The Seattle Children's Bicycle Helmet Campaign: Changes in Helmet Use and Head Injury Admissions

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PEDIATRICS Vol. 93 No. 4 April 1994 567

The

Seattle

Children’s

Bicycle

Helmet

Campaign:

Changes

in Helmet

Use

and

Head

Injury

Admissions

Frederick P. Rivara, MD, MPH; Diane C. Thompson, MS; Robert S. Thompson, MD; Lisa W. Rogers;

Bruce Alexander, MPH; Debra Felix, MPH; and Abraham B. Bergman, MD

ABSTRACT. Objective. To describe the impact of a

community bicycle helmet campaign on helmet use and

the incidence of bicycle-related head injuries.

Setting. Metropolitan community and a large health

maintenance organization.

Interventions. Communitywide bicycle helmet

cam-paign.

Outcomes. Rate of observed bicycle helmet use in the

community and incidence of bicycle-related injuries in an

health maintenance organization population.

Results. Helmet use among school-aged children

in-creased from 5.5% in 1987 to 40.2% in 1992. Bicycle-related

head injuries decreased by 66.6% in 5- to 9-year-old and

67.6% in 10- to 14-year-old members of an health

main-tenance organization.

Conclusions. Educational campaigns can increase

hel-met use and decrease the incidence of bicycle-related head

injury. Pediatrics 1994;93:567-569; bicycle-related head in-jury, bicycle helmet, educational campaign.

ABBREVIATION. GHC, Group Health Cooperative of Puget Sound.

Bicycling injuries to children account for some

300 000 emergency department visits’ and 500 to 600

deaths each year in the United States.2 Helmets have

been shown to be very effective, reducing the risk of

bicycle-related head injuries by 85%. A campaign

in Seattle, WA, which addressed barriers to helmet

use,4 was previously reported to increase helmet use from 5.5% to 15.7% in its first 2 years, compared with

no significant change in Portland, OR, a control

community.5

We wish to update our observations on the effects

of this campaign and to report on the changes in

bicycle-related admissions for head trauma.

METHODS

The campaign has been described in detail previously.4 The program sought to increase parental awareness of the need for helmets, reduce financial barriers to helmet purchase, and pro-mote use of helmets by children. A communitywide coalition used

several methods to accomplish these goals, including stories in the print and electronic media, public service announcements, press

conferences, posters, brochures, stickers, health fairs, bike rodeos,

From the Harborview Injury Prevention and Research Center, the

Depart-ment of Pediatrics and Epidemiology, University of Washington and the

Departments of Preventive Care, Group Health Cooperative of Puget Sound.

Received for publication Jun 14, 1993; accepted Aug 19, 1993.

Reprint requests to (F.P.R.) Harborview Injury Prevention and Research Center, 325 Ninth Ave. ZX-10, Seattle, WA 98104.

school and youth programs, and a discount coupon. The cam-paign has been held annually since 1986 with intensive activities

from April through September of each year.

The evaluation of the campaign employed observations of helmet use each fall as described previously.5 In brief, children estimated to be between 5 and 12 years old were observed at the same sites each year while riding two-wheeled bicycles. Using a formal sampling scheme, observation sites were chosen to

repre-sent bicycle-riding and helmet-wearing behaviors of children throughout the Seattle metropolitan area. The 139 census tracts in

Seattle were numbered according to median household income

and divided into tertiles based on the number of resident children

aged 5 to 15 years. Within each income tertile, a sample of 150 sites was randomly allocated with probability proportional to the num-ber of children residing in each census tract. Observers went to each site for 20 minutes and recorded data on all children ob-served riding bicycles. If the children were accompanied by adults, their helmet use was also recorded. Observations were conducted during a 2-week period on afternoons throughout

weekdays and the weekend. The same observation sites were used

each year.

Unadjusted rates of helmet use for each observation period are reported. In our previous report, a confounder score had been used to develop estimates adjusted for potential confounding

van-ables.5 However, adjusted and unadjusted rates were nearly

iden-tical; thus, for simplicity only crude rates are reported here. Population-based rates of bicycle-related injuries were obtained from Group Health Cooperative of Puget Sound (GHC), a large staff-model health maintenance organization. GHC membership is demographically similar to the surrounding population in the Seattle metropolitan area. GHC patients receive nearly all their outpatient, emergency department, and hospital care at GHC fa-cilities. Injured GHC cyclists were identified during a 1-year sun-veillance of the two GHC Seattle area emergency departments and their respective hospitals from December 1, 1986, to November 30,

1987, and again from March 1, 1992 to February 28, 1993. The results of the prior survey have been reported previously.6 mci-dence rates were calculated using the midyear 1986 and 1992 membership population of GHC, respectively.

