The cost effectiveness of three programs to increase use of bicycle helmets among children.

Each year in the United States, 280 children die from bicycle crashes and 144,000 are treated for head injuries from bicycling. Although bicycle helmets reduce the risk of head injury by 85 percent, few children wear them. To help guide the choice of strategy to promote helmet use among children ages 5 to 16 years, the cost effectiveness of legislative, communitywide, and school-based approaches was assessed. A societal perspective was used, only direct costs were included, and a 4-year period after program startup was examined. National age-specific injury rates and an attributable risk model were used to estimate the expected number of bicycle-related head injuries and deaths in localities with and without a program. The percentage of children who wore helmets increased from 4 to 47 in the legislative program, from 5 to 33 in the community program, and from 2 to 8 in the school program. Two programs had similar cost effectiveness ratios per head injury avoided. The legislative program had a $36,643 cost and the community-based one, $37,732, while the school-based program had a cost of $144,498 per head injury avoided. The community program obtained its 33 percent usage gradually over the 4 years, while the legislative program resulted in an immediate increase in usage, thus, considering program characteristics and overall results, the legislative program appears to be the most cost-effective. The cost of helmets was the most influential factor on the cost-effectiveness ratio. The year 2000 health objectives call for use of helmets by 50 percent of bicyclists.(ABSTRACT TRUNCATED AT 250 WORDS)     

A decrease in both mild and severe bicycle-related head injuries in helmet wearing ages--trend analyses in Sweden

Several international studies point at the efficacy of bicycle helmets in reducing head injuries. In Sweden, observational studies show that from 1988 to 1996 helmet use increased in all categories of cyclists. The objectives of this study were to analyse the trends of bicycle-related head injuries based on their main diagnosis and external cause of injury by different age groups. Our study area was the whole population of Sweden from 1987 to 1996. Outcome evaluation was based on data from the Swedish National Hospital Discharge Register concerning all bicycle-related injuries from 1987 to 1996, which presented 49 758 reported in-patient care. The trends in incidence rates (IRs) were studied with regression analyses. The results show that children under 15 years had the highest IRs. For these children, the IR decreased by 46%. The head injuries in children decreased both in collisions with motor vehicles and in other accidents. Similarly, the IR of concussion and skull fracture decreased. For non-head injuries, there were no significant changes for children. On the other hand, the incidence of both head and other injuries for adults aged 16-50 years increased. Ages above that showed no significant changes. Our conclusions are that the decrease in IR for bicycle-related head injuries refers to children in ages for whom bicycle helmet use during the period increased. This could not be explained by any general decrease in bicycle-related accidents or by any changes in the distribution of injuries after collision with motor vehicles. The increasing helmet use among younger schoolchildren probably contributed to the decrease in head injuries.     

Prevention of bicycle-related head injuries

Each year in the United States, bicycling accidents cause approximately 1,300 deaths and 60,000 injuries. The death and injury rates are particularly high among children. The death rate from bicycle injuries in children exceeds the death rate from accidental poisonings, falls, firearm injuries, and many major illnesses. Head trauma is the most frequent cause of death and serious injury among bicyclists. Bicycle helmets have the potential to decrease the frequency and severity of bicycle-related head injury. Unfortunately, however, most bicyclists do not use a helmet. The helmet-use rate is extremely low among children. The failure of bicyclists, particularly children, to use bicycle helmets presents an opportunity for prevention of thousands of the traumatic head injuries that occur annually in the United States. Helmet use could be encouraged by schools, community safety programs, and office-based education by physicians.     

The cost-effectiveness of compulsory bicycle helmets in New Zealand

Abstract: This paper examines the cost-effectiveness for primary school children (age 5–12 years), secondary school children (13–18 years) and adults (over 18 years) of the legislation enacted on 1 January 1994 requiring road-cyclists in New Zealand to wear helmets. The cost to cyclists not in possession of a helmet before they became compulsory of either obtaining one or quitting cycling was compared with the number of deaths and hospitalisations expected to be prevented over the average life of a helmet. Corresponding to Victorian and United States estimates of the efficacy of cycle helmets at preventing serious head injuries, the cost per life saved was $88 379 to $113 744 for primary school children, $694 013 to $817 874 for secondary school children, and $890 041 to $1 014 850 for adults (New Zealand dollars = approximately 0.95 Australian dollars). The cost per hospitalisation avoided was $3304 to $4252, $17 207 to $20 278, and $49 143 to $56 035 respectively. These estimates are extremely sensitive to the estimated efficacy of helmets at protecting cyclists. Mainly anecdotal evidence for New Zealand suggests that they are not be very effective at preventing serious head injuries; future research into the change in injury patterns as a result of the helmet regulation would be valuable. Nonetheless, the ranking of the above mentioned estimates does not contradict the policy in some parts of the world requiring helmets for children and/or teenagers, but not adults.     

