[Congressional Record Volume 140, Number 62 (Wednesday, May 18, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: May 18, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
  BICYCLE HELMETS SAVE CHILDREN'S LIVES: A SUCCESS STORY FROM SEATTLE

                                 ______


                           HON. MIKE KREIDLER

                             of washington

                    in the house of representatives

                        Wednesday, May 18, 1994

  Mr. KREIDLER. Mr. Speaker, as the House takes up the conference 
report on H.R. 965, the Child Safety Protection Act, I want to express 
my special support for title II of the bill, the Children's Bicycle 
Helmet Safety Act. This legislation authorizes Federal assistance to 
State and local programs that require or encourage children to wear 
bicycle helmets.
  Five to six hundred American children die each year from bicycling 
injuries, but we could prevent 85 percent of head injuries in bicycling 
if everyone used a helmet. That's why it is so important to see that 
children wear helmets when riding bicycles, and to get that message to 
every parent and child in this country. This bill will help accomplish 
that goal.
  Recently the Injury Prevention and Research Center at Harborview 
Medical Center in Seattle examined the effect of its bicycle helmet 
promotion campaign on bicycle-related head injury admissions to local 
hospitals. This is the first time such a direct correlation has been 
made between increasing helmet use and reduction in injuries.
  Harborview's center is one of eight injury control centers designated 
by the Centers for Disease Control and Prevention, and I want to share 
the findings of this research with my colleagues. As Dr. David 
Grossman, acting director of the center, wrote to me, ``saving lives 
and dollars and informing others how to do the same is something we can 
all be proud of.''
  That's why I am including with these remarks an article from the 
April 4, 1994 issue of Pediatrics, the professional journal of the 
American Academy of Pediatrics, reporting the success of Seattle's 
educational campaign to increase bicycle helmet use among children. The 
authors are Dr. Frederick P. Rivara, Diane C. Thompson, Dr. Robert S. 
Thompson, Lisa W. Rogers, Bruce Alexander, Debra Felix, and Dr. Abraham 
B. Bergman.
  Seattle's program is an outstanding example of what can be 
accomplished. This bill will help make such programs possible across 
this country. I commend the Seattle experience to everyone concerned 
about children's safety and health.

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

       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 campaign.
       Outcomes. Rate of observed bicycle helmet use in the 
     community and incidence of bicycle-related injuries in a 
     health maintenance organization population.
       Results. Helmet use among school-aged children increased 
     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 a health maintenance 
     organization.
       Conclusions. Educational campaigns can increase helmet use 
     and decrease the incidence of bicycle-related head injury. 
     Pediatrics 1994; 93:567-569; bicycle-related head injury, 
     bicycle helmet, educational campaign.
       Bicycling injuries to children account for some 300,000 
     emergency department visits\1\ 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%.\3\ 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\
---------------------------------------------------------------------------
     Footnotes at end of article.
---------------------------------------------------------------------------
       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 promote 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, school and youth 
     programs, and a discount coupon. The campaign 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 represent 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 
     number of children residing in each census tract. Observers 
     went to each site for 20 minutes and recorded data on all 
     children observed 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 variable.\5\ However, adjusted and unadjusted 
     rates were nearly identical; 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 facilities. Injured GHC cyclists 
     were identified during a 1-year surveillance of the two GHC 
     Seattle area emergency departments and there 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\ Incidence 
     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 of 38.1% in boys compared with 47.2% in girls, 
     and 47.8% in whites compared with 8.2% in black 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 children 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.

          TABLE 1.--OBSERVED BICYCLE HELMET USE, SEATTLE, 1992          
------------------------------------------------------------------------
                                                             Helmetusers
                 Category                     N     Percent  incategory,
                                                               percent  
------------------------------------------------------------------------
      Total...............................    701       100         40.2
                                           -----------------------------
Sex:                                                                    
    Male..................................    538      76.8         38.1
    Female................................    163      23.2         47.2
                                           =============================
Race:                                                                   
    White.................................    556      79.3         47.8
    Black.................................     73      10.4          8.2
    Asian.................................     58       8.3         15.5
    Other.................................     14       2.0          7.0
Medium household income of site:                                        
    Low...................................    168      24.0         31.6
    Middle................................    283      40.4         41.7
    High..................................    250      35.7         44.4
Site type:                                                              
    Street................................    130      18.5         23.1
    School................................    333      47.5         38.1
    Park/playground.......................    138      19.7         39.1
    Bike path.............................     81      11.6         82.7
    Store.................................     19       2.7         21.1
Companions:                                                             
    Adult with helmet.....................     57       8.1         94.7
    Adult without helmet..................     14       2.0         35.7
    Child with helmet.....................     99      14.1         81.8
    Child without helmet..................    143      20.4          7.0
    Riding alone..........................    388      55.4         34.0
------------------------------------------------------------------------

       There was a remarkable decline in head injuries among 5- to 
     9- and 10- to 14-year-old children in the 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 1987\4\ to 54% for 5- to 9-year-olds and 
     37.7% for 10- to 14-year-olds in 1992.

 TABLE 2.--INCIDENCE OF BICYCLE-RELATED INJURIES PER 100,000 IN 1987 AND
   1992: GROUP HEALTH COOPERATIVE OF PUGET SOUND EMERGENCY DEPARTMENT   
                              SURVEILLANCE                              
------------------------------------------------------------------------
                                       1987      1992   Percentdecreased
------------------------------------------------------------------------
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, percent of                                       
         total......................     32.1     16.4           48.9   
------------------------------------------------------------------------

                               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 injuries in a subset of the target 
     population of children. These results strongly suggest that a 
     concerted, coordinated communitywide approach which counters 
     a specific injury problem with a specific intervention can be 
     effective. Similar programs have now been developed 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 bicycle 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.
       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 generalized 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 influences 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 
     availability 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 multifaceted 
     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 components 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 helmet 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 medical care for the resultant head injuries which are 
     averted.\10\
       Observations in fall of 1993 indicate almost 60% of 
     children were helmeted.


                            acknowledgments

       This work was funded in part by grant R49/CCROO2570 from 
     the Centers for Disease Control and Prevention, and the Snell 
     Memorial Foundation.


                               footnotes

     \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. The Injury 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 Engl J Med. 
     1989; 320:1361-1367
     \4\Bergman AB, Rivara FP, Richards DD, Rogers LW. The Seattle 
     children's bicycle helmet campaign. AJDC. 1990; 144:727-731
     \5\DiGuiseppi CG, Rivara FP, Koepsell TD, Polissar L. Bicycle 
     helmet use by children. Evaluation of a community-wide helmet 
     campaign [see comments]. JAMA. 1989; 262:2256-2261
     \6\Thompson, DC, Thompson RS, Rivara FP. Incidence of bicycle 
     related onjuries in a defined population. Am J Public Health. 
     1990; 80:1388-1389
     \7\Cote TR, Sacks JJ, Lambert-Huber DA, et al. Bicycle helmet 
     use among Maryland school children: effect of legislation and 
     education. Peduatrics. 1992; 89:1216-1220
     \8\Vulcan AP, Cameron MH, Watson WL. Mandatory bicycle helmet 
     use: experience in Victoria, Australia. World J Surg. 1992; 
     16:389-397
     \9\DiGuiseppi CG, Rivara FP, Koepsell TD. Attitudes toward 
     bicycle helmet ownership and use by school-age children. 
     AJDC. 1990; 144:83-86
     \10\Thompson RS, Thompson DC, Rivara FP, Salazar A. Cost-
     effectiveness analysis of bicycle helmet subsidies in a 
     defined population. Pediatrics. 1993; 91:902-907

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