RESULTS

Helmet use among Seattle metropolitan area

school-aged children increased from 5.5% in 1987 to

40.2% in 1992 (Table 1). Helmet use was 38.1% in boys

compared with 47.2% in girls, and 47.8% in whites

compared with 8.2% in blacks and 15.5% in Asians.

Helmet use in 1992 was highest for children riding on

bike paths (82.7%) compared with children riding on

streets (23.1

%),

at schools (38.1

%),

or at playgrounds/

parks (39.1 %). Helmet use was highest among

chil-dren riding with adults who were helmeted (94.7%)

and lowest among children riding with unhelmeted

peers (7%). Helmet use was highest among children

riding in the highest income census tracts (44.4%).

Nevertheless, 31.6% of children riding in the lowest

income areas were helmeted.

There was a remarkable decline in head injuries

among 5- to 9- and 10- to 14-year-old children in the

at Viet Nam:AAP Sponsored on September 1, 2020

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TABLE 1. Observed Bicycle Helmet Use, Seattle, 1992 Category N % Helmet Users

in Category, %

701 100 40.2

538 76.8 38.1

163 23.2 47.2

Total Sex Male Female Race White Black 556 79.3 73 10.4 58 8.3 14 2.0 47.8 8.2 15.5 7.0

168 24.0 31.6

283 40.4 41.7 250 35.7 44.4

130 18.5 333 47.5 138 19.7 81 11.6 19 2.7 57 8.1 14 2.0 99 14.1 143 20.4 388 55.4 23.1 38.1 39.1 82.7 21.1 94.7 35.7 81.8 7.0 34.0

568 SEATFLE CHILDREN’S BICYCLE HELMET CAMPAIGN

Asian

Other

Medium household income of site Low Middle High Site type Street School Park/playground Bike path Store Companions

Adult with helmet

Adult without helmet

Child with helmet Child without helmet Riding alone

GHC surveillance population (Table 2). Medically

treated head injuries decreased by 66.6% in the

younger age group and by 67.6% among the older

children. In contrast, injuries to children not involving

the head decreased by 13.7% and 25.9%, respectively.

Head injuries accounted for 32.1 % of all injuries in

1987 and only 12.1% in 1992. Helmet wearing in this

population increased from 4.3% in children younger than 15 years of age in 1987k to 54% for 5- to 9-year-olds and 37.7% for 10- to 14-year-olds in 1992.

DISCUSSION

This study indicates that the campaign has been

associated with a continued increase in helmet use in Seattle. This has been accompanied by a gratifying and remarkable decrease in bicycling-related head in-juries in a subset of the target population of children. These results strongly suggest that a concerted,

co-ordinated communitywide approach which counters

a specific injury problem with a specific intervention can be effective. Similar programs have now been

de-veloped by the American Academy of Pediatrics, the

National SAFE KIDS program, and health providers

across the country.

In addition to educational programs and efforts to

lower financial barriers, recent efforts by others have

included legislation for mandatory helmet use. One

such evaluation showed a marked increase in helmet

use through legislation.7 Legislation mandating

bi-cycle helmet use has been very effective in increasing

use and has been associated with a decrease in

bicycling-related head injuries in the state of Victoria,

Australia.8 The gradual plateauing of the effect of our

educational program in the past 2 years indicates that

legislation may be necessary to achieve helmet use by the majority of children riding bicycles.

TABLE 2. Incidence of Bicycle-Related Injuries per 100 000 in

1987 and 1992: Group Health Cooperative of Puget Sound

Emer-gency Department Surveillance

1987 1992 Percent

Decreased

5- to 9-year-olds

Head injuries 283 94.6 66.6%

Non-head injuries 388 335 13.7% All injuries 671 429 36.1%

10- to 14-year-olds

Head injuries 188 60.9 67.6%

Non-head injuries 621 460 25.9%

All injuries 809 521 35.6%

Head injuries, % of total 32.1 16.4 48.9%

Use of bicycle helmets by school-aged children

seems to be associated with peer and adult role models. Efforts to increase helmet use should be

gen-eralized to all age groups to achieve the greatest

benefit.