A proposal for the mandatory inclusion of helmets with new children's bicycles.

To reduce bicycle-related head injuries in children, we propose new regulations be established that mandate the inclusion of approved helmets with the sale of all new children's bicycles. Currently, purchasing a helmet is a separate economic decision that acts as a barrier to helmet ownership and use. The inclusion of a helmet with the bicycle would markedly increase helmet ownership. The increased demand would reduce the manufacturing cost per helmet, so the cost of the bicycle with the helmet would be lower than the current retail price of the two separately. This proposal could potentially be implemented by federal or state legislation, a Consumer Product Safety Commission regulation, or voluntary adoption of a practice or standard by bicycle manufacturers. Increased helmet ownership is necessary but not sufficient to raise helmet use rates. The increased ownership generated by this proposal, complemented by enhanced educational, promotional, and legal interventions, is probably the most practical and cost-effective public health strategy available to increase helmet usage and prevent bicycle-related head injuries in children.     

Bicycle injuries: road trauma is not the only concern

Data on bicycle injury presentations at a public hospital emergency department for 1991–95 inclusive were analysed to determine the nature and extent of bicycle injuries in the community. There were 599 bicycle injury presentations during the study period, representing more than 2.0% of all injury-related presentations to the emergency department. The main outcome measures were severity and type of injury. Distribution by gender, age, helmet use (1991 and 1992 only), location and mechanism was examined. Rider-only injuries (falls or collisions with stationary objects) accounted for 79.3% of all presentations with only 5.2% due to collisions on a public road or footpath with other moving traffic. Of all injuries where a location was determined, 61.6% occurred in off-road locations. There was little difference in the overall proportions of hospital admissions from injuries on-road (12.4%) and off-road (9.0%). Cyclists injured in on-road collisions with traffic had a higher proportion of hospital admissions (40.0%) than those injured on-road by other mechanisms (7.6%). Children under 10 years of age who had been riding without a helmet suffered a much higher proportion of injuries to the head (53.2% of all injuries) than older cyclists riding without a helmet (19.4%). The majority (83.1%) of head injuries in children under 10 years of age occurred off-road and helmet use was lowest in this group (28.6%). Given previous evidence that helmet use can prevent head injuries, strategies to increase helmet use among cyclists, particularly young children, while riding both on and off-road, should be given a high priority. Rider-only injuries are also an important public health issue.     

Injury Control Recommendations for Bicycle Helmets

ABSTRACT: These guidelines were developed by the Centers for Disease Control and Prevention for state and local agencies and organizations planning programs to prevent head injuries among bicyclists through use of bicycle helmets. The guidelines contain information on the magnitude and extent of the problem of bicycle-related head injuries and potential impact of increased helmet use; characteristics of helmets, including biomechanical characteristics, helmet standards, and performance in actual crash conditions; barriers that impede increased helmet use; and approaches to increasing use of bicycle helmets within the community. In addition, bicycle helmet legislation and community educational campaigns are evaluated. (J Sch Health. 1995;65(4):133–139)     

Bicycle helmet campaigns and head injuries among children. Does poverty matter?

OBJECTIVES: To assess the impact of a community based bicycle helmet programme aimed at children aged 5-12 years (about 140,000) from poor and well off municipalities. METHODS: A quasi-experimental design, including a control group, was used. Changes in the risk of bicycle related head injuries leading to hospitalisation were measured, using rates ratios. RESULTS: Reductions in bicycle related head injuries were registered in both categories of municipalities. Compared with the pre-programme period, the protective effect of the programme during the post-programme period was as significant among children from poor municipalities (RR= 0.45 95%CI 0.26 to 0.78) as among those from richer municipalities (RR=0.55 95%CI 0.41 to 0.75). CONCLUSION: Population based educational programmes may have a favourable impact on injury risks in poor areas despite lower adoption of protective behaviours.     

