Evaluation of a Subsidy Program to Increase Bicycle Helmet Use by Children of Low-Income Families

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Evaluation

of

a Subsidy

Program

to Increase

Bicycle

Helmet

Use

by

Children

of

Low-Income

Families

Patricia C. Parkin, MD, FRCPC*; Xiaohan Hu, MB, MPH,

PhDII;

Laura

J.

Spence, BScN;

Katherine E. Kranz, BAAN; Linda C. Shomtt, BScN, MEdIJ; and David E. Wesson, MD, FRCSC

ABSTRACT. Objective. We have previously shown that an educational program was not effective in increasing

bicycle helmet use in children of low-income families.

The objective of this study was to evaluate a combined

educational and helmet subsidy program in the same

population, while controlling for secular trends. The

sec-ondary objective was to complete a third year of

survey-ing children’s bicycle helmet use throughout the study

community.

Design. A prospective, controlled, before-and-after

study.

Subjects. Bicycling children 5 to 14 years of age from

areas of low average family income.

Setting. A defined geographic community within a

large urban Canadian city.

Intervention. In April 1992, students in three schools

located in the area of lowest average family income were

offered $10 helmets and an educational program; three

other low-income areas served as control areas.

Main Outcome Measure. Helmet use was determined

by direct observation of more than 1800 bicycling

children.

Results. Nine hundred ten helmets were sold to a

school population of 1415 (64%). Reported helmet

own-ership increased from 10% to 47%. However, observed

helmet use in the low-income intervention area was no

different from the rate in the three low-income control

areas (18% versus 19%). There was no difference in the

trend in helmet use during the period of 1990 through

1992 in the intervention area (4% to 18%) compared with

the control areas (3% to 19%). Helmet use rates from all

income areas have increased from 3.4% in 1990, to 16% in

1991, to 28% in 1992. In 1992, helmet use in the

high-income areas was 48% and in the low-income areas was

20%.

Conclusions. There has been a trend toward increasing helmet use in all income areas during the 3-year period.

Despite encouraging helmet sales and increases in

re-ported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy

program in increasing helmet use in children residing in

areas of low average family income. Strategies to increase

helmet use in children of low average family income

remain a priority. Pediatrics 1995;96:283-287; bicycle

hel-met, low-income families, bicycle-related head injury; sub-sidy program.

From the Departments of *pediatrics and Surgery and the §Injury Preven-lion and Research Program, The Hospital for Sick Children, Toronto; the

IlDepartment of Preventive Medicine and Biostatistics, University of

To-ronto; and #{182}TheEast York Health Unit, East York, Ontario, Canada.

Received for publication Aug 15, 1994; accepted Nov 7, 1994.

Reprint requests to (P.C.P.) Department of Pediatrics, The Hospital for Sick Children, 555 University Aye, Toronto, Ontario, Canada M5G 1X8. PEDIATRICS (ISSN 0031 4005). Copyright © 1995 by the American

Acad-emy of Pediatrics.

Bicycle-related trauma accounts for at least 10% of all injury deaths in school-age children, 5 to 14 years of age.1 In the province of Ontario, bicycle-related

injuries account for 15% of all pediatric trauma

deaths, and 96% of these are caused by head and

neck injuries.2 Bicycle-related head injuries are also a

major reason for emergency department visits and

hospital admissions.3-6 Bicycle helmets can reduce

the risk of head injury by 50% to 85%. However, it

has been estimated that without intervention, fewer

than 5% of children wear them.105

Health-promo-tion activities to increase bicycle helmet use have

been carried out in several settings. Physician and

hospital-based promotion has met with varied

suc-cess,1618 as have studies of school-based

promo-tion.15’19 Community-based13’24 promotion has been

shown to be effective, as has legislation.20

In 1990, we studied bicycle helmet use in

school-age children in two Ontario communities. We found

that direct observation of bicycling children was an

accurate measure of bicycle helmet use and

demon-strated a helmet use nate of only 3#{149}5%#{149}26In 1991, we evaluated the effectiveness of a school-based educa-tional program in increasing children’s bicycle hel-met use.27 In a defined geographic area, 2

high-in-come and 2 low-income schools received the

intervention, and 18 schools served as control

schools. Helmet use in the high-income intervention

area increased from 4% to 36%, which was

signifi-cantly greater than the increase in the high-income

control area, from 4% to 15%. In the low-income

intervention area theme was a more modest increase, from I % to 7%, which was not significantly different

from the increase in the low-income control area,

from 3% to 13%. We concluded that the school-based

educational program was highly successful among

children from high-income families, but additional or alternate strategies are necessary for increasing

helmet use among children of low-income families.

