. Violence Against Women. Vol. 10, No. 73

11.Breitenbecher K. H., Scarce M. (2001). An Evaluation of the Effectiveness of a Sexual Assault Education Program Focusing of Psychological Barriers to Resistance. Journal of Interpersonal Violence. Vol. 16, No. 387

12.                  Adams-Curtis, L. E., & Forbes, G. B. (2004). College Women's Experiences of Sexual Coercion: A Review of Cultural, Perpetrator, Victim, and Situational Variables. Trauma, Violence, & Abuse, Vol. 5, No. 2

13.                  Sexual Violence and Alcohol and Other Drug Use of Campus. (2008). The Higher Education Center for Alcohol and Other Drug Abuse Violence Prevention. Infofacts Resources

14.                  Edberg, M. (2007). Chapter 4: Individual Health Behavior Theories. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones & Bartlett Publishers.

15.Thomas, L. W. (1995). A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. Vol. 11, No. 4

16.                  Marks, D.F. (1996). Health Psychology in Context. Journal of Health Psychology, Vol. 1, No. 1

17.                  Theory at a Glance: A Guide For Health Promotion (2005). National Cancer Institute

18.                  Berkowitz A. D. (2004). Working with Men to Prevent Violence Against Women: An Overview (Part One). National Electronic Network on Violence Against Women

19.                  Flood M. (2011). Involving Men in Efforts to End Violence Against Women. Men and Masculinities. Vol. 13, No. 3

20.                 Silvia P. J. (2005). Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. Vol. 27, No. 3

21.                  Potter, S. J., Moynihan, M. M., Stapleton, J. G. (2011). Using Social Self-Identification in Social Marketing Marterials Aimed at Reducing Violence Against Women on Campus. Journal of Interpersonal Violence. Vol. 26, No. 5

22.                 DeFlour, M. L., Ball-Rokeach S. J. (1989). Chapter 8: Socialization and Theories of Indirect Influence. Theories of Mass Communication. Longman Inc.

23.                 Banyard V. L., Moynihan M. M. (2011). Variation in Bystander Behavior Related to Sexual and Intimate Partner Violence Prevention: Correlated in a Sample of College Students. Psychology of Violence. Vol. 1, No. 4

24.                 Gladwell, M. (2000). The Tipping Point: How Little Things Can Make a Big Difference. Little, Brown and Company.

25.                  Banyard, V., Plante, E., and Moynihan, M. M. (2004). Bystander education: Bringing a broader community perspective to sexual violence prevention. Journal of Community Psychology. Vol. 32, No. 1

26.                 Know Your Power: About the Campaign. Prevention Innovations. University of New Hampshire. http://www.know-your-power.org/about.html

XII.      References

Journal Articles:

Adams-Curtis, L. E., & Forbes, G. B. (2004). College Women's Experiences of Sexual Coercion: A Review of Cultural, Perpetrator, Victim, and Situational Variables. Trauma, Violence, & Abuse, Vol. 5, No. 2

Banyard V. L., Moynihan M. M. (2011). Variation in Bystander Behavior Related to Sexual and Intimate Partner Violence Prevention: Correlated in a Sample of College Students. Psychology of Violence. Vol. 1, No. 4

Banyard, V. L., Moynihan, M. M., & Crossman, M. T. (2009). Reducing Sexual Violence on Campus: The Role of Student Leaders as Empowered Bystanders. Journal of College Student Development, 50(4), Pg. 446

Banyard, V., Plante, E., and Moynihan, M. M. (2004). Bystander education: Bringing a broader community perspective to sexual violence prevention. Journal of Community Psychology. Vol. 32, No. 1

Breitenbecher K. H., Scarce M. (2001). An Evaluation of the Effectiveness of a Sexual Assault Education Program Focusing of Psychological Barriers to Resistance. Journal of Interpersonal Violence. Vol. 16, No. 387

Crawford E., O'Dougherty Wright, M., & Birchmeier, Z. (2008). Drug-facilitated sexual assault: college women's risk perception and behavioral choices. Journal of American College Health. Vol. 57, No. 3

Flood M. (2011). Involving Men in Efforts to End Violence Against Women. Men and Masculinities. Vol. 13, No. 3

