NFPA Journal

Drawing on his engineering background, John created a warning system that alerts his neighbors of a problem in the home, should he be unable to escape. He spent months designing the system and hunting down the right hardware. The result is a system that features a set of interconnected smoke alarms, as well as a loud exterior bell that sounds when the home system is activated. He received encouragement from neighbors and invited the local fire chief to inspect the system.

The bottom line is that John now has an extra layer of protection should he not be able to call 911 himself.

John wasn’t content to merely worry about his safety—he took charge of it in a proactive way and devised a solution based on his needs. Unfortunately, this type of determination is not typical when it comes to fire and life safety—it’s more common to hear of people living, and sometimes dying, in homes without working smoke alarms, including people with physical challenges at least as severe as John’s.

We can look to the field of behavior change theory to better understand why John acted as he did. Behavior change helps us look beyond the idea that knowledge alone is enough to get people to do what is healthy or safe—it also attempts to explain why people make the choices and take the actions they do. It is not enough to simply be aware of the potential consequences of our actions. We see proof of this all around us: teens who text while driving, educated professionals who eat high-fat foods on the run, firefighters who smoke a pack of cigarettes every day. These offenders are most likely aware that their behaviors are dangerous or unhealthy, yet they still do it. But why? „

Knowing, or at least addressing, the why can be the difference between an educational initiative that falls flat and one that succeeds in creating a genuine behavioral shift. That’s why professionals in a variety of fields—health care, human services, criminology, sales and marketing—tap into these theories every day.

Fire and life safety educators are beginning to look at behavior change theory to improve the effectiveness of their programs. This is an important development in the public education field, because too many of our programs are premised on changing behavior solely through making audiences aware of risks—which means that many of our prevention programs may not be as effective as they could be. Health and safety behaviors are ingrained, personal, and difficult to change, and the challenge for safety professionals is to look closely at their programs and identify strategies that move beyond simply providing knowledge. Effective programs also must include attitude development and skill-building opportunities for participants, essential components in our work to initiate meaningful changes in behavior.

While this may require some serious review and retooling of favorite lessons and activities, the result could mean changes in behavior that result in fewer deaths and injuries related to fire and other risks—the ultimate positive outcome for any public education effort.

Why knowledge doesn’t equal action

As public health efforts in the mid 20th century moved from considering health as merely the absence of disease to the improvement of quality of life, the field of health behavior change in the United States grew. People were not dying as readily from infectious disease, thanks to improved water quality, immunizations, and the knowledge that simple hand washing went a long way toward preventing the spread of communicable disease. But since people were living longer, they faced increasing rates of heart disease, cancer, and the physical limitations of arthritis due to aging. These and other chronic conditions were the result of multiple contributing factors, including lack of physical activity, a high-fat diet, and lack of preventative medical care. Health education efforts focused on teaching people how their daily behaviors impact their current and future risk of disease and disability.

But these behaviors required more than just knowledge to enact; they required an attitude that allowed people to recognize personal risk, as well as the resources and skills necessary to lead a healthy lifestyle. Numerous behavior change models emerged to address issues of people’s perception of risk, their ability to cope with change, and their readiness to make that change. Based largely on the fields of psychology and social sciences, these health behavior change models helped to explain why people continued to engage in unhealthy or unsafe behaviors, despite “knowing better.”

The behavior change models recognized that people engage in various behaviors due to a complex interaction of knowledge, perception, culture, experience, environment, and attitudes—no wonder getting people to do even simple tasks can seem difficult. Different models are used depending upon the context and the complexity of change required by the person to improve their habits and situation; the more change is required, the deeper the requirement for attitude development and skill-building opportunities for participants.

The challenge for safety professionals is to look closely at their programs and identify strategies that move beyond simply providing knowledge. For example, many people know that working smoke alarms can reduce their risk of being injured in a home fire. Reminders to take action come in the form of television commercials, news stories, and banners hanging on the local fire house. Even so, too many people fail to have these life-saving devices in their homes—a seemingly simple step, but one that millions of Americans are unwilling to take.

A closer look at John

John McDevitt may be unusual in his built-in ability to assess risk and his own capabilities and to act on those needs with skills he already possessed, but in that way he is an ideal model for fire and life safety educators. Our goal should be to create public safety programs that offer participants the same set of tools that
John used to evaluate his situation and act accordingly.

Ultimately, innovative solutions like John’s should also be included in discussions on the related codes and standards that address the safety of all types of building occupants.

John’s story is a good example of the health belief model, or HBM, which is well matched with fire and life safety concepts. This model was developed by social psychologists in the 1950s to examine the tuberculosis screening process, and was used to improve vaccination rates in communities. Since then, the model has been updated and used in many different health behavior programs, including those designed to impact lifestyle behaviors such as smoking prevention, safe driving, and participation in cancer detection screenings.

The underlying premise is that health behavior is determined by a set of attitudes and perceptions that impact whether a person will engage in the health-enhancing behavior. Those perceptions include perceived susceptibility, or one’s belief in the chance they could contract the condition; perceived severity, one’s belief of how serious the condition is and how it could impact their lifestyle; perceived benefits, one’s belief in how well the desired behavior will work to reduce the chances of contracting the condition; and perceived barriers, one’s belief of the tangible and emotional costs of the desired behavior.

