Review of Helmet Safety Literature
The vast majority of children and youth between the ages of 5 and 14 ride bicycles, with estimates of 70% (Sacks, Kresnow, Houston, & Russell, 1996). Although cycling confers significant health benefits, the bicycle is associated with more injuries than any other consumer project with the exception of motor vehicles (Wilson, Hoover, Baker, Teret, Shock, & Garbarino, 1991). Data from the National Highway Traffic Safety Administration (2008) indicate 698 bicyclists were killed and 44,000 were injured in 2007 and 15% of those killed and 29% of those injured were under the age of 16. These data also show the 10 to 15 year age group had the highest fatality and injury rates, with fatality rates 46% and injury rates 162% more than the average rate for all bicyclists. Bicycle fatality rates are highest in the state of Florida.
Head injuries account for 75% of bicycle related deaths and more than two thirds of bicycle related hospital admissions (Brewer et al., 1995; Rivara et al., 1998). Bicycle helmets have been documented to reduce the risk of head injury by 85% and brain injury by 88% (Thompson, Rivara, & Thompson, 1996). Another study by Thomas, Acton, Nixon, Batttistutta, Pitt, & Clark (1994) examined crashes in children and found a 63% reduction in the risk of head injury. They also found that the majority of children that receive head injuries were injured in collisions with a motor vehicle, while less serious head injuries involve crashes or falls that did not involve a motor vehicle. Of particular interest is the finding of Rivara et al. (1999) that children and youth who wore poorly fitted helmets were more likely to be injured than those who wore properly fitted helmets. Foss and Beirness (2000) found that helmet misuse in the 6 to 15 age group was more than double the level observed in the 16 to 30 age group. These data indicate that countermeasures that target helmet use in this age group must also target appropriate helmet use.
A number of studies indicate that helmet use is lower among young teens than younger children (Schieber et al. 1992; Dannenburg et al., 1992). A number of studies have attempted to determine why middle school aged children are less likely to wear helmets or respond to education programs and helmet giveaways then elementary aged students. One factor that appears in many studies is lack of peer support and unappealing helmet design (Lajunen, T., & Rasanen, M., 2001; Liller, Morissette, Noland, & McDermott, 1998). Another study (Loubeau, 2000) conducted focus group discussions with young adolescents who reported that bicycle helmets were uncomfortable because they were difficult to fit, and made them “feel dumb,” “like a nerd,” “you’re a loser,” “your mother makes you,” “your mother is over protective.”
Other studies have shown that the introduction of bicycle helmet legislation is associated with both increased helmet use and reductions in bicycle related deaths and injuries (Graitcer, Kellerman, & Christoffel, 1995; Mackinan, & Medenorp, 1994; MacPherson et al., 2002; Wesson, Stephens, Parsons, & Parkin, 2008). A study by Thomas, Hunter, Feagues and Foss (2002) concluded that the law, in North Carolina, mandating helmet use for children ages 0-15 years failed to generate a differential increase in helmet use” and suggest that this law should to be combined with enforcement and promotion of the benefits of proper helmet use. These studies suggest that helmet use should be a major intervention target for middle school-aged children.
Currently 18 states have laws requiring helmet use for cyclist less than 16 years of age (National Highway Traffic Safety Administration, 2008). Although helmet use laws have been shown to increase helmet use, enforcement of helmet laws for children is relatively rare. There are several reasons why the enforcement of bicycle helmet use laws is more challenging than the enforcement of motor vehicle laws. First, drivers of motor vehicles must be in the possession of a valid license. This provides identification and loss of the driving permit can be a consequence of not paying fines associated with violations. Young cyclists often do not possess identification, and are not required to have a permit to operate a bicycle. Second, the person that typically would pay a fine for a child or youth violation is typically the parent rather than the violator.
One alternative enforcement technique that attempts to overcome these drawbacks is the impoundment of the bicycle, and requiring the parent to retrieve it at the police station with their child, where the safety message was reinforced and helmet ownership was verified or provided before releasing the bicycle (Gilchrist, Schieber, Leadbetter, & Davidson, 2000). This program was paired with education, and a helmet giveaway program. The program was associated with an increase in helmet use from 0% to a mean of 45% for children ages 5-12 with a smaller increase from 0% to a mean of 18% for teens aged from 13-15. Overall 650 helmets were given away and 167 bicycles were impounded. The absence of a poor experimental design, however, makes it difficult to determine the overall impact of the impoundment treatment. Impounding a bicycle would be a more practical approach then attempting to ticket parents for their child’s infraction. Ticketing parents for their child’s helmet infraction could lead to court challenges and would likely compromise public support.
Experts in the field are finding that it is so challenging to pass State bicycle helmet laws, that local jurisdictional laws may be a more practical way to increase coverage in areas with significant bicycle use - personal communication with Paula Bawer, National Highway Traffic Safety Administration, and Safety Programs. Bawer suggests that proclaiming helmet use laws at the local municipal level would be easier to attain by advocacy groups and could even involve middle and high school students interested in promoting bicycle safety in their communities.
