 |
Bicycle Injury Interventions
Programs to Increase Helmet Use
Education
Background
Despite the clear and what should be convincing
data regarding the effectiveness of bicycle helmets, few people across the United
States and in most parts of the world (children included) can be observed wearing
bicycle helmets. The latest estimates (1994) of helmet ownership and helmet use
among children in the United States are 50.2% and 25.0%, respectively.11 Helmet use varies widely across the
country, due to the local variation in educational campaigns and presence of helmet
laws. Telephone surveys of helmet use tend to overestimate actual use compared to
observational surveys. Education of bicycle helmet effectiveness in preventing head
injury is one popular method used in the attempt to increase (and sustain) bicycle
helmet use. Education interventions can be community-based, school-based, physician-based,
or some combination of these settings. These programs can focus only on helmet use
or can include helmet use along with other goals. They can be multifaceted in their
means of increasing helmet use, or may just have on method of employing the strategy.
Also, they may or may not combine education with helmet discounts. These intervention
programs can be evaluated by direct observation of helmet use, sales of helmets,
injuries reported, or some combination of these data.
Review of helmet education interventions:
Author | Cook & Sheikh, 2000 |
Study design and target population | Time series analysis.
Cycle injuries resulting in admissions to NHS hospitals in
U.K. 1991-1995. |
Intervention | Increase in bicycle helmet use in
UK over the same time period.
Specific information on helmet use 1991-95 not available in the article.
Observations by Transportation Research Laboratory (TRL) indicate
children's helmet use rose from 2% in 1991 to 20% in 1995.
1996 survery in London observed 17% helmet use in adults and
14.4% in children.
Self-report survey: 36.8% use for elementary ages and 13.7%
for teens. |
Outcomes | Head injury admissions as a percent
of all bicycle injury admissions.
Head injury defined as skull fracture or intracranial injury (ICD-9:
800, 801, 850-4) |
Results | Linear regression models indicated
a 12% drop (95% CI 10%-15%) in serious head injuries as a percent of all bicycle
injuries. From 40% in 1991-92 to 28% in 1994-95, while total bicycle trauma
did not changes.
Consistent year to year trend in which the proportion of head injuries
related to bicycle trauma became lower in each successive year.
Reduction occurred in each age group of cyclists (6-10, 11-15,
16 and older). |
Study quality and conclusions | Time series analysis carries a stronger
ability to make causal inferences than a pure observational before-and- after
study with only two time period measures.
Proportion of head injury admissions as a percent of total admissions
controls for any secular trend change in cyclist\rquotes habits.
Further evidence that helmets benefit both children and adults. |
Author | Floerchinger, 2000 |
Study design and target population | Ecologic mixed study.
Elementary school children in rural Idaho. (Idaho's South
Central District Health Department) |
Intervention | Inter-school contest designed to increase
bicycle helmet use. Included community activities.
Intervention schools (n=4).
Control schools (n=19). |
Outcomes | Observed helmet use of children riding off school grounds.
Baseline 1997, Post-Intervention, 1998. |
Results | Increase in helmet use in participating
schools compared to scontrol schools (p.=.01).
Multivariate analysis adjusted for baseline use rates. Control
group allowed adjustment for secular trend. |
Study quality and conclusions | Small numbers of children in rural
schools.
Contest successfully involved children and community members
in prevention activities. |
Author | Lee, 2000 |
Study design and target population | Ecologic time-trend study.
5-15 years old in Reading West Berkshire, U.K. |
Intervention | "Helmet Your Head" Multi-faceted
hospital led helmet promotion campaign.
Included media support and low cost helmets. |
Outcomes | Bicycle-related head injuries in children
under 16 seen in A&E department of Reading hospital.
Multiple measures of injury rates, 4 years pre-program and
6 years post program. |
Results | Reduction in rate of head injuries
from 112.5/100,000 to 60.8/100,000 (p<.005).
Head injuries as a percent of total bike injuries decreased
from 21.6% to 11.6%
Self-reported helmet use among 11-15 year olds was 16% higher
in intervention area compared to control area. |
Study quality and conclusions | Evidence that an intensive community-wide campagin decreased
bicycle-related head injuries.