Marks, D.F. (1996). Health Psychology in Context. Journal of Health Psychology, Vol. 1, No. 1

Messman-Moore, T.L., Coates A.A., Gaffey K.J., & Johnson, C.F. (2008). Sexuality, Substance Use, and Susceptibility to Victimization: Risk for Rape and Sexual Coercion in a Prospective Study of College Women. Journal of Interpersonal Violence. Vol. 23, No. 12

Potter, S. J., Moynihan, M. M., Stapleton, J. G. (2011). Using Social Self-Identification in Social Marketing Marterials Aimed at Reducing Violence Against Women on Campus. Journal of Interpersonal Violence. Vol. 26, No. 5

Potter S. J., Moynihan, M. M., Stapleton, J.G., Banyard, V. L. (2009), Empowering Bystanders to Prevent Campus Violence Against Women: A Prelimiary Evaluation of a Poster Campaign. Violence Against Women. Vol. 15, No. 106

Silvia P. J. (2005). Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. Vol. 27, No. 3

Sochting, I., Fairbrother N., Kock, W. (2004). Sexual Assault of Women: Prevention Efforts and Risk Factors. Violence Against Women. Vol. 10, No. 73

Thomas, L. W. (1995). A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. Vol. 11, No. 4

Ullman, S.E. Starzynski, L.L., Long, S.M., Mason, G.E., & Long L.M. (2008). Exploring the Relationships of Women’s Sexual Assault Disclosure, Social Reactions, and Problem Drinking. Journal of International Violence. Vol. 23, No. 9

Young A., Grey M., Abbey A., Boyd C.J., & Esteban McCabe, S. (2008). Alcohol-Related Sexual Assault Victimization Among Adolescents: Prevalence, Characteristics, and Correlates. Journal of Studies on Alcohol and Drugs. Vol. 69, No. 1

Book:
Gladwell, M. (2000). The Tipping Point: How Little Things Can Make a Big Difference. Little, Brown and Company.
Book Chapters or Articles:

DeFlour, M. L., Ball-Rokeach S. J. (1989). Chapter 8: Socialization and Theories of Indirect Influence. Theories of Mass Communication. Longman Inc.

Edberg, M. (2007). Chapter 4: Individual Health Behavior Theories. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones & Bartlett Publishers.

Reports or Other Documents:

Berkowitz A. D. (2004). Working with Men to Prevent Violence Against Women: An Overview (Part One). National Electronic Network on Violence Against Women

Fisher, B. S., Cullen, F. T., & Turner, M. G. (2000). The sexual victimization of college women: Findings from two national-level studies. Washington, DC: National Institute of Justice and Bureau of Justice Statistics.

Karjane, H. M., Fisher, B. S., Cullen, F. T. (2005). Sexual Assault on Campus: What Colleges and Universities Are Doing About It. U.S. Department of Justice: Research for Practice

Sexual Violence and Alcohol and Other Drug Use of Campus. (2008). The Higher Education Center for Alcohol and Other Drug Abuse Violence Prevention. Infofacts Resources

Shifting the Paradigm: Primary Prevention of Sexual Violence. (2008). American College Health Association

Theory at a Glance: A Guide For Health Promotion (2005). National Cancer Institute

Website:
Know Your Power: About the Campaign. Prevention Innovations. University of New Hampshire. http://www.know-your-power.org/about.html

Promoting Sports Concussion Awareness to Minimize Long-Term Consequences: A Critique Based on Health Promotion Theory - Jacqueline Byrd

Introduction

Pediatric traumatic brain injury (mTBI) has an estimated annual incidence of 180 cases per 100,000, and accounts for over 400,000 hospital visits each year.  Eighty to ninety percent of all TBI cases are considered to be mild TBI (MTBI).  In fact, it is believed that even more cases of MTBI go unreported.  While many deficits resulting from MTBI have resolved 2-3 months post-injury, there are studies indicating that a sizeable minority of patients are experiencing persistent problems following their injury (1). Of the TBIs that are accompanied by loss of consciousness, twenty percent occur in sports – indicating a need to address the delivery of care not just in emergency departments, but on the field (2).  While these injuries may be classified as “mild,” they still pose a risk of long-lasting effects on pediatric patients if they are ineffectively and improperly diagnosed and managed.  In fact, due to patient perception of the injury’s true severity, the experts in the field use the term “concussion” to refer to mild traumatic brain injury (3).

