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PEDIATRICS Vol. 106 No. 1 July 2000, pp. 6-9
,,
From the * Epidemic Intelligence Service, Epidemiology Program
Office, Centers for Disease Control and Prevention, Atlanta, Georgia;
Division of Unintentional Injury Prevention, National Center for
Injury Prevention and Control, Centers for Disease Control and
Prevention, Atlanta, Georgia; § Office of Statistics and Programming,
National Center for Injury Prevention and Control, Centers for Disease
Control and Prevention, Atlanta, Georgia; and Injury Control
Section, Division of Public Health, Department of Human Resources,
State of Georgia, Atlanta, Georgia.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
References
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Background. Bicycle-related head injuries cause >150 deaths and 45 000 nonfatal injuries among children in the United States annually. Although bicycle helmets are highly effective against head injury, only 24% of US children regularly wear one. Georgia mandated bicycle helmet use for children, effective July 1993. During that summer, 1 rural Georgia community passed an ordinance instructing police officers to impound the bicycle of any unhelmeted child. We evaluated the effect of active police enforcement of this ordinance, combined with a helmet giveaway and education program.
Methods. During April 1997, ~580 children in kindergarten through grade 7 received free helmets, fitting instructions, and safety education. Police then began impounding bicycles of unhelmeted children. We conducted an observational study, unobtrusively observing helmet use just before helmet distribution, several times during the next 5 months, and once 2 years later.
Results. Before the program began, none of 97 observed riders wore a helmet. During the next 5 months, helmet use among 358 observed children averaged 45% (range: 30%-71%), a significant increase in all race and gender groups. In contrast, adult use did not change significantly. Police impounded 167 bicycles during the study, an average of 1 per day. Two years after program initiation, 21 of 39 child riders (54%) were observed wearing a helmet.
Conclusions. Without enforcement, the state and local laws did not prompt helmet use in this community, yet active police enforcement, coupled with helmet giveaways and education, was effective and lasting. Key words: bicycling, child, head protective devices, head injury, legislation.
Bicycling is a common recreational activity and mode of
transportation among children. Approximately 27.7 million American children <15 years of age ride a bicycle.1
However, this activity is not without risk. In 1997, an estimated
367 700 such children sought emergency department care for a
bicycle-related injury,2 of which an estimated 111 300
(30%) sustained a head, facial, or ear injury. Among the 224 children
killed in 1997 from bicycle-related injuries, approximately two thirds
sustained a head injury.3 Several studies indicate that
bicycle helmets prevent 69% to 88% of serious head or brain
injuries.4,5 Furthermore, as helmet use increases,
hospital admissions and deaths from bicycle-related head injuries
decrease.6-8 Despite such evidence supporting helmet
effectiveness, a 1994 national study indicated that only approximately
one half of the children who rode a bicycle reportedly owned a helmet,
and only one quarter of these riders wore a helmet every time they
rode.1
Bicycle helmet promotion programs have used several strategies, alone
or in combination, including education, helmet giveaways, and adoption
of helmet use laws at the state or local level. Passage of bicycle
helmet legislation in all 50 states is a national objective in
Healthy People 2000; 16 states currently have helmet use
laws for children. (The 16 states currently with helmet use laws for children include: AL, CA, CT, DE, FL, GA, MD, ME, MA, NJ, NY, OR, PA,
RI, TN, and WV.) However, the effectiveness of such laws has varied. In
some geographic areas, enactment has coincided with an increase in
reported and/or observed helmet use,9-11 whereas in
others, legislation has had little effect.12 We sought to
study the effectiveness of adding enforcement to these legislative
efforts. We report here our evaluation of a combined giveaway,
education, and enforcement program conceived and conducted by a rural
community in Georgia.
The Georgia Assembly passed a state law effective July 1, 1993 mandating that all bicycle riders <16 years old wear helmets. Although
the law allowed a parent to be cited for a child's noncompliance, in
practice, citations have rarely been issued. Later that summer, the
city council of a small, rural Georgia community passed an ordinance
strengthening the state law by instructing local police to impound the
bicycle of any child <13 years old seen riding without a helmet.
Rather than issuing a citation or a fine, police impounded the bicycle
and required a parent to retrieve it at the police station, where the
safety message was reinforced to the parent and child and helmet
ownership was verified or a helmet was provided. This local enforcement
program allowed us the opportunity to study the effectiveness of the
enforcement strategy on bicycle helmet use before and after initiation
of the program.