No control group used.
Authors concluded that national helmet initiative is justified. |
Author | Wesson, 2000 |
Study design and target population | Ecologic time-trend study.
Children 0-14, Toronto, Canda. |
Intervention | Community-based bike helmet promotion
campaign began 1989; helmet legislation passed 10/1995. |
Outcomes | Observed helmet use; hospital admissions to regional
trauma center for bike-related injuries.
Ontario Trauma Center Registry used
to identify injuries. |
Results | Helmet use increase from 4% in 1990
to 67% in 1996.
Legislation provided a 20% boost.
Head injury admissions decreased from 46 in 1990 to 24 in
1996. |
Study quality and conclusions | Standardized observation methods used.
Counts of head injury admissions doesn't control for cyclinhg
exposure.
Combination of legislation and campaign effective. |
Author | Durkin, 1999 |
Study design and target population | Ecologic time-trend study.
Northern Manhattan Surveillance Area, New York, New York.
Children 16 and younger.
Pre-intervention 1983-1988;
Post-intervention time period 1987-1995. |
Intervention | Harlem Hospital Injury Prevention Program:
Multifaceted program including courses
on bicycle safety & rules of road, recreational bicycle programs and distribution
of 1000 helmets.
Urban Youth Bicycle Corp taught bicycle
safety to elementary schools, & repaired bikes.
State-wde helmet law passed 1993 required
helmets for kids 13 and younger. |
Outcomes | Hospitalized bicycle injuries included fatal injuries..
ICD-9 codes and E codes used to identify injuries from
databse.
Incident rates (per 100,000 per year)
calculated for major & minor head injuries and injuries not involving
head. |
Results | Poisson regression used to quantify & test for
changes in monthly incidence rates and control for year to year variability
present before intervention.
73% decrease in major head trauma (1.58 to 0.43), 52%
decrease in minor head trauma (21.6 to 12.5).
Decline in bicyclist injury incidence
not involving head trauma was 42% (from 21.6 to 12.5).
Peak incidence of bicycle injuries
at age 15. |
Study quality and conclusions | Well analyzed study included comparison
data for areas of NY city not subject to intervention.
Decrease in major and minor head injuries.
Authors suggest expanding helmet law
to cover older cyclists.. |
Author | Britt, 1998 |
Study design and target population | Non-random controlled trail.
Low income children attending preschool enrichment programs
in Washington State.
Intervention: 18 sites, 880 kids.
Controls: 200 chidlren. |
Intervention | Multifaceted bicycle helmet promotion
program:
Classroom activities, education of parents during school meeting
and home visits, fitting and distribution of helmets, bicycle skills and safety
"rodeo" event, helmets required while riding at school. |
Outcomes | Observed helmet use during home visits..
Child was asked to ride bike and helmet use was recorded. |
Results | Helmet use doubled in intervention group, 43% to 89%
with smaller increase in control group (42% to 60%) p<.05. |
Study quality and conclusions | Intervention at level of Head Start
Program.
Innovative evaluation strategy used.
Multifaceted program substantially increased helmet ownership
and use among low income preschool children. |
Author | Logan, 1998 |
Study design and target population | Ecologic time-trend study.
Children kindegarten through 8th grade, rural towns in Texas,
N=403. |
Intervention | Bicycle helmet give-away program plus
a full day of educational activities including bike rodeo and prizes. |
Outcomes | Observed helmet use. Helmets identical
for ease of identification. |
Results | Multiple observation periods, 1 before
program & 4 after.
Use increased from 3% to 38% 7 months after program.
Increase in K-6 only; teen use negligible.
Use decline in summer when incentives
stopped. |
Study quality and conclusions | Smaller number of observations.
Give-away programs alone do not sustain high helmet use.
Ineffective for teens. |
Author | Abularrage, 1997 |
Study design and target population | Ecologic group study.
Queens & Brooklyn, New York, NY. |
Intervention | Educational campaign designed to supplement
statewise helmet law for children 1-14 years (June 1994).
Campaign for 1 week in Queens.