It has been suggested that economic barriers may

prohibit the purchase of bicycle helmets by

low-income families.10 The primary objective of this study was to evaluate the effectiveness of a school-based

educational program plus a helmet subsidy program

in increasing helmet use among school-age children,

5 to 14 years of age, from low-income families. The

secondary objective of this study was to continue to

survey children’s bicycle helmet use throughout the

Borough of East York.

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Study Community

METHODS

The project was conducted in the Borough of East York, in

collaboration with the East York Health Unit, from April to Octo-ber 1992. East York is a borough of metropolitan Toronto in south central Ontario with a total population of approximately 100 000

and a school-age population of approximately 10 000. For census purposes, East York had been divided into 21 census tracts for which sociodemographic data were available through the 1986 Census from Statistics Canada. The census tracts were grouped into seven areas, which were geographically distinct in that their boundaries-expressways, ravines, railway tracks, and hydroelec-tric power lines-were natural barriers to travel for child cyclists. These natural barriers helped minimize misclassification, that is,

classifying a cyclist in an area in which he or she did not reside. The seven areas were ranked by average family income and la-beled areas I through 7. For the purposes of analyses, the seven areas were grouped into two high-income areas (areas 6 and 7),

one middle-income area (area 5), and four low-income areas (areas I through 4). Six elementary schools were located in the high-income areas, 4 in the middle-income area, and 13 were located in the low-income areas. In 1990, we studied baseline helmet use rates.26 In 1991, the year before this study, 2 high-income schools from area 7 and 2 low-income schools from area 3 received an educational helmet promotion program.27

Intervention

Three low-income schools, encompassing kindergarten to grade 8 (1415 children 5 to 14 years of age), were selected from area 1.These schools received the helmet promotion and subsidy

program and were identified as the intervention schools. In each intervention school, an educational week was identified as Be Bike Smart week in April 1992. This was modeled after the program developed for our 1991 project and is described in greater detail elsewhere.27 In addition to the educational and promotional aspects of the program, helmet sales and fitting were arranged at the school, and high-quality helmets were sold at $10 (retail, $40) by a local retailer. Children and/or their parents purchased helmets at their own discretion.

Study Design

The primary outcome measure, helmet use, was measured by means of direct observation as described previously.26’27 The

meth-ods used to determine demographic data, to select observational

sites, and to document observations were identical to those used during the 1990 and 1991 observational surveys. Briefly, observa-tional sites were selected in each of the seven East York areas. These included the schoolyards of elementary and middle schools (kindergarten to grade 8), parks, major intersections, and residen-tial streets. All schools and parks in each area were observed. Five each of major intersections and residential streets were randomly selected from each area. Observers were trained to collect reliable observational data (age, gender, helmet status, and riding com-panionship) as previously described.26 Children were included in

the observations if they seemed to be between the ages of 5 and 14 years and were riding two-wheeled bicycles. Observations of adults, younger children, and children riding any other type of vehicle were excluded.

Observations made in August and September 1990 were con-sidered to represent the baseline rates of helmet use before any interventions.26 Observations made from June through October 1991 represent rates of helmet use after the school-based educa-tional program in one high-income area and one low-income area and have been previously reported.27 To evaluate the effectiveness of the subsidy plus the education program, postintervention ob-servations were made in June through October 1992. Children at

only the schools with intervention programs completed preinter-vention and postintervention questionnaires regarding bicycle and helmet ownership.

Area I was identified as the intervention area, because three of the schools located in this area received the subsidy plus educa-tional intervention in 1992. Areas 2 and 4 were identified as the

control areas, because the schools located in these areas did not receive the intervention. Area 3 was identified as the

education-only control area, because two of the schools received the school-based educational program in 1991 but did not receive the subsidy

program. Areas 5 through 7 were identified as the middle- and high-income areas, which did not receive any interventions in

1992.