Promotion of bicycle helmet use among schoolchildren: a randomized clinical trial

Although bicycle helmets have been shown to reduce the rates of head injuries and brain injuries from bicycle mishaps, use of helmets is very uncommon. We compared a comprehensive awareness program to increase bicycle helmet use among schoolchildren to the impact of that same awareness program plus a bicycle helmet subsidy. Results showed no impact of the educational program (no children observed riding to school wore helmets before or after the program). The proportion of helmet wearers at the school that obtained the subsidy increased from 0% to 22% (p = 0.036). An educational program in conjunction with a subsidy may have a significant impact on bicycle helmet use.     

Helmet Use Among Users of the Citi Bike Bicycle-Sharing Program: A Pilot Study in New York City

The use of bicycle helmets to prevent or reduce serious head injuries is well established. However, it is unclear how to effectively promote helmet use, particularly in the context of bicycle-sharing programs. The need to determine rates of helmet use specifically among users of bicycle-sharing programs and understand if certain characteristics, such as time of day, affect helmet use, is imperative if effective promotion and/or legislative efforts addressing helmet use are to be developed. We estimated the prevalence of helmet use among a sample of Citi Bike program users in New York City. A total of 1,054 cyclists were observed over 44 h and across the 22 busiest Citi Bike locations. Overall, 85.3 % (95 % CI 82.2, 88.4 %) of the cyclists observed did not wear a helmet. Rates of helmet non-use were also consistent whether cyclists were entering or leaving the docking station, among cyclists using the Citi Bikes earlier versus later in the day, and among cyclists using the Citi Bikes on weekends versus weekdays. Improved understanding about factors that facilitate and hinder helmet use is needed to help reduce head injury risk among users of bicycle sharing programs.     

EFFECTS OF BICYCLE HELMET LAWS ON CHILDREN'S INJURIES

In recent years, many states and localities in the USA have enacted bicycle helmet laws. We estimate the effects of these laws on injuries requiring emergency department treatment. Using hospital‐level panel data and triple difference models, we find helmet laws are associated with reductions in bicycle‐related head injuries among children. However, laws also are associated with decreases in non‐head cycling injuries, as well as increases in head injuries from other wheeled sports. Thus, the observed reduction in bicycle‐related head injuries may be due to reductions in bicycle riding induced by the laws. Copyright © 2013 John Wiley & Sons, Ltd.     

Pedal-cycle injuries among children aged <6 years--Wisconsin, 2002-2004

Measures to improve pedal-cycle safety and increase helmet use often target school-age children rather than younger children, even though preschool children wearing helmets have fewer injuries and are more likely to wear helmets in the future, compared with children who do not wear helmets. Children aged <6 years also use pedal cycles; whether they are passengers on a parent's bicycle, riding a tricycle or pedal car, or learning to ride a bicycle, these young cyclists often sustain injuries. To provide guidance for intervention strategies targeted to young children in Wisconsin, CDC and the Wisconsin Division of Public Health analyzed data collected from January 1, 2002 through December 31, 2004, from all nonfederal emergency departments (EDs) and hospitals in Wisconsin regarding pedal-cycle injuries among children aged <6 years. This report describes the results of that analysis, which indicated that, during 2002--2004, a total of 2,046 ED visits by Wisconsin residents aged <6 years for pedal-cycle injuries occurred; for 1,305 (63.8%) of these visits, the primary diagnosis was a head or neck injury. These findings underscore the need for interventions designed to reduce head and neck injuries in the youngest users of pedal cycles.     

What school children need to learn about injury prevention

Unintentional injuries are the leading cause of death and a major cause of morbidity among school age children. A survey of the educational needs concerning injury prevention of a group of fifth and sixth grade children (ages 10-12) in Holliston, MA, revealed educational deficiencies, including bicycle safety, seatbelt use, firearms use, and water safety. It is well known that the use of helmets can prevent bicycle injuries. Yet, not one of the children in this study reported using a bicycle helmet. Although most States have laws requiring seatbelts for young children, school age children are not covered by this legislation. The hazards of firearms have been well-documented. But it is clear that the children surveyed were in need of education about firearms; nearly half had used some form of firearms. Individual counseling by pediatricians combined with school- and community-based programs can address injury prevention. It is anticipated that many pediatricians will begin using the questionnaire for school age children as that component of the American Academy of Pediatrics Injury Prevention Program is introduced.     