4 components: educational packet, perscriptions for helmets
by pediatricians, newspaper ads, "bicycle helmet day" at medical
center, discount coupon & prizes. |
Outcomes | Observed helmet use in children 1-14 before education
campaign & legislation (May 1994) and after (July-August 1994). |
Results | Helmet use increased in study group
from 4.7% (13/276) to 13.9% (44/316) p<.001.
Helmet use decreased in control group from 5.6% (19/342) to
4.2% (13/312) p=.10. |
Study quality and conclusions | Statistically significant increase
in helmet use in area receiving educational campaign.
Legislation alone is inadequate in multiracial population. |
Author | Ekman, 1997 |
Study design and target population | Ecologic-mixed study; Skaraborg County,
Sweden 1987-1993.
Children under 15 years with focus on pre-school group. |
Intervention | Multifaceted bicycle-helmet campaign,
included discount helmets.
Various other local bicycle-helmet campaigns complemented by national
information campgain. |
Outcomes | Hospital discharge data from Swedish
national registry.
E codes & ICD-9 codes used to define bicycle related injuries,
concussions, & other head injury. |
Results | Linear regression analysis used to
calculate rates of hospitalized bicycle head injuries.
Annual decrease of 3.4% for children compared to increase of 4.7%
in elderly.
Concussions in helmet wearers 1/3 fewer than non-wearers.
Children <15; 59% decrease in all bike injuries (Skaraborg),
43% decrease in head injuries, 32% decrease all bike injuries (Sweden).
Adult helmet use 9% children's helmet use 90% (preschool),
31%-45% for older children. |
Study quality and conclusions | Other research shows increases in
bicycling helmet use and improvement in cycling environment.
Authors favor adding legislation. |
Author | Mock, 1995 |
Study design and target population | Time series study.
Bicycle crash injuries admitted to
Level 1 trauma center 1986-1993.
Harborview Medical Center, Seattle,
Washington. |
Intervention | Seattle bicycle helmet campaign- a
multifaceted community campaign, 1986-1993. |
Outcomes | Head AIS score, length of stay (LOS),
length of ICU stay, deaths. |
Results | Proportion of severe brain injuries
(AIS 4, 5) as a proportion of all bike injuries declined yearly. (29% in 1986
to 11% in 1993).
LOS decreased by 0.33 day/year (p=.05); ICU stay decreased
0.17 day/year (p=.02).
Slight increae in bike crash admissions.
Observed helmet use in community increased from 5% in 1987
to 62% in 1993. Helmeted bike crash admissions increased from 0% to 32% over
period. (p=0.01). |
Study quality and conclusions | Trauma center data, not population
based.
Multifaceted community campaign increased helmet use and decreased
severe brain injuries. |
Author | Rouzier, 1995 |
Study design and target population | Ecologic time-trend study.
Target population, elementary school children and families.
(n=8600).
Grand Junction, Colorado. |
Intervention | "Headstrong West", as multifaceted
bicycle helmet campaign including discount helmets & lower retail prices. |
Outcomes | Observed helmet use at baseline, 1992 and after campaign
1993, 1994.
23 sites. |
Results | Increase in helmet use for 3 age groups:
Age 5-13, 5.6% to 11.3%, (p=.004). Age 14-21, 3.2% to 25%, (p=<.001). Age
>21, 28.9% to 47.1%, (p=.2).
6400 helmets sold in 2 year period.
Program a successful community health education teaching model
for family practice physicians and medical students. |
Study quality and conclusions | Observation periods, short, few riders,
observed.
Participation of local retailer important.
Campaign was modified and is continuing.
Local legislation not considered; population resists any legislation. |
Author | Wright, 1995 |
Study design and target population | Non-random controlled trial.
3 junior and 3 senior high schools in urban and rural areas
of Washington state. |
Intervention | Think First head and spinal cord injury
preventionprogram (A one-hour school assembly designed to provide students with
basic information about the frequency and causes of TBI and SCI, and is based
on the health belief model).
Discusses use of bike helmets. |
Outcomes | Observed bike helmet use.
Observations done at 1 high school , 1 middle school and i control
school. |
Results | No change in bike helmet use. Very
fre bike riders. |
Study quality and conclusions | One time intervention covering a wide
variety of topics was too diffuse and relied solely on education.