Athletes are at increased risk of concussions due to the acceleration/deceleration nature of the injury.  As the damage of a concussion is restrained within the skull, no protective equipment is effective.  The majority of concussions occur outside of sports (in motor vehicle accidents, falls, abuse, etc), but contact sports and even cheerleading pose higher risks of falls and hard hits than non-sports activities (2).  The deleterious long-term consequences of concussion appear to be linked to repeat concussions, so tracking the occurrence of a concussion and the injury mechanism is vital.  While preventing all concussions may not be possible, risk of second impact syndrome and chronic traumatic encephalopathy can be reduced by empowering athletes to speak up if they suspect a concussion, adhering to return to play guidelines, and considering changes to youth sport rules.

Current approach: imPACT, Heads Up and Concussion Laws

The most popular practice targeted at concussion in high school sports is baseline computerized cognitive assessment for student athletes.  This testing was used in 41.5% of all concussion cases reported, representing a rapid increase from the previous academic year (3). While athletes are at a higher risk of concussion, and repeat concussion, there is no equivalent (either in education or baseline cognitive assessment) for non-sports related concussions. This expensive practice needs more follow-up testing as there is not data to indicate this reduces the risks of returning to play too soon (1). It is important to note that this intervention is focused on the risk of repeat concussions and even then, can only identify a concussion if a baseline has been established.  This is not a one-time diagnostic test for concussion.  This testing typically occurs once or twice a season, as sideline assessment is expected for in-play injuries.  If a concussion is suspected or diagnosed, an athlete must wait until medically cleared to return to play.  This can mean missing championship games, scouting visits or simply time with the team.  There are varying guidelines about rest after sports-related concussion before return to play. The decision must be made carefully due to risk of second-impact syndrome (3).  However, there is still not adequate evidence to determine the exact time to wait, so most physicians err on the side of caution.

Most states have specific concussion laws regulating coaches’ concussion training and response to concussions.  These laws exist separately from the school systems’ adoption of baseline testing, as few of these laws mandate baseline testing.  These laws have evolved from the media attention that concussions in professional sports have gained over the past few years (3).  Concussion laws require training for coaches and require that coaches follow return to play guidelines.  These laws do not specify which guideline coaches should follow, nor do they provide financial resources for training of coaching staff and school staff.  Most educational programs to satisfy the law are online trainings, like the Center for Disease Control and Prevention’s “Heads Up” initiative.  Launched in 2005, “Heads Up: Concussion in High School Sports” initiative provides materials and multimedia presentations online for coaches.  More recently, the CDC launched “Heads Up to Schools: Know Your Concussion ABCs” for grades K-12 school personnel (4).

No current intervention addresses the complex environment shaping youth athletes’ decision making around the issue of concussion.  Unlike other prevention issues, concussion prevention is complex and cannot be accomplished through any single change or use of a piece of protection equipment.  Concussion education should encompass prevention and response and must account for barriers – financial, cultural and structural – to implementing recommended practices.  An effective intervention should work with individual young athletes, but must work to change the sports culture in the US to be more safety-conscious.

Criticism of Intervention 1: Legislation creates a burden, not a behavioral change

Thirty one states have a concussion law in place that requires a form of education for athletes, coaches, parents, educators or some combination of the four key groups (10).  Specific education programs are not created or recommended by concussion laws, nor do the laws create specific guidelines to follow.  Most coaches have turned to the Center for Disease Control and Prevention’s “Heads Up” program and report that they view the CDC as a credible expert on the issue.  However, as Chris Nowinski, former professional wrestler and co-founder of the Sports Legacy Institute, observes, “stuff's been online for five years.  The problem is nobody goes and does it unless they're required to. And everybody in the industry knows that" (9).  The concussion laws require education, which is satisfied by the CDC’s course in most states.  However, evaluation of the success of these courses has been limited to small studies.   These small studies have found improvements in coaches’ self-reported awareness of the risk and severity of concussions (4).  However, requiring training that also mandates specific actions in response to a concussion may backfire if coaches feel, as youth do, that “they [do] not want to be told what to do” (11).