The community has a population of ~2400 residents (25% white
and 75% black), of which 41% have an income below the federal poverty
level.13 The town provided an ideal setting for this study
because: 1) its geographic isolation reduced the possibility that
nonresidents not exposed to the program would be observed riding; 2)
its small size facilitated relatively complete observation of the
entire population by only a few observers; 3) its small population
allowed for the local coalition of the National SAFE KIDS Campaign and
the Georgia Division of Public Health to affordably provide each rider
in the target age group a bicycle helmet; 4) the police force and city
officials were committed to the ongoing enforcement of this ordinance;
and 5) a classroom show-of-hands in kindergarten through grade 5 before initiation of the program demonstrated a very low rate of helmet ownership.
The intervention program had 2 components, a helmet giveaway/education
program (distribution) and an enforcement program. Intervention here
refers to both the distribution and ongoing enforcement components.
Because the local ordinance had been enforced only briefly when passed
in the summer of 1993 and not subsequently, police reinstituted the
program by initially issuing warnings to unhelmeted children in April
1997. The distribution program described below began in late April,
after which the police began impounding the bicycle of any unhelmeted
child rider. The enforcement program has continued to the present.
The distribution program consisted of a helmet giveaway with fitting
instructions and 10 minutes of bike safety education in late April
1997; a parent education program; and 2 bicycle rodeos. Helmets were
distributed at the only local elementary school to all 426 children in
kindergarten through fifth grade (5-10 years of age). Approximately
150 local students were in grades 6 through 7 (11-12 years of age);
they attended a different school with students from a different town,
yet received helmets and training from the police on roadsides and in
parks. To deliver the safety message to parents and to remind them of
the penalty, an information pamphlet was sent home from school with
each child and 2 articles were printed in the local newspaper. In
addition, a bicycle rodeo was held just after the helmet distribution
to reinforce safety messages and provide helmets to any target-aged child who had previously not been given one. A second rodeo was held 20 weeks after helmet distribution. Altogether, 650 helmets were
distributed at the beginning of the study to the ~576 target-aged children and to any teen requesting one. Additionally, 100 helmets were
distributed during both of the 2 years since the end of the study to
sustain the program.
Helmet use was determined by unobtrusive observation. This study was
exempted by the Centers for Disease Control and Prevention Institutional Review Board, because we only observed public behavior, no identifying data were collected, and no interaction with the bicyclists occurred.14 Each of the same 4 trained
community workers repeatedly canvassed a quadrant of town by automobile using a predetermined route according to a previously described method.15 Observers recorded helmet use, time of day, race, and gender. In addition, the rider's approximate age was estimated from the rider's size and presence or absence of secondary sexual characteristics. Each observation period lasted ~12 hours (Friday afternoons after school until dark and daylight hours on
Saturday). Observations were conducted the weekend before helmets were
distributed, weekly for 3 consecutive weeks, and monthly for 4 consecutive months, totaling 7 postdistribution observation periods
during the 5-month study. Although not a part of the formal study, 2 years after the initial helmet distribution most of the authors and 1 volunteer observed bicyclists 1 Thursday after school in May 1999, using the same canvassing technique to determine whether use was
sustained. Because the 2-year follow-up observations were not conducted
during the same 12-hour period as previous observations and are not
considered part of the study, the follow-up data are reported but not
included in the tables or analysis.
The unit of analysis was the observed ride rather than the observed
rider. If a rider was seen more than once, observers were instructed to
record subsequent observations if >30 minutes apart, because these
were considered separate rides. Previous observational studies have
counted rides,6,7,9,11,12,15,16 although telephone surveys
have counted riders.1,9,10 These 2 methods yield identical
results only if each rider is counted once or the telephone survey
inquires about a single ride. However, because we thoroughly and
repeatedly canvassed this small town, we assume that some unknown
number of bike rides were counted 2 or more times during the
observation period. We made no attempt to identify a rider or to track
his/her helmet usage across observation periods because our previous
experience indicated that this could not be done accurately or
consistently. By counting rides instead of riders, this may incorporate
some measure of exposure.
Statistical significance between predistribution and pooled
postdistribution observation results for children was tested using the
Pearson During the 5-month study, 777 total observations were recorded.
Eighteen observations were excluded because of missing data: unknown
gender (n = 7), unknown age (n = 9),
and unknown race (n = 2). Eight records were excluded
because the riders were estimated to be <5 years old. The remaining
751 complete observations (97 predistribution and 654 postdistribution)
used in the analysis included 419 children (56%), 141 teens (19%),
and 191 adults (25%).
