3.2 Promote Bicycle Helmet Use With Education

Overall Effectiveness Concerns: This countermeasure has been examined in several research studies. There is some evidence that certain approaches may lead to increased helmet use and more favorable attitudes towards helmet use, especially among children. However, more research is needed to conclude that the countermeasure is effective when broadly targeted towards all cyclists.

Bicycle helmet promotions increase use of helmets and thereby decrease severe and fatal brain injuries to bicyclists involved in crashes. Bicycle helmet promotions are frequent but usually aim at child bicyclists only, often through youth health organizations and schools. Promotions can target barriers to helmet use, including absence of a helmet, child and families’ lack of understanding of the importance of helmet use, cost of helmets, and negative attitudes or beliefs about helmet use. Programs that provide helmets can include sponsoring organizations and often involve law enforcement and schools to deliver helmets, fit the helmets, and teach proper fitting and use. Promotions can be conducted through single events or extended campaigns to promote helmet distribution and use. These should not be limited to just children, but should include adults requires as well because crashes are not limited to just children to those who are deemed less skilled at bike riding. Expanding helmet promotions to adults requires expansion in focus, and perhaps different sponsors. However, adding adult-oriented riding tips may increase the appeal of the program. Other adult-oriented strategies should also be included, such as peer-based interventions on a college campus (Buckley et al., 2009).

Regardless of the target audience, bicycle helmet promotions must include instruction on how to properly fit the helmet and the importance of wearing helmets on every trip. See Sections 1.1 and 2.1 for more information. The Bicycle Helmet Safety Institute has extensive information on helmets, purchasing a helmet, helmet fit, when to buy a new helmet, helmet recalls, and the difference between helmet brands, see www.helmets.org/. Programs might also need to target differences in tendency to adopt helmet use for different riding purposes (recreational versus commuting), or riders who identify as only one type of rider (Kakefuda et al., 2009). All bicyclists could benefit from using resources that demonstrate how helmets work to reduce injury. Moreover, further efforts are needed to encourage parents and authority figures (LEOs, school officials and staff, and health-care professionals) to reinforce and model desired behaviors including the use of a properly fitted bicycle helmet every ride (Maitland, 2013). Trained and skilled cyclists may also be more likely to adopt helmet use (Kakefuda et al., 2009), so adult bicycle training programs that incorporate the importance of helmet use may help increase wearing by adult riders. A survey of U.S. attitudes toward bicycling and walking indicates that about 34% of respondents who had ridden bicycles in the past year used helmets for all or nearly all their rides (Schroeder & Wilbur, 2013).

Use: Most States have conducted bicycle helmet promotions for children in the last few years, although only a few have ongoing or regular programs. Some States have conducted bicycle helmet promotions for general audiences.

Effectiveness: Bicycle helmets are proven to reduce injuries and fatalities (see the Bicycle Safety chapter, Sections 1.1 and 2.1). Helmet promotions are successful in getting more helmets into the hands of bicyclists. Rouzier and Alto (1995) described a comprehensive program of presentations, media coverage, messages from doctors to patients, as well as low-cost helmet availability, which significantly increased helmet purchases and use for all ages. A peer-led, social marketing program on a medium-sized college campus also raised observed helmet use, at least for the short term (Ludwig et al., 2005). A school-based injury-reduction program targeting 13- and 14-year-olds incorporating opportunities for instruction, demonstration, rehearsal, feedback, social reinforcement and practice was associated with a 20% increase in observed rate of helmet use among this challenging target age group at 6 months follow-up (Buckley et al., 2009). In France, voluntary helmet use increased from 7.3% in 2000 to 22% in 2010. During that time, national public awareness and informational campaigns were initiated and carried out promoting helmet use among youth, adults with children, and the general population (Richard et al., 2013). In Cambodia a school-based helmet distribution program “Helmet for Kids” helped achieve and sustain high helmet usage rates (Ederer et al., 2014). Prior to program implementation, helmet usage rates were less than 0.5% in 9 intervention and four control schools. Free, high-quality tropical helmets that were fitted to each student and designed for use with both bicycles and motorcycles were distributed to more than 6,700 students in 9 schools. Voluntary helmet use increased to 87.9% in the first 2 weeks after distribution, and the use rate was sustained (86.5%) 3 to 4 months after. Helmet use stayed below 1% in the control schools during this time.

A Cochrane systematic review and meta-analysis of 22 studies evaluating non- legislative helmet promotion programs aimed at children under 18 found the odds of observed helmet wearing were significantly greater among those receiving the interventions (Owen et al., 2011). The study found the more effective programs were community-based rather than aimed at people, provided free rather than subsidized helmets, and were set in schools. A Canadian program, Operation Headway, involving enforcement of bike helmet legislation, education, rewards for wearing and economic penalties for non-wearing, and provision of helmets to low-income groups was evaluated by Lockhart et al. (2010). The researchers found the program increased wearing rates (based on observations pre- and post-intervention), increased knowledge and commitment to wearing a helmet, saw greater public awareness of the law through media tracking, and improved relationships between police and the public (based on anecdotal evidence). Another helmet-use promotion program, involving distributing helmets and information, was evaluated in France (Constant et al., 2012). This study found that the helmet promotion program was of value in increasing helmet use, but not sufficient to achieve high rates of helmet use among adult cyclists. A related theme of these studies is that population-wide, multifaceted, integrated, and repeated prevention programs are needed, which should include distribution of free helmets and safety information and strategies to increase peer and parental pressure.

Programs that increase proper use of helmets would be expected to reduce injuries in the event of a bicycle crash (see Section 1.3).

Costs: The cost for underwriting large numbers of helmets can be quite high, including supporting communications and outreach material. Adequate helmets can be purchased for as little as $8 each, in reach of most adult bicyclists. Purchase of large quantities of helmets by businesses, hospitals, or through partnerships with merchants for example can also lower the cost per helmet and make free or subsidized distribution of helmets to at-risk segments of the population more feasible.

Time to implement: A good campaign, including market research, material development, and message placement, will require at least 6 months to plan and implement.