Similar evaluations of Think First have not documented changes in
behavior. |
Author | Farley et al., 1996 |
Study design and target population | Non-equivalent control group study
5-12 year-olds in one of 50 municipalities
of Quebec, 1991-1993 |
Intervention | 4-year helmet educational program including poster
contests, role playing, and safety pamphlets in schools; helmet coupons and
awards for helmet use. |
Outcomes | Observed rates of helmet use on local streets, bicycle
paths, and school roads.
Multiple logistic regression used to examine
adjusted (age, year of observation, cycling circumstance, municipality type)
risk estimates of factors associated with helmet use. |
Results | Helmet use rates increased for both control (3.9% to
14.3%, p<0.0001) and intervention (9.6% to 32.5%, p<0.0001) sites from
1991 to 1993.
Intervention groups significantly associated
with helmet use (p<0.001).
Regardless of where observed, higher
SES groups were three times as likely to wear helmets than low SES groups.
Intervention most effective for local street helmet use, regardless of SES
(Adj. OR=3.39, 1.66-6.91). |
Study quality and conclusions | Design allowed for interaction terms in logistic regression
model.
SES determined by proxy; all children within
one group assigned same SES (although this would underestimate true risk).
Educational program increased helmet
use.
Helmet use much greater among high
SES groups. |
Author | Jaffe et al., 1996 |
Study design and target population | Interrupted time series study
Bicycle riders in Israel, 1993 and 1994. |
Intervention | Two-month national media campaign |
Outcomes | Observed helmet use in 15 cities. |
Results | Baseline helmet use (7.9%) increased significantly
after media campaign (14.8%, p<0.01).
Helmet use increased significantly from 14.6% (before)
to 19.4% (after) among children less than 10 years old (p<0.001). |
Study quality and conclusions | No mention of inter-rater reliability.
No control for any possible confounders (gender, city);
no significant increase in female riders wearing helmets. |
Author | Hatziandreu et al., 1995 |
Study design and target population | Non-equivalent control group study
Cost-effectiveness review of three bicycle
helmet intervention studies. |
Intervention | Bicycle helmet use through legislation (Howard Co.,
MD), community-based education (Seattle, WA), and school-based education (Oakland
Co., MI). |
Outcomes | Deaths prevented, head injuries prevented, and years
of life saved. Cost-effectiveness, expressed as the ratio between [cost of program
+ cost of helmets - savings in health care] and [health outcome with program
- health outcome without program].
Health outcome is an expression of number
of cases avoided, calculated from expected injuries and pre- and post-intervention
helmet use prevalences. |
Results | Legislative and community-based interventions had similar
cost-effectiveness of avoiding one head injury (approx. $37,000).
School-based intervention had cost-effectiveness
of avoiding one head injury of approximately $145,000.
Percentage of children wearing helmets
increased significantly in all three programs:
Howard Co.: 4% to 47%
Seattle, WA: 5% in 1987 to 33% in 1990
Oakland Co.: 2% to 8% |
Study quality and conclusions | Helmet price has highest impact on cost effectiveness.
Legislative intervention resulted in almost immediate
increase in observed helmet use.
Study assumed constant observed effectiveness;
studies may not be entirely comparable. |
Author | Liller et al., 1995 |
Study design and target population | Non-equivalent control group study
School-aged children (K-2) in participating
(n=9) Hillsborough County, Florida schools. |
Intervention | Helmet discounts and education program (helmet use,
safety town, egg drop, etc.) |
Outcomes | Observed helmet use in intervention and control schools;
helmet sales in intervention schools. |
Results | Pre-intervention (baseline) use of helmets 8.5% in
all schools; post-intervention helmet use in intervention schools (32%) greater
than in control schools (10%), p<0.01 (21% overall helmet use for all schools
in study).
From pre-intervention data, children more likely to
wear helmet if child companion wore a helmet (p<0.01, no data given).
Significant increase in percentage
of helmeted children seen riding with helmeted peers (before: 9.3%; after:
26%; p=0.02).
Children over four times more likely
to wear helmet if in intervention school (OR=4.44, 2.81-7.07). |
Study quality and conclusions | No pre-intervention evaluation of helmet sales.
Which portion of MORE HEALTH intervention is most important
in increasing helmet use?
