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