As a consequence, most Massachusetts coaches and families felt a burden from the requirements of the law rather than encouraged at the attention the issue was receiving.  Evaluation of concussion laws and the educational programs that satisfy them finds an increased awareness of the severity of the issue, but these evaluations have not been able to examine changes in behavior (12). The scope of each concussion law varies state to state, but these laws impose financial burdens on youth athletics programs and schools that need to put a doctor on every sideline.  The national attention the NFL, and former NFL players, is garnering at the national level is also drawing legislator’s attention to the possibility of a national concussion law. 

These state laws are not transferrable without consideration of resources and geography.  Furthermore, requiring parents and coaches take action ignore the extraordinary control the player has in this arena.  Laws require that adults in positions of supervision remove athletes suspected of a concussion from play and follow one of several return to play guidelines.  If the law required removing every player with a knee injury, coaches and parents could spot the injury without requiring any input from the athlete.  Unfortunately, the “unseen” nature of concussions requires that recognition of the injury is up to the player.   The director of the the Chicago Neuropsychology Group commented in the Chicago Tribune, "We only have as much power as an athlete is willing to tell us" (9).  Legislation helps engage parents and coaches, but behavioral change has to start with the athletes as the focus of this legislation ignores the power the athletes wield over disclosing concussions.

Criticism of Intervention 2: Interpersonal - Interventions ignore social norms          

Education and public awareness are crucial components of any intervention addressing sports concussions.  Providers often dismiss the severity of a concussion as post-concussive symptoms resolve with 1-2 weeks of injury in most individuals (1). Even providers who try to stay on top of the latest guidelines are at a disadvantage as guidelines for pediatric population, especially in sports-related concussions, lag behind adult TBI due to lack of data for evidence-based conclusions.  Despite insufficient data, more is known now than a generation ago, but the underlying beliefs of providers (as well as those of the general public and the youth sports community) can complicate diagnosis and management. This confusion can extend to a difficulty recognizing subtle, long-term cognitive signs of post-concussive syndrome. Unfortunately, this belief in the minor and transient nature of the injury also exists among providers who may more readily dismiss concerns from patients because “it’s just a concussion.” Pediatricians and emergency department physicians are not always aware of latest brain injury management guidelines (3).  

            An evaluation of the CDC “Heads Up” concussion initiative for high school coaches found that coaches and parents underestimated the potential risks of concussions (4).  The idea of a “bell ringer” or other harmless hit is entrenched in football and hockey culture, and is consistent with the sports’ aggressive culture where hard hits are rewarded.  An analysis of Canadian and American newspaper coverage of brain injuries in ice hockey found that where papers once only reported injuries to star players, they are now reporting those injuries in the context of the larger issue.  This represents an improvement in the media’s focus on the issue.  Unfortunately, the previous media coverage and the conflicting views of fans and athletes create confusion in the public.  Even as injuries to star and unknown players are reported, there is still a public perception that these injuries are “just a part of the game.” The conflict between this perception and what the papers are reporting could reduce the impact of these media messages about harmful brain injuries. (5).

The culture at the amateur and professional levels of these contact sports has created a social norm where athletes expect to get hit and do not want to show weakness by withdrawing from play – they want to win the game at any cost (5).  This norm influences the behavioral intention of young athletes according to the Theory of Planned Behavior (6).  Injuries are so expected in playing the sport that star professional athletes are remembered for playing through injury.  As a result of this social norm, a young athlete may believe that his peers and coaches would disapprove of letting a suspected concussion end his game.  This is considered an injunctive norm, the perception of what is approved or disapproved, within, in this case, sports team culture.  Injunctive norms are especially important to address as they can mediate the boomerang effect of promoting the descriptive norm, the prevalence of a behavior, in a society (7). 