Schools matched on location and median
family income; intervention and control schools selected such that communication
between them was minimal. |
Author | Parkin et al., 1995 |
Study design and target population | Non-equivalent control group study
East York, Ontario, school-aged children (5-14
yr.; K-8), June-Oct, 1992. |
Intervention | Bike helmet subsidy program among low-income school
children. Education program in schools included bike rally, assemblies, posters,
and Be Bike Smart Week. |
Outcomes | Observed bicycle helmet use stratified by site (schoolyard
v. all sites) and income (high v. low). |
Results | Helmet use increased significantly within all three
schools from 1990 to 1992:
education/subsidy schools, 4% to 19%
education only schools, 0% to 15%
control schools, 4% to 15%
all schools, 3% to 17%
(all p<0.001).
No significant differences in helmet
use between three schools. |
Study quality and conclusions | Removal of economic barriers successful based on helmet
sales, but purchase of helmet did not ensure its use.
Observations made in August and September of 1990 used
as baseline data; assumption that 1992 intervention independent from 1991
intervention may not be valid. |
Author | Morris et al., 1994 |
Study design and target population | Non-equivalent control group study
Elementary through college students bicycling
to school in Barrie, Ontario, Canada, 1990 and 1991 |
Intervention | Community-wide helmet education program that included
posters, local media coverage, police officer visits, and bulk helmet purchase
discounts. |
Outcomes | Observed rates of helmet use on school grounds. |
Results | Among elementary school children only, helmet use rates
increased significantly from 1990 (3.4%) to 1991 (18.3%) (p<0.001).
No change in baseline helmet use seen among
either secondary children (4.9%) or college students (16.2%).
Girls are twice as likely to wear helmets
than boys (OR=2.11, 1.27-3.51). |
Study quality and conclusions | Community-wide program effective in increasing helmet
use among elementary school-aged children.
No observations after program complete;
no control group/city used for comparison.
Secondary school students used as observers–validity
uncertain. |
Author | Rivara et al., 1994 |
Study design and target population | Interrupted time series study
Seattle children between 5 and 14 years annually
from 1987 through 1992 |
Intervention | Community-wide helmet education campaign (including
media, public service announcements, health fairs, bike rodeos, school and youth
programs, and discount coupons). |
Outcomes | Observed bicycle helmet use and incidence of bicycle-related
injuries |
Results | Helmet use increased from 5.5% in 1987 to 40.2% in
1992 (p<0.0001).
Bicycle-related head injuries decreased by
66.6% in 5-9 year-old and 67.6% in 10-14 year-old members of Seattle HMO.
(p<0.0001)
In HMO population, helmet use increased
49.7% in 5-9 year-olds and 33.4% in 10-14 year-olds. (p<0.0001)
Helmet use was highest for children
riding with helmeted adults (94.7%) |
Study quality and conclusions | Annual educational campaign is associated with continued
increase in helmet use and a decrease in bicycle-related injuries among members
of Seattle-based HMO.
Gradual plateauing of helmet use may indicate that
legislation may be necessary to boost helmet use rates.
Very difficult to control for expanding
effect of multifaceted campaign, although only discount coupons suspected
to act significantly alone. |
Author | Rourke, 1994 |
Study design and target population | Non-equivalent control group study
Schools in Goderich and Kincardine, Ontario,
Canada, September 1991 to May 1993 |
Intervention | School-based helmet education (posters, assemblies,
guest speakers, videos, local media coverage, and bike rodeo) and helmet subsidy
campaign.
Goderich community had (unexpected) opportunity
to examine effect of child fatality. |
Outcomes | Self-reported and observed helmet use. |
Results | Fatality associated with a significant increase in
observed helmet use, from 12.8% to 51.8% (p<0.001).
Children in Goderich community (exposed to more intensive
campaign and fatality) were over 5 times as likely to wear a helmet when cycling
compared to Kincardine community (crude OR=5.37, 3.76-8.56). |
Study quality and conclusions | No details given regarding observation sites, times,
etc. Two observers’ numbers were merely averaged to give rates.
Only about 28% to 44% of school-children ride
to school.