The most commonly employed countermeasures to increase bicycle helmet use other than legislation include helmet give away programs and education programs. A review evaluating the effects of bicycle helmet legislation has documented variable increases in helmet use following the introduction of bicycle helmet laws (Karkhaneh, Kalengal, Hagel & Rowe, 2006). Another strategy for increasing helmet use is the use of a helmet give away program. Two studies evaluated the effects of a helmet give away program on helmet use (Logan et al., 1997; Parkin et al., 1995). Parkin et al. (1995) found an extensive helmet give away program failed to produce an increase in low income students bicycle helmet use. In another study, Logan et al. (1997) found that a helmet give away program increased bicycle helmet use in elementary aged students from 3% to 38% but had no effect on bicycle helmet use of middle school students. These data suggest that giving middle school students helmets alone will not increase middle school children’s helmet use. Parkin, et al. (1993) evaluated the effects of an educational program on bicycle helmet use at 18 Canadian schools. They found an increase in helmet use from 3.4% to 16% following the introduction of the educational intervention. It is interesting to note that a meta analysis of non-legislative interventions to increase helmet use among children and young people found stronger evidence for effectiveness for studies with short-term follow-up than those with longer-term follow-up (Royal, Kendrick & Coleman, 2007). Future studies should assess methods of promoting long term helmet use and whether adults maintain helmet use when outside areas under supervision. One of the few studies examining whether helmet use is maintained when outside the range and time frame when data is typically collected is the Van Houten, Van Houten and Malenfant (2007) study.
Behavior strategies to change transportation safety behaviors related to the use of safety equipment have typically focused on safety-belt use. Some interventions employed to increase safety-belt use are posted feedback (Malenfant, Well, Van Houten, & Williams, 1996), enforcement (Van Houten, Malenfant, & Rolider, 1985), peer monitoring (Cooper & Phillips, 2004) and incentives and rewards (Geller, Kalsher, Rudd, & Lehman, 1989).
Van Houten, Van Houten & Malenfant (2007) applied these behavioral strategies to increase the helmet use of middle school children. A program that consisted of peer data collection of correct helmet use, education on how to wear a bicycle helmet correctly, peer goal setting, public posting of the percentage of correct helmet use, and shared reinforcers, all of which were implemented by the school resource officer, increased afternoon helmet use and afternoon correct helmet use in all three schools. Probe data collected a distance from all three schools indicated that students did not remove their helmets once they were no longer in close proximity to the school, and probe data collected in the morning at two of the schools showed that the behavior change transferred to the morning. Two of the target schools had a history of helmet enforcement in the past while the third school had no history of enforcement. Helmet use increased from 82% to 98% and from 52% to 95% at the two schools with a history of enforcement and from 14% to 45% at the school with no history of enforcement. These data suggest that the effects of enforcement as part of a comprehensive approach to increase helmet use can lead to higher use levels then when enforcement is absent.
Review of Adolescent Behavior Change Literature
Many factors can contribute to the participation of school-aged children in community or school-based activities. Fletcher, Glen, Elder, & Mekos (2000) identified parent endorsement and modeling involvement in activities as important elements and Huebner and Mancini (2003) found that endorsement by peers influences involvement. Further some of these factors can vary across subcultures. For example, studies of Hispanic youth suggest that parental endorsement can be an important variable in youth participation, while studies of African American youth suggest enjoyment of the activity (Gambone & Arbreton, 1997), getting along with others, and the development of competence and self esteem were important to low income youth from a variety of backgrounds.
Klassen, MacKay, Moher, Walker, and Jones (2000) indentified community involvement and ownership of the intervention increases the likelihood of modeling and peer pressure that can result to wide scale adoption of a safety behaviors. Klassen et al. also state that in order to make health or safety messages effective one needs to get teens to perceive a susceptibility to a negative safety outcome, perceive the severity of the condition, and see the benefits of the preventive behavior that outweighs the personal costs of the action. They also believe that behavioral processes based on social learning theory are needed to accompany the safety message to cement the behavior change. Examples of these behavioral processes critical to produce a sustained behavior change in youth are modeling, reinforcement and social group contingencies. A meta-analysis of 120 studies targeting drug use in middle school aged students found that interactive peer interventions produced better results than non-interactive programs led by adults (Black, Tobler, & Sciacca, 1998).
One prerequisite for program success is teen participation. One variable that has been linked to teen participation is program quality (Walker & Arbreton, 2005). One of the best ways to achieve high program quality is through hands on programs that provide numerous sources of reinforcement including feelings of empowerment and success. The goal is to include as many evidence-based procedures as possible to help insure success. Such a multifaceted program can take advantage of the synergistic interaction of numerous effective variables.
Program efficacy is also potentiated if students are able to take credit for much of the success of a program. Program ownership will enhance the feeling of satisfaction engendered in the participants. The curriculums of successful programs also need to take into account relationship building, and altering social norms. Group goal setting is one way to address the issue of changing social norms (Walker et. al., 2005).
Evidence also indicates that adults and youth leaders also play a large role in determining whether teens become engaged in programs (Pearce, and Larson, 2006). Successful programs were found to be related to youth forming personal connections with adult leaders and peers. Behavioral programs can be designed to establish and support such connections.
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The vast majority of children and youth between the ages of 5 and 14 ride bicycles, with estimates of 70% (Sacks, Kresnow, Houston, & Russell, 1996). Although cycling confers significant health benefits, the bicycle is associated with more injuries than any other consumer project with the exception of motor vehicles (Wilson, Hoover, Baker, Teret, Shock, & Garbarino, 1991).
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