A classroom show-of-hands before the distribution indicated that only
8% of children in kindergarten through grade 5 owned a helmet.
Observations before distribution found that helmet use among 61 child
bicycle riders was 0% (Table 1). After helmet distribution and initiation of enforcement, 167 bicycles were
impounded. Bicycle impoundment during the study averaged 1 bicycle per
day (range: 0-5) or 33 bicycles per month (range: 22-45). Observed
helmet use in children increased from 0% predistribution to between
30% and 71% postdistribution (mean: 45%; P value = .001; Fig 1). By comparison, mean helmet use
in adults did not change significantly, from 0% predistribution to 3%
postdistribution (Table 1). Children's helmet use increased
significantly in all race-gender strata for which significance could
be determined (Table 2). Two years after
the initiation of the intervention, 21 of 39 child riders (54%) were
observed wearing helmets during 1 afternoon, compared with only 2 (15%) of 13 teens and none of the 23 adults.
TABLE 1 TABLE 2
METHODS
Top
Abstract
Methods
Results
Discussion
References
2, Mantel-Haenszel
2, or Fisher's exact test, as appropriate.
Statistical significance was established for P values <.05.
Riders were classified as children if their estimated age was between 5 and 12 years old, teens if between 13 and 15 years old, and adults if
16 years of age or older. We report the observed helmet use of teens
and adults but do not statistically compare them with children. Teens
and adults were not considered to be valid control groups because some,
but not all, teens received a free helmet, none of the teens received safety instruction, and neither the teens nor the adults were subject
to bicycle impoundment because they exceeded the age limit of the local
ordinance.
RESULTS
Top
Abstract
Methods
Results
Discussion
References
Observed Helmet Use by Age Group Predistribution and Postdistribution
View larger version (14K):
[in a new window]
Fig. 1.
Observed helmet use in children (point estimate and 95% confidence
limit).
Observed Helmet Use in Children by Gender and Race Predistribution and
Postdistribution
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DISCUSSION |
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Results
Discussion
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In this study, the combination of a bicycle helmet giveaway, education, and active police enforcement using bicycle impoundment was highly effective in increasing helmet use among children. The observed change in helmet use was immediate, dramatic, and apparently sustained. Helmet use in this study exceeded that of another study in a similar population in which a universal helmet giveaway program was not accompanied by enforcement.15 That rural population, although lacking a state helmet law, noted an increase in helmet use among target-aged children from 0% to a maximum of 38% after universal helmet giveaways, education, and incentives; however, helmet use plummeted to 5% when the incentives program ceased. In the group of children observed here, a state bicycle helmet law with an unenforced local ordinance resulted in minimal helmet ownership and no observed helmet use. Because no other local helmet safety programs were provided during this time, our findings suggest that this combination of giveaways, education, and enforcement caused the behavioral change. Unfortunately, this study design did not allow us to determine whether enforcement alone motivated helmet use, but the results support our conclusion that the addition of an enforcement component to a program of giveaways and education is a highly effective intervention strategy.
Helmet use in children varied between 30% and 71% among the 7 postdistribution observation periods. Possible reasons for this variation include intermittent helmet use, changing perceptions of the vigor of enforcement, or the degree of peer influence by a child whose bicycle was impounded. Other observational studies have had similar variable results.15
Our results are subject to several limitations. We could not be certain that all children in grades 6 through 7 received a helmet. However, the number of helmets distributed exceeded the number of children in kindergarten through grade 7 (the target population), with the additional helmets distributed to teens. Age group misclassification was possible, although local residents conducted these observations. Age misclassification is always a concern in observational studies; however, observed helmet use is more reliable than reported use from phone or mail surveys. These results from a rural community may not be generalizable to an urban or suburban community, and such a program should be tested there. We could not study the effect of this program on teens, the age group hardest to reach, because they were not subject to the local ordinance. It is highly likely that riders were observed multiple times over the 8 observation periods, but the extent of this is unknown. In the analysis, we presumed that each observation was independent, which would lead to conservative test results. Although we hesitate to suggest program plans based on the small number of observations in each race/gender group, we provide data on race and gender that suggest that this program may be effective in each of these groups. Finally, 2 bicycle rodeos were held during the study. Each was attended by ~40 children (~10% of the target group). However, we do not believe that the rodeos contributed greatly to the increased helmet use. A similar study that included rodeos with the giveaway and education components was unsuccessful.15 Thus, we believe that adding the enforcement component in this study contributed to the increased helmet use.