Despite fatality’s effect, observed
helmet use never rose above 50% level. |
Author | Dannenberg et al., 1993 |
Study design and target population | Non-equivalent control group study
Comparison of three different interventions
in separate Maryland counties. |
Intervention | Bicycle helmet use through education and legislation
(Howard County), education only (Montgomery County), and no intervention (Baltimore
County). |
Outcomes | Self-reported helmet use during 1990 (before interventions)
and 1991 (after interventions).
Observed bicycle helmet use before (July 28,
1990) and after (May 4, 1991) interventions were implemented.
(Observed data taken directly from
Cote et al., 1992.) |
Results | Education with legislation (Howard County) significantly
more likely to increase observed helmet use (from 4% to 47%) than either education
alone (from 8% to 19%, Montgomery County; OR=3.88, 1.74-8.74) or no intervention
(decrease from 19% to 4%, Baltimore County; OR=20.9, 4.48-190.5).
Weighted by county population, same pattern is seen
in observed helmet use (c 2 for trend = 21.7, 2df, p<0.0001) |
Study quality and conclusions | Counties may not be entirely comparable (median family
income in Baltimore County–$40,600–is less than median family income
in other two counties–approximately $58,000).
Observations made only once, in different
seasons and at non-randomly selected sties.
No controlling for demographic differences
across counties due to small number of observations. |
Author | Parkin et al., 1993 |
Study design and target population | Non-equivalent control group study
East York, Ontario, school-aged children (5-14
yr.; K-8), Aug-Sep, 1990 and June-Oct, 1991. |
Intervention | Helmet education through community (bike rally and
posters) and schools (guest speaker, assemblies, and helmet coupons). |
Outcomes | Observed bicycle helmet use stratified by site (schoolyard
v. all sites) and income (high v. low). |
Results | Significant fourfold increase in observed helmet use,
from 3.4% to 16% (p<0.001).
Hi-income/schoolyard:
Significant increase in helmet use
for both intervention (from 4% to 48%) and control schools (from 4% to 8%)
(p<0.001); intervention significantly better than control (p<0.001).
Lo-income/schoolyard:
Significant increase in helmet use
for both intervention (from 4% to 8%) and control schools (from 3% to 14%)
(p<0.001); intervention significantly WORSE than control (p=0.01). |
Study quality and conclusions | Low-income schools discouraged riding to school; small
numbers of observed riders at low-income area schools; ratio of schoolyard to
recreational observations differed dramatically by income group.
Intervention and control schools’ areas
overlapped substantially.
No assessment of annual bike rally’s
impact on control schools. |
Author | Towner et al., 1992 |
Study design and target population | Non-equivalent control group study
Public school-based children (K-5) in participating
(n=6) Wasau, Wisconsin |
Intervention | Five-day education program advocating helmet use, including
helmet coupons, poster contest, physician visit to classrooms, and egg-drop
demo. |
Outcomes | Parental self-report on bicycle safety attitudes; observed
helmet use. |
Results | No significant increase in helmet use in control (from
3.5% to 4.2%) or intervention schools (from 0.5% to 2.6%).
Parental awareness of helmet benefit significantly
increased in intervention schools (70% to 95%, p<0.05). |
Study quality and conclusions | Baseline rates between control and intervention schools
seem to be different.
Low response rate (10%) from parents seriously
affects survey conclusions. |
Author | Morris et al., 1991 |
Study design and target population | Randomized controlled trial
Three K-8 schools in Barrie, Ontario, Canada,
Fall 1988 and Fall 1989. |
Intervention | School-based helmet education and subsidy campaign,
including classroom instruction, poster contest, safety pamphlet, and helmet
coupons. |
Outcomes | Observed helmet use before and after intervention at
control school, education only school, and education and subsidy school. |
Results | No helmet use seen in any of three schools before campaign.
Helmet use increased significantly only among education/subsidy
school from 0% to 22.2% (p=0.036). Helmet use increase was significantly different
from control school (p=0.019).
Control and education only school showed
no helmets worn either before or after campaign. |
Study quality and conclusions | Education intervention alone is not sufficient in increasing
helmet wearing; concurrent subsidy program is needed to increase helmet use
rates.
Small numbers of children riding bicycles
(about 4% of student population).
