Health Promotion International, Vol. 17, No. 2, 161-169,
June 2002
© Oxford University Press 2002
Development of a Swedish bicycle helmet promotion programme—one decade of experiences
1 Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, Stockholm and 2 National Institute of Public Health, Stockholm, Sweden
Address for correspondence: Professor Leif Svanström Social Medicine, Norrbacka SE-171 76 Stockholm Sweden E-mail: leif.svanstrom{at}phs.ki.se
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SUMMARY |
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Objective: to describe 10 years of experiences of the Swedish National Bicycle Safety Programme which started during 1990 as part of an initiative taken by the World Health Organization (WHO). In relation to WHO's efforts with regard to accident and injury prevention, a global programme to increase helmet-wearing by two-wheel riders was launched. The idea was to introduce a simple ‘vaccine’ for everyone that was achievable at a low cost. The Swedish initiative was taken up by the Karolinska Institute and the National Institute of Public Health. Method: at an operational level, all available methods and data sources were utilized in the programme: surveillance of injuries, provision of information and advice, training and supervision, environment and product improvements, and legislation. Results: considerable progress has been made in reducing bicycle-related injuries in Sweden over the last two decades. Cycling injuries among the elderly must be a matter of particular concern. Conclusions: our 10 years of experiences from a bicycle helmet promotion programme lead to the conclusion that there is a case for mandatory helmet wearing, as one of the most important strategies on the national level. But regional and community-based efforts will still need to be more comprehensive. Besides this, efforts must be made to intensify the activities of parties already involved in prevention programmes. New target groups must be approached, such as immigrants, vulnerable social groups, and teenagers. Sustainability of the Swedish Bicycle Helmet Initiative Group, including continued participation of group members and organizations, is the key—in the long term—to protecting Swedish bicyclists against head injuries.
Key words: bicycle helmet; bicycle-related injury; head injury; helmet legislation; safety programme
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSINITIATION OF A NATIONAL...OBJECTIVES OF THE PROGRAMMEPROCESS AND CHANGES IN...CONCLUSION: IMPLICATIONS FOR...REFERENCES |
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Bicycle use is widespread throughout the world. Millions of people travel by bicycle on a daily basis—both as an economical means of transportation and for recreational and sporting purposes. In Sweden in 1992, cycling accounted for
300 000 million (3%) of total miles (1 Swedish mile = 10 km) covered for personal transportation (H. Thulin, Swedish Road and Transport Research Institute, Linköping, personal communication, 1995). Between 1980 and 1992/1993, cycling doubled among people aged 25–44 years. Cycling also increased, to a lesser extent, among 45- to 64-year-olds (H. Thulin, Swedish Road and Transport Research Institute, Linköping, personal communication, 1995). Since the mid 1990s, however, cycling in Sweden has decreased among all age groups (H. Thulin, Swedish Road and Transport Research Institute, Linköping, personal communication, 2000).
Injuries are a major global public health problem. In Sweden, they are the most frequent cause of death among children, adolescents and adults up to 44 years of age (Sweden's National Board of Health and Social Welfare, 1998
). Sweden has a population of 8.8 million, of which 6 million are cyclists. Among these only 15–20% use head protection according to 1998/1999 data (Sweden's National Road Administration, 1998; Nolén, 1999). Sweden has at the moment no mandatory bicycle helmet-wearing legislation.
Between 1967 and 1996, 2830 cyclists died due to traffic injuries in Sweden—approximately 97 each year, accounting for 10% of all fatalities on the roads (Statistics Sweden, 1997). Each year, between 30 000 and 40 000 people are involved in bicycle-related injuries, and 10 000 suffer head injuries [Lind and Wohlin, 1986; SMP (Svensk Maskinprovning AB), 1998]. On the basis of 1993 figures (adjusted according to the 1996 Consumer Price Index), head injuries to cyclists are currently estimated to impose a cost to society of SEK 4.7 billion a year (Gabrielsson and Christensson, 1996). Each year, 5% of the population buy bicycles (K. Dahlin, personal communication) and bicycle-related injuries account for half of all traffic injuries [Olkkonen et al., 1990; Thulin, 1991; SMP (Svensk Maskinprovning AB), 1998].