Aside from teammates, other individuals whose approval is important to young athletes are their parents.  While some concerned parents were involved in the advocacy efforts for the Massachusetts Concussion Law, all parents are reliant on coaches and the media for information about concussions in sports.   The terminology is confusing; some parents think a “concussion” is distinct from a brain injury (8). Public perception was once that a second blow to the head could cause the return of things forgotten in the first blow to the head.  As many parents of young athletes were once young athletes themselves, they think their children are fine playing the sports the way they played them.  As we know now more about the risks of repeat concussions, it is important that the overall attitude about youth sports change.  This will require targeted education efforts to key groups involved – on and off the sidelines.

Criticism of Intervention 3: Intrapersonal - The Intervention is Ineffective at Changing Individual Knowledge and Attitude

Existing interventions have either focused on athletes or coaches, but have not appropriately incorporated behavioral theory to these and never expanded to other key members of the community. “Heads Up” posts education videos directed at coaches online for others to view, but they videos are coach-specific.  While some interested parents and providers may seek these videos out, there are currently no interventions targeted at them on a large scale.  This is significant as pediatricians (rather than athletic trainers) see the majority of pediatric athletes with concussions; without proper training and education, many of these physicians lack the tools to assess and manage concussions (1). Medical management of concussions may not prevent their occurrence, but it can mediate long-term effects; provider education cannot be overlooked in any comprehensive concussion care model.

Concussion education for athletes and their supervising parents initially focused on addressing the Health Belief Model by increasing perceived severity and perceived susceptibility. However, as it has expanded to try to address the culture of youth sports, the Theory of Reasoned Action has been applied to include social influence (6). This theory suggests that education about concussion also runs the risk of the boomerang effect. Education that provides information on descriptive norms, whether the prevalence of concussions, the (low) prevalence of lasting consequences from a single concussion or the number of athletes suspected of not reporting concussions, can provide the level from which an athlete does not want to deviate (7).  If an athlete has not yet had a single concussion, but learns how many others have, he may take more risks if he sees concussions as the standard in sports.  Legislation that requires coaches or athletes – or both – to undergo education can backfire if social and behavioral theory is not first applied to the development of educational interventions.  

Individual interventions targeted at athletes must remain a key technique of the health promotion model targeted at preventing and responding to athletes.  These education efforts must be carefully constructed.  The current model focuses primary on how to recognize and respond to a concussion.  This intervention is framed as a response effort and not a prevention effort, leading to the impression that any intervention to prevent concussions is futile (15).  Even if athletes are convinced, in accordance with the Health Belief Model, that they are susceptible to a serious harm, they may not change their behavior if they believe that susceptibility is unavoidable.

One non-health deterrent for athletes reporting concussions is the consequences such reporting could have on their fledging athletic career.  Experts recommend “retiring” from the sport, even at the high school level, when a concussion can be obtained with decreasing force.  Players realize that each reported concussion could be another step towards the end of a career – and the loss of any chance at scholarships or endorsements.  For instance, heading a soccer ball should not produce a concussion. If it does, that soccer player’s physician should recommend ceasing involvement in the sport. That player, regardless of talent, could never obtain the rewards that so many young athletes (and parents of young athletes) hope for. 

Proposed Intervention: Use Athletes to Educate the Public, Empower Young Athletes, and Change the Social Norms of Youth Sports

Legislation should be a component of all state’s interventions and it demonstrates widespread commitment to the issue, but it cannot effect behavioral change in isolation.  Advocates for legislation must also transmit their passion for reducing concussions in youth sports to state and local education and awareness programs for all key individuals in youth sports.  Training can be required for athletes and school employees – coaches, teachers and administrators –  but it can only be made available for parents, doctors and the general public.  Just as legislation cannot independently change behavior or culture, neither can education alone make all the difference in injury prevention.  The strong advocacy network that compelled legislators to act needs to evaluate what can compel young athletes to act. 

 These activated parents and coaches need to focus not just on changing the laws at the state level, but on changing the rules and regulations of youth sports.  This normative shift will come gradually, but will be possible through the involvement of parents and athletes in education directed at fellow parents and athletes.  Utilizing in-person events at schools and competitions in conjunction with an active presence on social media and online video-chat programs (Skype and Google Hangout), professional athletes who have made the decision to sit out a game will share their thought process with young athletes.  This gives young athletes to ask professional athletes about the consequences on their careers and whether they would do it again.  A network of young athletes, mentored by these professional athletes, will be established.  This will create an opportunity for peer education.  These young athletes will share the stories they hear from professional athletes with their teammates.  Coaches and parents will help facilitate this peer education system and will publicly recognize young athletes with concussions who identify their suspected injury at the moment it happens. 