Although bicycle impoundment may seem to be a severe penalty, in this poor community it was better accepted than a fine. The penalty was directly related to both the infraction and its solution. Thus, the police action strongly reinforced the safety messages. In fact, confiscating the bicycle actually protected these children by removing their risk of bicycle-related head injury.
Another common criticism of increased enforcement is that it requires large expenditures of otherwise limited resources. However, this program did not require financial resources or even much additional time by local police. The helmets were donated, and police officers, community volunteers, and Department of Health workers conducted the distribution component. The principal responsibility for enforcement was assigned to 1 officer each day, to be performed during routine patrol. The perception of enforcement, perhaps augmented by local conversation and media attention, might have been more important than the actual enforcement itself. If so, personnel requirements for such a program may not be prohibitive for larger communities.
Anecdotally, during the 2-year follow-up observation, we saw children participating in other activities wearing bicycle helmets not required by any law. Each of 2 children rollerblading, all 3 children jumping on a trampoline, as well as 3 children walking along a street without bicycles were observed wearing bicycle helmets. Such qualitative data suggest that wearing a bicycle helmet might have become the social norm to children in this community.
These results support the value of enforcement as 1 option in a sustained, multifaceted community-based approach among children.17 Other multifaceted programs have had a positive effect without enforcement, yet took longer to accomplish. In Seattle, Washington, helmet use increased from 6% to 40% between 1987 to 1992 without a mandatory use law.16 In Pittsburg, California, between 1994 and 1997, a sustained program of giveaways, safety education, and a state law (without a special enforcement effort) resulted in an increase from 22% to 72% helmet use in grade school children.18
Enforcement provides yet another strategy for increasing and sustaining bicycle helmet use. To our knowledge only 1 other published report involves active enforcement of bicycle helmet laws. In Victoria, Australia, legislation was passed and enforced in 1990 after a decade of comprehensive, multifaceted education, incentives, and promotion aimed at increasing helmet use in all ages. Helmet use rates there increased from 31% in 1990 (prelaw) to 75% 1 year later after initiation of tickets and fines.6
The nature and degree of enforcement make this study unique. It suggests that targeted enforcement of safety laws may be an effective means for increasing bicycle helmet use in children. The enforcement effort may not require prohibitive personnel or financial resources. In the effort to increase helmet use among children, 1 option includes local enforcement of bicycle helmet laws to supplement the traditional helmet distribution and education components of a bicycle helmet promotion program.
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ACKNOWLEDGMENTS |
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Helmets were provided by the Georgia Division of Public Health, the East Central Health District of Georgia, and the local SAFE KIDS campaign.
We acknowledge the support of Sally Adams of the Mayor's Office and Carl Wagster, coordinator of the local coalition of the National SAFE KIDS Campaign.
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FOOTNOTES |
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Received for publication Jun 3, 1999; accepted Oct 20, 1999.
Reprint requests to (J.G.) Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Mail Stop K63, Atlanta, GA 30341. E-mail: jgilchrist1{at}cdc.gov
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REFERENCES |
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Methods
Results
Discussion
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Victoria, Australia.
MMWR CDC Surveill Summ
1993;
42:359-363 Texas, 1995.
Pediatrics
1998;
101:578-582 This article has been cited by other articles:
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  B E Hagel, J W Rizkallah, A Lamy, K L Belton, G S Jhangri, N Cherry, and B H Rowe Bicycle helmet prevalence two years after the introduction of mandatory use legislation for under 18 year olds in Alberta, Canada. Inj. Prev., August 1, 2006; 12(4): 262 - 265. [Abstract] [Full Text] [PDF]
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 A J Lee and N P Mann Cycle helmets Arch. Dis. Child., June 1, 2003; 88(6): 465 - 466. [Full Text] [PDF]
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 J. L. Lohse A Bicycle Safety Education Program for Parents of Young Children The Journal of School Nursing, April 1, 2003; 19(2): 100 - 110. [Abstract] [PDF]
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G B Rodgers Effects of state helmet laws on bicycle helmet use by children and adolescents Inj. Prev., March 1, 2002; 8(1): 42 - 46. [Abstract] [Full Text] [PDF]
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 Police Enforcement Increases Bicycle Helmet Use Journal Watch (General), July 11, 2000; 2000(711): 7 - 7. [Full Text]
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