Ethics

The study received ethics approval from the Hospital for Sick Children Research Ethics Board, the East York Board of Education, and the Metropolitan Separate School Board.

Statistical Analysis

Descriptive statistics for each area within East York were ob-tamed from the 1986 Statistics Canada Census report. Helmet use in the preintervention and postintervention periods, and in the intervention and control areas, was compared using analysis.

P < .05 was considered significant. A sample size of 175 observa-tions per area was calculated to be adequate to detect a doubling in helmet use in the low-income areas from the 1991 level 12% or

a doubling in the entire borough of East York from the 1991 level

of 16%, with a type I error of 0.05 and a power of 0.90.

Study Community

RESULTS

The low-income intervention and control schools

had similar census data profiles with respect to the

incidence of lone-parent families, owned

dwell-ings, university education, English as the mother

tongue, low-income families, and average family

income (Table 1). Low-income schools differed

from high-income schools with respect to these

same variables.

Helmet Purchase and Ownership

Nine hundred ten helmets were sold in the three

low-income intervention schools. This represented approximately 64% of 1415 students enrolled at these schools. By questionnaire, 80% of children indicated

that they owned bicycles. Ten percent of children

indicated that they owned helmets before the

inter-vention, and 47% indicated that they owned helmets

after the intervention (P < .001).

Helmet Use

During the 5-month period from June through

Oc-tober 1992, 1861 observations were made, of which

I 106 were from the four low-income areas. Overall

helmet use increased in the four low-income areas

from 2% in 1990 to 20% in 1992 (P < .001). However, theme was no difference in helmet use mates between

the area that received the education plus subsidy

intervention compared with the control areas (18%

versus 19%; P = NS). Only the low-income area that

had received the education-only intervention in 1991

had a higher rate of helmet use (26% versus 18%;

P = .04) (Table 2).

TABLE 1. Census Data Profiles of Areas Surrounding

Inter-vention and Control Schools

Low-Income High-Income All Schools

.

Intervention Control Schools Schools

Lone-parent families 14% 17% 12%

Owned dwellings 39% 33% 60%

University degree 10% 10% 26%

Mother tongue English 63% 74% 87%

Incidence of low income 15% 13% 4%

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TABLE 2. Observed Helmet Use in Intervention and Control

Areas (All Sites) in Areas of Low Average Family Income

Preintervention, Postintervention, P

1990 1992 value

All areas 2% (527)* 20% (1106) <.001

Area 1

1992 Intervention area 4% (129) 18% (335) .04

(education plus subsidy) Areas 2 and 4

Control areas 3% (246) 19% (524) <.001

Area 3

1991 Intervention area 1% (152) 26% (229) <.001

(education only)

* Numbers in parentheses represent number of children observed in each category.

Similarly, an analysis of observations made at

schoolyards only shows that overall helmet use

in-creased in the four low-income areas from 3% in 1990

to 17% in 1992 (P < .01). However, theme was no

difference in helmet use rates between the area that

received the education plus subsidy intervention in

1992, the control areas, and the area that had

me-ceived the education-only intervention in 1991 (15%

versus 15% versus 19%; P = NS) (Table 3).

Three-Year Trend in Helmet Use

Helmet use throughout the borough and in all

income areas has increased significantly during the

3-year period of 1990 through 1992 (Figure ). Overall

helmet use rates have increased from 3.4% in 1990 to

16% in 1991 to 28% in 1992 (P < .001). In 1992, helmet use in the high-income areas was 48%, in the

middle-income area was 13%, and in the low-income areas

was 20%.

Associations With Helmet Use

Approximately twice as many boys as girls were

observed riding bicycles (male-to-female ratio, 2.5:1).

In the high-income areas, helmet use was equal

among boys and girls (37% versus 41%; P = NS).

However, helmet use by boys in low-income areas

was significantly less than by girls in the same areas (16% versus 30%; P < .001).

In low-income areas, helmet use in schoolyards

did not differ significantly from helmet use at

recre-ational sites (16% versus 21 %; P = NS). However, in

high-income areas, helmet use was significantly

greater in schoolyards than at recreational sites (55% versus 26%; P < .001).