Authors claim parents may have discouraged
children from riding in intervention schools, but that is not the case for
the education only school (25 cyclists before, 73 cyclists after). |
Author | Bergman et al., 1990 |
Study design and target population | Ecological study
Bicycle riders 5-12 years old in Seattle |
Intervention | Three-pronged educational campaign advocating helmet
use:
(1) raising parental awareness through mass media and
local physician exposure,
(2) lowering helmet cost through increase
in demand, and
(3) inducing children to wear helmets
through professional athletes’ visits to schools and bike rodeos. |
Outcomes | Helmet discount coupon redemption and observed use
of bicycle helmets. |
Results | Overall coupon redemption was almost 5% (extremely
high for product promotion).
Helmet use increased from 5% to 16% in Seattle;
a comparison city (Portland, OR) showed an increase in helmet use from 1%
to 3% over the same period. |
Study quality and conclusions | Mass media used effectively to proliferate safety messages;
‘victim’ stories seemed to have powerful impact.
Prices of safety helmets lowered enough for more potential
buyers.
Narrow focus of campaign (5-12 year-olds;
attempt to increase helmet use only) helped in study’s success. |
Author | Stutts et al., 1990 |
Study design and target population | Non-equivalent control group study
Fourth and fifth grade students in four elementary
schools in Raleigh, NC, spring and summer 1990 |
Intervention | School-based bicycle safety campaign, covering correct
bike helmet fit and use, bike size and mechanical check, and riding behavior
(hand signals for stopping and turning; when and where to stop/turn). |
Outcomes | Self-reported and observed bicycle riding behavior
between two intervention and two comparison schools. |
Results | Baseline only survey showed helmet ownership 12% among
intervention schools and 14% among comparison schools.
90% of children tested in intervention schools could
fit and use helmet properly,
Among intervention schools, vast majority
of children demonstrated proper riding skills in all areas. Among comparison
schools, less than 50% could properly signal left turn, less than 20% right-turn,
and less than 14% stop. |
Study quality and conclusions | All intervention school children completed survey;
only 70% response rate from comparison schools.
No reporting of actual data from intervention
schools; terms such as ‘virtually all’ and ‘vast majority’
make for very imprecise risk assessments. Intervention school riding performance
is archived on video, however.
Study presents a good attempt at evaluating
which components of riding safety are feasible in a school setting. Actual
data needed to make valid conclusions. |
Author | DiGuiseppi et al., 1989 |
Study design and target population | Non-equivalent control group study
Seattle and Portland children 5-15 years observed
riding bicycles in May and September of 1987 and 1988 |
Intervention | School and community-based helmet education campaigns:
(1) raising parental awareness through mass media and
local physician exposure,
(2) lowering helmet cost through increase
in demand, and
(3) inducing children to wear helmets
through free baseball tickets and bike rodeos. |
Outcomes | Observed rates of helmet use in Seattle and Portland. |
Results | Adjusted helmet use in Seattle increased (4.6% to 14%)
significantly more than in Portland (1.0% to 3.6%) 16 months after intervention
(p<0.001).
Increase in helmet use among low-income Seattle
children (9.0%) significantly greater than increase among Portland children
(2.2%), p=0.012.
Strongest association with helmet use
by children was biking with helmeted adults (adj. OR=28.5, 18.5-44.1) or helmeted
children (adj. OR=22.2, 14.3-34.4). |
Study quality and conclusions | Analysis took non-random assignment of control and
intervention cities into account.
Association with income may be an artifact
of travel; effects should be similar in both cities and would bias results
toward null.
Community-based campaign most likely
had effect of reaching all SES levels, making access to helmets easier for
lower-income households. |
Author | Wood and Milne, 1988 |
Study design and target population | Interrupted time series study
School-aged children and adult commuter cyclists
in Melbourne, Australia from 1983 through 1985. |
Intervention | Publicity campaign involving television and radio commercials,
helmet rebates, newspaper articles, school-based education. |
Outcomes | Bicycle helmet wearing surveys of school-aged children
and adult commuters.