As more and more youth athletes, teams, and youth athletic associations see the benefits of caution in youth sports, they will be empowered to slowly institute changes in the structure of youth sports.  This will be a form a passive protection, which will go hand in hand with active prevention efforts as part of the Health Promotion Framework. The successful stories of professional athletes who abided by return to play guidelines and are continuing to compete will contrast sharply with the serious issues in other athletes who sustained repeat concussions in quick succession.  The prior attempts at public awareness have veered towards a fear campaign with the risks of chronic traumatic encephalopathy; this intervention will work within the positive culture of youth sports to encourage teaching precaution as well as teamwork.

Defense 1: Provides effective intervention support to the legislation

Concussions will never result in the obvious symbols of sports injury – casts, crutches, or slings – but their effects can be more long-lasting and life-altering.  Recognition of the problem at the legislative level is a victory for concussion advocates, however there is still a lot of work to be done to change the public perception of concussion and the role of youth sports in minimizing them.  Public awareness and education efforts are critical as parents need to learn about the risks of sports injuries even before they have children.  President Obama recently commented that he would have to think long and hard before letting a son play football.  In the same interview, he expressed an understanding that the sport would have to change (16).  He, along with many other parents, may be prepared to see action taken, but they may resist regulation changes they are not a part of. 

The best advisors for an education effort in hopes of championing changes to youth sports are future and current parents themselves.  In fact, the Principle of Participation suggests that parents’ behavior change will be greatest if they are involved in planning the intervention planning.  Parents are put at risk by youth concussions as well as the child, so they should also be engaged in the effort.  Rather than doctors suggesting changes to youth sports, the experts should engage parents on what concerns and suggestions they have.  This is in accord with the Principle of Relevance which argues that change is the greatest with the organizers of the change effort engage the community members at risk (15).

            This proposed intervention does not rely on single individual-level theories, but instead acknowledges the need for changes to behavior and environment, as examined through the Health Promotion Framework (15).  If the sports and the way they are played (e.g., tackle football at a young age) are contributing to the high rate of concussions and trend of multiple concussions, then more than just individual behavior needs to change.  This proposal aims to educate all involved stakeholders so that they are equipped to change youth sports.

Defense 2: Increases awareness of youth sports culture and motivates changes to norms

Concussions can be prevented through modifications to youth sports practices, however, such a structural change must begin with individual behavioral changes.  Intrapersonal interventions are the first component of an active strategy to encourage behavioral change.  All young athletes are in the pre-contemplation phase of the Transtheoretical Model where they need to be aware of the need to act differently than they are used to when it comes to concussion.  The goal of a comprehensive intervention is to provide young athletes with enough age-specific information and advice that they are prepared to take action when the time comes.  The action of reporting a concussion to a coach is only possible after sustaining a concussion, so rather than cycling through the Stages of Change at their own pace, athletes wait in the precontemplation-preparation steps until sustaining a hard hit (17). 

Educating young athletes about the odds of concussions over their careers and the dangers of concussions increases their awareness of the need to change their response to concussion.  Teaching athletes about their susceptibility to harm and the need to support their team mate’s decisions to protect their brains integrates principles of the Health Belief Model and the Theory of Planned Behavior within the timeline of the Transtheoretical model.  If they have heard professional athletes describe the signs of a concussion in play and the risks of playing with a concussion, these young athletes will be motivated to decide on action plans in the event of a concussion.  Ideally, this action will entail communicating their injury to their coaches immediately.  Young athletes who have sustained concussions will also be valuable additions to the peer education program.