The Effect of an All-Ages Bicycle Helmet Law on Bicycle-Related Trauma

In 2003, Seattle implemented an all-ages bicycle helmet law; King County outside of Seattle had implemented a similar law since 1994. For the period 2000–2010, the effect of the helmet legislation on helmet use, helmet-preventable injuries, and bicycle-related fatalities was examined, comparing Seattle to the rest of King County. Data was retrieved from the Washington State Trauma Registry and the King County Medical Examiner. Results comparing the proportions of bicycle related head injuries before (2000–2002) and after (2004–2010) the law show no significant change in the proportion of bicyclists admitted to the hospital and treated for head injuries in either Seattle (37.9 vs 40.2 % p = 0.75) nor in the rest of King County (30.7 vs 31.4 %, p = 0.84) with the extension of the helmet law to Seattle in 2003. However, bicycle-related major head trauma as a proportion of all bicycle-related head trauma did decrease significantly in Seattle (83.9 vs 64.9 %, p = 0.04), while there was no significant change in King County (64.4 vs 57.6 %, p = 0.41). While the results do not show an overall decrease in head injuries, they do reveal a decrease in the severity of head injuries, as well as bicycle-related fatalities, suggesting that the helmet legislation was effective in reducing severe disability and death, contributing to injury prevention in Seattle and King County. The promotion of helmet use through an all ages helmet law is a vital preventative strategy for reducing major bicycle-related head trauma.     

Injury risks in children of California migrant Hispanic farm worker families

BACKGROUND: Few data are available addressing occupational and other injury risks among children of migrant Hispanic farm workers. METHODS: We conducted the U.C. Davis Farm Worker Injury Study (UCD-FWIS), a longitudinal follow-up study of injury among migrant Hispanic farm worker families living in six Northern California Migrant Housing Centers (MHCs). Nine hundred forty-one children (age < 18 years) were interviewed through parental proxy. RESULTS: Fifty-one injuries resulting in medical care or at least one-half day of lost or restricted work or school time occurred among 49 children (3.8 injuries/100 person-years). Open wounds (31.4%) and fractures (29.4%) were most common. Falls comprised over one-third of the cases, followed by being struck and bicycle injuries. Over three-quarters of subjects never use a helmet when riding a bicycle. Seventy-eight (8.3%) children reported employment in the preceding year, typically involving manual agricultural tasks. Two injury cases were occupational and involved agricultural work. CONCLUSIONS: Occupational injury was uncommon in this group of children in migrant Hispanic farm worker families. Injury prevention in this population should include a focus on the home and surrounding environment as well as the work place.     

Exploring the economics of motorcycle helmet laws--implications for low and middle-income countries

This paper reviews economic evaluations of motorcycle helmet interventions in preventing injuries. A comprehensive literature review focusing on the effectiveness of motorcycle helmet use, and on mandatory helmet laws and their enforcement was done. When helmet laws were lifted between 1976-80, 48 states within the U.S.A. experienced a cost of $342,047 per excess fatality of annual net savings. Helmet laws in the USA had a benefit-cost ratio of 1.33 to 5.07. Taiwan witnessed a 14% decline in motorcycle fatalities and a 22% reduction of head injury fatalities with the introduction of a helmet law. In Thailand, where 70-90% of all crashes involve motorcycle, after enforcement of a helmet law, helmet-use increased five-fold, the number of injured motorcyclists decreased by 33.5%, head injuries decreased by 41.4%, and deaths decreased by 20.8%. There is considerable evidence that mandatory helmet laws with enforcement alleviate the burden of traffic injuries greatly. For low and middle-income countries with high rates of motorcycle injuries, enforced, mandatory motorcycle helmet laws are potentially one of the most cost-effective interventions available.     