Head injuries among bike-car incidents. |
Results | Helmet-wearing rates increased significantly after
1984 campaign for all groups. For primary schools children, from 4.6% in 1983
to 38.6% in 1985; secondary school children, from 1.6% to 14.0%; commuters,
from 26.1% to 42.0%.
Significant reduction (p<0.01) in head injury, comparing
rates before and after 1984 campaign. |
Study quality and conclusions | No causal association shown between publicity campaign
and head injury decrease. |
Author | Bercham et al., 1987 |
Study design and target population | Interrupted time series study
Bicycle riding residents of Madison, Wisconsin,
April-June, 1986 |
Intervention | Community-based educational bike safety campaign, including
television public service announcements, bicycle helmet rebates, and radio and
television exposure. |
Outcomes | Observed bicycle helmet use before and after campaign. |
Results | Observed bicycle helmet use increased significantly
from 15.0% before campaign to 19.2% after campaign (p<0.05).
Self-report telephone survey indicated newspaper as
most likely source of bike safety exposure.
Mean increase in bike helmet sales
among 10 dealers was 92%. |
Study quality and conclusions | A broad campaign ranging from political to commercial
involvement can achieve a significant increase in helmet use.
No information on duration of increase available.
Time of observations (before: April,
after: June) may be affected by large student population in Madison. Possible
confounding by age of cyclists/occupation. |
Summary of helmet education interventions
Interventions based on increasing helmet
use through education have been successful when done properly. From the studies
reviewed, an important element in intervention programs is the participation of
parents. The studies by Liller15 and DiGuiseppi25 provide further evidence that children are more likely to
wear helmets if their riding partners (whether adults or children) are also wearing
helmets. It appears that the most effective education interventions have a broad
scope that includes media announcements, bike rodeos, and helmet discounts. Helmet
subsidies are effective in increasing helmet use among low SES children. Only one
study21 examined whether emphasizing proper riding behavior would
prove beneficial. Unfortunately, the data from that study do not allow any comparison
between intervention and control schools.
Injury prevention strategies that have relied solely on education, even when well
done, have often b etween unsuccessful. Those injury prevention strategies that
have produced the best results have used a combination of education with other approaches
such as legislation, regulation, or lowering barriers to implementation. These include
child seat rest r aints, poisoning prevention, motorcycle helmet use, legislation,
and bike helmets. In addition, successful programs have usually been narrowly focused
on single issues and have offered specific interventions. Economic incentives are
particularly importa nt and have been a part of many successful helmet campaigns.
Recommendations on helmet education programs
Helmet education interventions should be
based on research data, focus on a carefully selected target age group, include
the use of a bicycle helmet (through discounts or donation) in addition to other
tactics, and have a built-in evaluation component. A community-wide intervention
that has these four factors can give an intervention the best chance for success
and possibly provide the basis for local, state, and nationwide campaigns. Campaigns
that are too narrowly focused (providing helmets in emergency departments, schools,
and from pediatric offices) have not been particularly successful23,29,30 in reducing injuries.
Recommendations for future research
While the studies cited above
provide good evidence that helmet education interventions can increase the helmet
usage rates among children, future studies that examine the duration of such an
increase are needed. The study by Rivara and colleagues22 found that the increase in helmet use eventually
plateaued with annual continuation of its education program, suggesting that legislation
might be necessary to increase rates any further. Randomized controlled trials may
no longer be feasible given the widespread publicity of helmet use and its effectiveness
in preventing head injury (one randomized trial by Morris and colleagues20 showed helmet education to be effective in increasing
helmet use among children). Future studies should determine which elements of an
educational program are most beneficial in getting children to wear their helmets.
The best way to do such a study is to use either an interrupted time series design
or a non-equivalent control group design. Relevant data (through observation of
helmet use, helmet sales, injury rates, or some combination) should be collected
at least twice before and after the intervention. Confounders such as gender, income,
and education of family should be measured as well in order to provide an unbiased
estimate of a helmet education intervention’s success. The Stutts study21 provides a good template of such a study.
In general teens have lower levels of helmet use than other age groups.
Innovative and different educational campaigns should be developed and evaluated
for this age group.
Harborview Injury Prevention and
Research Center ©1997 University of Washington Last
updated: 09-July-2001
^ Back to Top
| |
| 
| 