In fact, these injured young athletes are one example of an effective communicator to lead the necessary educational efforts.  Sports culture is created by the stories of perseverance and physical performance in the media about famous college and professional athletes.  Young athletes aspire to this level of competition, where aggression and playing through injury is rewarded by the fans, media and teammates.  Only recently have athletes come forward to reveal suspected concussions that led them to remove themselves from competition.  The media must continue to highlight these stories, as examples of role models prioritizing their own cognitive health over a sports competition.  If this intervention hopes to communicate the message that young athletes should immediately disclose a suspected concussion to adults, the communicators must be carefully chosen. 

Concussion prevention messages are typically delivered by coaches and doctors.  However, these messages should be delivered by fellow young athletes who sustained a lasting injury or professional athletes who sat out a game due to a suspected concussion.  Reactance theory suggests that attraction to the communicator increases the positive force towards similarity.  A credible athlete can also undermine resistance as these athletes made their decisions despite the same team-oriented competitive point of view (14).  Coaches can be trained to recognize the signs, but athletes are more likely to respond to a fellow athlete’s advice about action to take with a concussion than their coach – especially if their coach was not an athlete.

Most professional athletes played youth sports, just as many parents involved in their children’s sports did.  A few professional athletes have come forward to discuss their decision to stay on the sideline with a concussion.  In one case, one of the most famous NASCAR drivers stayed out of a race after sustaining a concussion in a prior race crash.  Dale Earnhart Jr.’s own words demonstrate that it is not an easy choice, but that he feels better for having made it: "I feel fortunate to have recovered from this concussion quickly, and I feel lucky I made the choices I did. Had I tried to push through it like I did the other ones I was putting myself in a lot of danger” (18).  It is these athletes who have the most power to wield in communicating the message of reforming youth sports. 

They acknowledge that the decision is hard and leaves them yearning to be in the competition, but demonstrate that they value their long term mental health over any single competition.  These athletes demonstrate that the perceived benefits outweigh the perceived costs even at the highest levels of competition.  Their public statements, even if they would rather compete than serve as a spokesperson for an issue, go a long way in serving as a cue to action for younger athletes. In addition to meeting the health motivation constructs of the Health Belief Model, the involvement of these athletes changes the norms of sports competition.  If athletes are sitting out of competition because of a bad crash or hard hit, they are demonstrating that continuing to compete is not acceptable.   

Defense 3: Education of athletes and parents improves self-efficacy

Equipped with a role in evaluating the danger of youth sports and aware that their children are being mentored on how to avoid and recognize concussions, parents of younger athletes will feel they have more control over their behavior in regards to concussions.  Similarly, recognizing young players who independently chose to report a concussion will demonstrate to other players that every player is in control of his own behavior.  The Theory of Planned Behavior adds perceived behavioral control to the Theory of Rational Action, which was previously discussed with regard to norms (17).  While coaches should be educated on proper protocol, especially for head injuries requiring immediate medical intervention beyond sideline cognitive assessment, athletes should feel empowered to remove themselves from a game as a precaution if they suspect a concussion.  Accomplishing this requires both changing athlete’s attitudes about concussions and improving communication between coaches, parents, athletes and doctors about the appropriate steps to take. 

Athletes who report a suspected concussion (whether it happened on or off the field) should be used by coaches as a positive example.  Publicly recognizing these athletes will help other athletes realize that their own decisions are in their control and will be approved by their coach and teammates (15).  Athletes need to feel a high degree of control of their ability to recognize a concussion and remove themselves from play.  As the proposed intervention aims to ultimately reform youth sports, these athletes also need to have a sense of control over their behavior in the sport. Every professional athlete who has gone public with his or her own concussion should be connected with young athletes.  It is especially important for professional athletes to recall concussions earlier in their careers and for high school athletes who have sustained concussions to share their own experiences.  The use of professional and young athletes as communicators will reduce resistance, while the messages they share will not only promote compliance but empower young athletes to take action to change their sports.

Conclusion

Reducing sports concussions requires more than one intervention.  The approach must be multi-faceted and must engage the stakeholders.  While education should be age-specific, young athletes should be brought into discussions about potential interventions and should contribute to curricula.  Establishing a program to connect young athletes with professional athletes will create an initial effective communication that can be extended further through a system of peer education.   Applying the Ecological Model and Health Promotion Framework in addition to individual-level theories, highlights the need to create active and passive changes, in behavior and structure, respectively.

References

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