H地区骑自行车者伤害的动态研究

[目的 ]分析H地区自行车伤害的发生率和死亡率及其动态变化 ,为开展伤害预防提供依据。 [方法 ]采用1994年到 1998年公安部交通管理局及部分H地区公安局的道路交通事故统计数据 ,及H地区人口统计资料进行分析。[结果 ]自行车伤害在不同交通方式伤害中居首位 ,其伤害的死亡率最高值为 2 5 82 /10万 ,是美国的 8倍多。其中至少有 61 5 %的死亡者为头部损伤 ,其中大部分 (74 6% )由头部与水泥或柏油路面碰撞引起。所有的病人无一在受伤时佩带头盔 ,而且在所有骑自行车的人群中都没有使用头盔。 [结论 ]在H地区同自行车相关的头部损伤是一个严重的公共卫生问题 ,应尽快建立自行车事故伤的监测系统 ,通过采取立法手段在公众中强制推行佩带头盔同时进行自行车安全教育干预 ,改善道路环境等措施控制自行车事故伤害     

Barriers to bicycle helmet use among Dutch paediatricians

Background In the Netherlands, bicycle helmet wearing rates are very low and perceived social barriers to helmet use are important. We aimed to determine why Dutch paediatricians do or do not wear helmets while bicycling and whether their personal behaviour is influencing their position about the promotion of helmet use. Methods Attendants to the annual meeting of the Dutch Paediatric Society (7–9 November 2006) were surveyed about bicycle riding frequency, helmet use, reasons for not wearing a helmet, helmet use among their own children and personal position about the promotion and legislation of bicycle helmet use. Results Of the 1110 paediatricians who are active in the Netherlands, 258 answered the survey. Ninety‐six per cent of the respondents ride a bicycle (68% more than once a week). Bicycle was used as a mean of transport (32%), as a recreation/sport (11%) or with both purposes (57%). When cycling for transportation, 94% never wear a helmet and 2% always wear it. When cycling for recreation, 70% never wear a helmet and 18% always wear it. The most common reasons given for not wearing a helmet were: ‘I never thought about that’ (43%), ‘Poor appearance’ (31%), ‘Nobody uses it in the Netherlands’ (27%) and ‘Uncomfortable’ (25%). A majority (91%) of the respondents agreed that bicycle helmets are effective in reducing the rate of head injury to bicyclists and that they should be advised to children (82%) and adolescents (54%). Conclusions Our results indicate that among Dutch paediatricians, cycling rate is high and helmet wearing rate is very low and that they experience numerous personal barriers to bicycle helmet use. This might explain why bicycle helmet promotion campaigns are scarcely supported by Dutch paediatricians.     

Selection of controls in injury case-control studies

PURPOSE: To assist in elucidating principles underlying the design of injury case-control studies.APPROACH: We begin by defining "event" as the sequence of circumstances that place a person at risk of injury (e.g. bicycle crash) and "injury given the event" as the resultant physical damage (e.g. head injury in bicycle crash). We then identify two broad classes of research question: 1) Studies of risk factors for the event, and, 2) Studies of risk factors for injury given the event. The study base for the first type of research question is all persons at risk of the event, while the study base for the second type is all persons who experience the event, and are therefore at risk of injury. It follows that in studies of risk factors for injury given the event, the controls should be a sample of all persons who experience the event. For example, in a study of bicycle helmets and head injuries, a suitable case group would be cyclists treated for head injury following a bicycle crash. The appropriate control group is drawn from the base population of all cyclists who crashed, including those who had no injuries. The control group may be restricted to cyclists who crashed and sought treatment for non-head injury under the assumption that the exposure distribution (prevalence of cycle helmet use) in the crash/no injury group is identical to the exposure distribution in the crash/non-head injury group.CONCLUSIONS: It is over ten years since innovative researchers in Seattle first applied the case-control design to the problem of bicycle crashes. Since then, successive bicycle injury studies at other centers have largely failed to extend and refine the Seattle methodology. A more critical approach to the design of case-control studies is required if we are to continue to advance the field of injury epidemiology.     

Measuring community bicycle helmet use among children

Bicycling is a popular recreational activity and a principal mode of transportation for children in the United States, yet about 300 children die and 430,000 are injured annually. Wearing a bicycle helmet is an important countermeasure, since it reduces the risk of serious brain injury by up to 85%. The Centers for Disease Control and Prevention (CDC) have funded state health departments to conduct bicycle helmet programs, and their effectiveness has been evaluated by monitoring community bicycle helmet use. Although it would appear that measuring bicycle helmet use is easy, it is actually neither simple nor straightforward. The authors describe what they have learned about assessing helmet use and what methods have been most useful. They also detail several key practical decisions that define the current CDC position regarding helmet use assessment. Although important enough in their own right, the lessons learned in the CDC's bicycle helmet evaluation may serve as a model for evaluating other injury prevention and public health programs.