By acknowledging susceptibility, John believed he was at risk of being injured in a home fire, and he believed his lack of mobility could make it difficult for him to escape in an emergency. By acknowledging severity, he also believed any injuries he might sustain in a home fire would be very serious both in terms of his physical wellness and his lifestyle, and that he may not be able to continue his travels as a result. By acknowledging benefits, he believed that by designing and building an external alarm system he was reducing his risk of fire injury and death. By acknowledging barriers, John believed the time, money, and mental energy he spent in building the system was worth it. He clearly believed he was able to take control of his personal safety, and that his time and effort would result in a positive outcome. Had he not believed he was capable of producing this outcome, he probably would not have attempted to create his home alarm system. Henry Ford said it best: “Whether you think you can or think you can’t—you’re right.” As educators, it is incumbent on us to do everything in our power to make sure our audiences think they can. As John’s initiative demonstrated, knowledge of the risk he faced was only one of a handful of valuable tools he used to make himself safer.

To help us develop those tools, effective public safety programs also investigate and address the behavior change notions of “cues to action” and “self-efficacy.” Cues to action are the “triggers,” the external forces that activate behavior change. These are the motivators, the things that will often be the tipping point in a person’s life to initiate change. Self-efficacy is about the internal confidence necessary to engage in the behavior. People need skills, resources, and support in order to believe that they will be able to successfully engage in the behavior.

There are numerous other behavior change theories that can be applied in community risk reduction. For example, the transtheoretical model examines an individual’s readiness to make a change and is often used in smoking cessation programs. The theory of reasoned action looks at how social pressure and role models shape intentions to change and is often applied when dealing with adolescent health behaviors.

Making it happen

We are not yet at the point where behavior change theory and practice have aligned in the world of injury prevention, and the trickle-down process of translating research-based information into useful programs and strategies for life safety educators working in the trenches has been slow. A decade ago, a team from the Johns Hopkins Bloomberg School of Public Health and the National Center for Injury Prevention and Control conducted research to determine the connection between injury prevention research and behavioral theories. In a 2005 paper, the team concluded, “While injury prevention should be no exception, results from our review suggest that there are few scholarly applications of the most commonly used theories to this important public health problem. This reticence to include theory is particularly distressing given the enormity of the injury problem in the U.S.”

Similarly, while there are many on-the-ground safety-based programs available, only a limited number have been developed with behavior theory as a guiding principle, and few have been evaluated to determine behavioral outcomes. Even so, there have been enough positive outcomes from studies examining theoretical approaches to injury prevention programs to suggest that the behavior change approach is beneficial.

Another problem we face are the assumptions held by the implementers of those programmers. For many public safety educators, it is easy to presume they have buy-in from workshop participants simply because they show up; who would make the effort if they weren’t interested and ready to take on safety behaviors? This assumption is misguided, however, and only amplifies the need to ensure safety programs include attitude development and skill building opportunities based in behavior change theory.

Despite these challenges, this is an ideal moment to initiate improvements across fire and life safety programs. Many communities have transitioned from fire department-focused public education programs to a community-wide risk reduction philosophy. Program leaders are embracing the use of data to answer questions about accountability and prove program worth. Technology provides access to scientific information once reserved for the academic community, as well as speed-of-light communications to encourage global support networks among like-minded lifesavers. Like these advances, behavior change theory is another tool with fingertip availability for those working to engage communities in safety-focused lifestyles. In short, it’s easier than ever for educators to improve their risk reduction programs.

However, this shift may require many program planners to step outside of their comfort zones and enter new territory. Over the past two years, for example, NFPA’s Remembering When™ program, an effort aimed at fire and fall prevention, has undergone a transition. The original version of Remembering When was an information-rich program for older adults that included strategies to help them live safely at home for as long as possible. The revised version has the same desired outcome, but in addition to strengthening each participant’s knowledge base, we strive to empower older adults to develop supporting attitudes and adjust specific behaviors. At our annual scholarship conference, facilitators are trained to help Remembering When participants focus on the physical, social, and emotional benefits of taking preventive action, and to encourage them to believe in and celebrate their abilities to do the work related to personal risk reduction. Facilitators are also taught to work with clients to identify barriers that may prevent them from making meaningful changes, and to develop strategies to overcome those barriers so they can live with a reduced fear of fire- or fall-related injuries. We’ve updated all of the Remembering When materials and added this program to our cache of free, online resources, allowing us to make ongoing improvements.

As educators, we must ensure resources dedicated to risk reduction activities are providing the biggest return on investment. Behaviors are connected to a complex set of emotions, barriers, and habits, and safety professionals must rely on a mix of tools and approaches to get the job done. John McDevitt may be an extreme example of the time, energy, and resources a person can put into protecting himself, but his efforts remind us of what the product of real safety education can look like: not just imparting knowledge, but motivating, empowering, encouraging, and reinforcing. Only through that mix can people make changes that could save their lives.

KAREN BERARD-REED, M.ED., is a senior project manager for high-risk outreach in the Public Education Division at NFPA. ANDREA G. VASTIS, MPH, is a public health educator and consultant in Rhode Island and Massachusetts.