TABLE 3. Observed Helmet Use in Intervention and Control

Schoolyards in Areas of Low Average Family Income

1990 1992 P Value

All schools 3% (95)* 17% (227) <.001

Area 1

1991 Intervention schools 4% (23) 19% (89) <.001

(education plus subsidy)

Areas 2 and 4

Control schools 4% (55) 15% (105) <.001 Area 3

1992 Intervention schools 0% (17) 15% (33) <.001

(education only)

* Numbers in parentheses represent number of children observed in each category.

Children were more likely to wean helmets when

riding with adults than when riding alone or with

other children; this trend was significant in both

income areas (P < .001). However, in the low-income

areas fewer children wore helmets when riding with

other children than in the high-income areas (16%

versus 37%; P < .001). Children from the high-income

areas were more likely to wean helmets when riding

alone than those from the low-income areas (38%

versus 19%; P < .001). Children were more likely to

wear helmets when riding with other helmeted

chil-dren (high income, 80%; low income, 63%), and they

almost always wore helmets when riding with at

least one helmeted adult (high income, 89%; low

income, 83%). The positive influence of helmeted

peers and adults was significant in both income areas

(P < .001).

DISCUSSION

We have shown previously that a school-based

educational program is very successful in increasing

bicycle helmet use among children residing in areas

of high average family income. However, the same

program was not effective in children residing in

areas of low average family income.27 It has been

hypothesized that economic barriers may play a

large mole in the low mates of helmet use among

children of low average family income. In the current

study, we attempted to overcome this economic

ban-miem by offering helmets at a significantly discounted

price. Despite encouraging helmet sales and

in-creases in reported helmet ownership, the results of

this observational study do not support the

effective-ness of this helmet subsidy program in increasing

helmet use by children residing in areas of low

av-erage family income. That is, the removal of

eco-nomic barriers did result in helmet purchase but did not ensure helmet use.

One of the limitations of community-based studies such as this is the difficulty in controlling for

con-tamination. Although the three schools with

inter-vention programs were targeted for the helmet

sub-sidy program, it was not possible to limit helmet

sales to the children attending these schools for eth-ical reasons. It is possible that some of the 910

hel-mets sold were to children residing in other

low-income areas. However, it is very unlikely that

helmet sales to children in the low-income control

areas would be significant enough to account for the

lack of difference in observed helmet use between

the intervention and control areas. Another limita-tion is the possibility that cycling children could be

observed on more than one occasion. However, as a

child’s behavior (that is, helmet use) may differ on

different occasions, each observation was treated as

an independent observation.

The 3-year observational survey demonstrates

some interesting findings about the various income

groups. Helmet use increased more significantly in

the low-income, education-only area (1991 interven-lion) compared with the low-income education-plus-subsidy area (1992 intervention). This may have been a result of the longer time period from intervention

to evaluation. Low-income boys always have

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40

w HhSES

. Mdle SES

-a--- LOW SES

p

AllEastYork

Figure. Trends in observed helmet

use by average family income, 1990

through 1992.

10

All East York

Low SES

Midd SES

l90 19l

Year

192

50

Hh SES

4530

‘a

45

E 20

0

onstrated the lowest rates of helmet use, suggesting

that behavior change within this group is

particu-lamly difficult, perhaps because of the importance of

peer pressure. Middle-income children showed a

de-crease in helmet use over time, perhaps because of

the absence of any reinforcing interventions during

the 3-year period. High-income children have

dem-onstrated greater helmet use at schools compared

with other observational sites, perhaps as a result of educational strategies based at the schools. This sug-gests that further education is required to ensure the use of helmets at all times.

Thompson et al,28 in a cost-effectiveness analysis of a hypothetical cohort of 5- to 9-year old children,

found that helmet subsidies of $5 to $10 (achieving a

cost of $14 to $20 per helmet) would be cost-effective if helmet use mates of 40% to 50% could be achieved. Under these conditions, 600 to 800 head injuries per

100 000 would be prevented, for a cost savings of

$200 000 to $400 000. However, this was a

middle-class population, and these results may not be

appli-cable to a low-income population, such as we

stud-ied. Furthermore, we were unable to attain the

requisite 40% to 50% helmet use mates, despite the

lower helmet cost of $10. As suggested by Thompson et al,28 helmet discounts alone or as a component of a

promotional program may not be sufficient, and

hel-met discounts combined with legislation may be the

most effective approach.

