The promotion of safe behaviours at the community level : evaluation of a bicycle helmet-wearing campaign among 5- to 12-year-old children

Abstract

Bicycle-related injuries are among the most important public health problems in childhood. In the Montérégie Region (Québec, Canada), at the beginning of the 1990s, a 4-year community-based program aimed at promoting voluntary bicycle helmet wearing among children aged 5-12 was implemented. The program's target was to increase the rate of helmet use from 1.3% before the program (1989) to 20% in 1993 and, thereby, to reduce the rate of bicycle-related head injuries leading to hospitalisation. The aim of the thesis is to assess the impact and outcome of the Montérégie program, considering children's age and sex and socio-economic status. Four studies form the thesis, each of which includes a comparison community and repeated measures in both the intervention and reference community.

The first two studies focus on behavioural changes over time. Study 1 was questionnaire-based and addressed self-reported measures including e.g., children's intention to wear a helmet and to own a helmet. Study 2 was observation-based and essentially concerned with behavioural changes de facto, both in general and according to various cycling environments (i.e., sites and living areas). The results show an increasing adoption of the target behaviour over time. The program was effective in increasing children's motivation both to use and to own a bicycle helmet. After the program had been operating for four years, 56% of the children in the target community, compared to 36 % in comparison community reported owning a helmet. The program had an accelerating effect on ownership and it was the main predictor of high intention to use a bicycle helmet. Furthermore, helmet use when cycling grew steadily and substantially over time in the target community, from a rate of 1.3% before the program implementation to 32.5% after the fourth year of the program, compared to 14% in comparison community. Helmets were worn less among boys, older children, among children observed both on school roads, and in poor municipalities. The program proved to be only one-in-three times as effective among children observed in poor municipalities as is richer ones.

Study 3 and 4 dealt with changes in head-injury risks over time, considering in turn age and sex of the child (study 3) and living area socio-economic status (study 4). Data on children who were hospitalised because of bicycle-related injuries for the years 1988-1996 were obtained from the Provincial Government inpatient register that offers full coverage of hospitalisations in Québec. A reduction of the rate of hospitalisation for bicycle-related head injuries over time was observed among boys and girls, younger and older children and also among children from both poor and average-rich municipalities. The program's positive impact on head-injury risk reduction was maintained. during the three-year period following the completion of the program. In spite of the lower penetration of the program among higher risk groups in terms of helmet wearing (i.e., boys, children from poor municipalities), all groups obtained a reduction of injury-risk levels.

As a whole, the results reveal favourable results in terms of increased bicycle-helmet wearing and decreased head-injury morbidity. It is very likely that the program in itself is responsible for a large share of those favourable results. Among other assets, it was based on multiple strategies consistent with underlying theory of behavioural change and planning framework and it included a wide variety of activities undertaken yearly and targeted towards determinant stakeholders. Also, the process was followed up very closely.

In general terms, the result support the idea that population-based educational programs have the potential to impact on bicycle-related head injury reduction for all. They can benefit children from less accessible and most at risk groups, without stigmatising them unduly or threatening their autonomy.