Unlike our previous report on this campaign, the

present study did not control for other possible in-fluences on helmet use in Seattle. Interest of both the

lay and professional communities in bicycle helmet use has certainly expanded nationally in the last few

years. This has been accompanied by information in the media on the need for helmet use, as well as by a general lowering of helmet prices and increased avail-ability of helmets in many stores. The impact of these factors in Seattle cannot be separated from the specific

bicycle helmet promotion campaign. This was a

mul-tifaceted communitywide campaign. It is therefore

very difficult to disaggregate the components of the program which appeared to be causally related to the

increased use of helmets and decreased incidence of

head injuries. We believe, in fact, that each of the corn-ponents is likely to be ineffective when used by itself.

The power of communitywide campaigns lies in the

multiple avenues of health education used. We do

believe, however, that the discount coupon played a

central role by lowering the cost and barriers to

hel-met use.4’9 With the increasing emphasis on health

care costs in this country, more attention should be

paid to actual subsidies to lower the cost of helmets further and to push usage rates higher. Such subsidies can be cost-effective through the cost savings of

medi-cal care for the resultant head injuries which are

averted

. Observations in fall of 1993 indicate almost 60% of children were helmeted.

ACKNOWLEDGMENTS

This work was funded in part by grant R49/CCR002570 from the Centers for Disease Control and Prevention, and the Snell Memorial Foundation.

REFERENCES

1. Centers for Disease Control. Bicycle related injuries: data from the National Electronic Injury Surveillance System. MMWR. 1987; 36: 269-271

2. Baker SP, O’Neill, Ginsburg MJ, Li G. Tl,e liijun1 Fact Book. 2nd ed. New

York: Oxford University Press; 1992

3, Thompson RS, Rivara FP, Thompson DC. A case-control study of the effectiveness of bicycle safety helmets. N Enyl I Mid. 1989;320: 1361-1 367

4. Bergman AB, Rivara FP, Richards DD, Rogers LW. The Seattle chil-dren’s bicycle helmet campaign. AJDC. 1990;144:727-731

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ARTICLES 569

5, DiGuiseppi CC, Rivara FP, Koepsell TD, Polissar L. Bicycle helmet use 8. Vulcan AP, Cameron MH, Watson WL. Mandatory bicycle helmet use: by children. Evaluation of a community-wide helmet campaign Iso- experience in Victoria, Australia. World JSing. 1992;16:389-397

commentsj. JAMA. 1989;262:2256-2261 9. DiGuiseppi CG, Rivara FP, Koepsell TD. Attitudes toward bicycle

hel-6. Thompson DC, Thompson RS, Rivara FP. Incidence of bicyclerelated met ownership and use by school-age children. AJDC. 1990;144: injuries in a defined population. Am JPublic Health. 1990; 80:1388-1389 83-86

7, Cote TR, Sacks JJ,Lambert-Huber DA, et a!. Bicycle helmet use among 10. Thompson RS, Thompson DC, Rivara FP, Salazar A. Cost-effectiveness

Maryland school children: effect of legislation and education. Pediatrics. analysis of bicycle helmet subsidies in a defined population. Pediatrics. 1992;89:1216-1220 1993;91 :902-907

CANADA’S FAILURE

The direct costs of Canada’s national health insurance are not as troublesome as

the distortive effect they have on health care delivery. Health care facilities have been forced to cut back severely on their capital expenditures, thus depleting the

availability of advanced medical equipment. As a result, many patients must seek

advanced treatment elsewhere. According to a recent study reported in the New

England Journal of Medicine, nearly one-third of Canada’s doctors have sent

patients outside the country for treatment during the past five years. About 10% of all British Columbia residents requiring cancer therapy have been sent to the U.S.

In Toronto, because the government doesn’t provide enough money for personnel,

3,000 beds have been removed from service, while thousands of patients are on

waiting lists for admission.

Even where advanced equipment is available, bureaucratic absurdities prevent

proper use. According to the April issue of “Fraser Forum,” dogs at York Central

Hospital in metropolitan Toronto were able to get CAT scans immediately while

humans were put on a waiting list. The reason? Canadian patients are not allowed

to pay for CAT scans, and the procedure costs too much to operate more than a few

hours a day for nonpaying customers. Dog owners, on the other hand, were

permitted to pay to use it. The user fees paid by the dog owners allowed the

machine to operate longer, thus more human patients could be scanned. When this

information was released, instead of considering user fees for humans, the

Cana-dian government banned the tests for dogs!

Arnett JC, Goodman WE. Canada’s single-payer health scheme a singular failure. The Wall Street Jourizal.

August 6, 1993.

Noted by J.F.L., MD

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1994;93;567

Pediatrics

Alexander, Debra Felix and Abraham B. Bergman

Frederick P. Rivara, Diane C. Thompson, Robert S. Thompson, Lisa W. Rogers, Bruce

Injury Admissions