Children from low-income families have a twofold

to threefold higher risk of injury-related deaths than

do children from other income groups.29 In a US

survey of parental attitudes and knowledge of child

safety, parents of lower socioeconomic status were

found to have a limited understanding of child safety and to underestimate the risks of childhood injury.#{176} Interviews with camegivers of medically indigent

ur-ban children younger than 6 years have shown that

previous injuries and hazardous practices and living conditions are common. In addition, these camegivems are more frequently isolated and lack safety informa-tion, leading to poor supervision of their children.31

These factors, rather than economic barriers, may

play a more important role in determining the

suc-cess of an intervention intended to increase helmet use.

Another example of a subsidy program aimed at a

high-risk community has been successful. Corman et

al32 studied the efficacy of a smoke detector

give-away program in Baltimore City, after the

distribu-tion of 3720 smoke detectors to households that

me-quested them. In a survey of a randomly selected

households 8 to 10 months after the giveaway

pro-gram, 92% of the smoke detectors were installed, and

88% were operational. The investigators speculate

that the success of the program may have been

at-tributed to the removal of economic barriers coupled

with a public awareness campaign. In addition, it is

noted that use of a smoke detector is a one-time

activity rather than requiring prolonged on repetitive

behavior. In contrast, bicycle helmet purchase is a

one-time activity, but helmet use is a repetitive be-haviom. This suggests that some injury prevention

interventions may be better suited for a subsidy

program than others.

Despite the discouraging results of this subsidy

program, overall helmet use rates within all the

low-income areas have increased significantly during the

3-year period of 1990 through 1992. The use of

con-trol areas has allowed us to separate secular trends from the effects of interventions. We speculate that the secular trends may be the result of interventions beyond the control of this study (eg, helmet

promo-tion through retail stores and media promotion) and

a general increased awareness and acceptance by

children, parents, and teachers as a result of

observ-able increases in helmet use in the community. This

suggests that repeated and varied interventions in all income groups are likely to result in long-term

effec-tiveness. As suggested by Rivara et al,33 each

mdi-vidual component of a promotional campaign may

be less effective than the combination of components.

However, we do not find convincing evidence that

helmet subsidies play a more important mole than

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other components. Several investigators, including ourselves, have noted that the strongest association

with children’s helmet use is adult helmet use, and

strategies to increase parental awareness may be a

key.19’27’33

We conclude that within a low-income area,

hel-met subsidies, even coupled with education, may

remove economic barriers and allow families to

pun-chase helmets, but this does not ensure a change in

the child’s behavior. Other interventions, such as

repeated community- and school-based campaigns,

including activities based in surrounding higher-in-come areas, are necessary to gradually increase hel-met use in children of low income families. Finally, legislation has been shown to be extremely effective,

especially in communities that have a reasonable

baseline participation mate.20’ Therefore, for many

communities that have introduced strategies to

en-courage voluntary helmet use, legislation would be

the logical next step. In the province of Ontario,

legislation mandating helmet use in all cyclists will be introduced in October 1995, and it will be

impor-tant to measure postlegislation helmet use in all

income groups.

ACKNOWLEDGMENTS

This work was supported by grant 9210 from the Ontario Ministry of Transportation and grant 92-70-0408 from the On-tario Ministry of Culture, Tourism, and Recreation. The views of the authors do not necessarily reflect the views of these ministries.

We gratefully acknowledge the contributions of Peggy

Howorth, BAAN, and Tish Willekes, BScN, community nurses at

the East York Health Unit, for coordinating the intervention, the

East York Board of Education, the Metropolitan Separate School

Board, and the Kiwanis Club East York Division.

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1995;96;283

Pediatrics

David E. Wesson

Patricia C. Parkin, Xiaohan Hu, Laura J. Spence, Katherine E. Kranz, Linda G. Shortt and

Low-Income Families