A comparison between categories of vehicle users in Sweden shows that the ratio of head injuries to hospital discharges is lowest when helmet use is compulsory. Bicyclists in jurisdictions with no helmet legislation have the highest rate of head injuries of all road users, whereas moped riders and motorcyclists (to whom mandatory restrictions apply) have the lowest (Simpson et al., 1988; Sweden's National Board of Health and Social Welfare, 1991).
The objective of this article is to describe 10 years of experiences of the National Bicycle Helmet Initiative in Sweden. The purpose is not to evaluate the effectiveness of the programme.
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METHODS |
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Describing the development of the Swedish National Bicycle Safety Promotion Programme was performed on the basis of both process, and mortality and morbidity statistics. Process description is based largely on participants' reports, minutes and protocols, and newspaper clippings, whereas changes in injury pattern are based on available data from Sweden's official mortality statistics and death certificates for the period 1967–1996. Another source is hospital discharge data from a national register maintained by Sweden's National Board of Health and Social Welfare. The periods cover the years prior to the introduction of bicycle helmets in Sweden, the time of introduction of the first bicycle helmets and the time of development of the Swedish bicycle helmet promotion programme. Bicycle-related injuries over the study period 1985–1996 were divided according to three victim age groups (
14, 15–64 and 65+ years), and also by external cause (with reference to ICD-9) into two vehicle-injury categories (E819G and E826) (Sweden's National Board of Health and Social Welfare, 1986). The injuries were further divided into two diagnostic groups: ‘head injuries’ (800–804, 850–854, 870–873, 900, 920–921, 925, 930–935, 940–941, 950–951) and ‘all diagnoses’.
Incidence rates were defined as number of fatalities or hospital discharges in any one year divided by the population of the geographic area in that year multiplied by 100 000 (for fatalities) and 1000 (for discharges). A 95% confidence interval (CI) was calculated for each inter-area difference. Linear regression was employed to analyse the trends in incidence rate in each area (Ott, 1984). The slope of the regression line represents the average annual change in incidence.
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INITIATION OF A NATIONAL BICYCLE HELMET PROMOTION PROGRAMME IN SWEDEN |
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In 1986, Swedish consumers were offered a guide to the shock-absorbing and impact-distributing properties of bicycle helmets (National Swedish Board for Consumer Policies, 1986
). The first guidelines came into force in March 1987 and were revised in 1992 (National Swedish Board for Consumer Policies, 1985; National Swedish Board for Consumer Policies, 1992a; National Swedish Board for Consumer Policies, 1992b). A national conference was held in 1987 to further knowledge about bicycle helmet-wearing, and to disseminate experiences of promoting their use.
During 1990, a WHO initiative, a global programme to increase helmet-wearing among two-wheel riders, was launched. The idea was to introduce a simple ‘vaccine’ for everyone at a low cost. The initiative was taken up by a group of WHO Safe-Community collaborating centres, one at the Karolinska Institutet in Stockholm. Sweden's National Institute of Public Health initiated the implementation of strategies for promoting the use of bicycle helmets as part of its National Safety Promotion and Injury Prevention Programme (Ekman et al., 1991; Schelp and Svanström, 1996). An intersectoral approach was adopted in order to involve all agencies already involved in safety promotion. The group initially consisted of the following national authorities:
- Karolinska Institutet
- The Swedish National Institute of Public Health
- Sweden's National Road Administration
- The National Board for Consumer Policies
- The National Board of Occupational Safety and Health
- The Swedish Road and Traffic Research Institute
- The Child Environmental Council/The Office of the Children's Ombudsman (up to 1996)
- Some regional and local government authorities were also represented:
- Götene Municipality (to host the Helmet Secretariat)
- Stockholm County Council (to develop an urban regional programme)
- Skaraborg County Council (to develop a rural regional programme).
During the 1990s the group was joined by representatives of:
- Västerbotten County Council
- The National Swedish Police Board
- Linköping University (Department of Health and Environment/Social Medicine and Public Health Sciences)
- The Swedish National Testing and Research Institute
- The Swedish National Society of Road Safety
- The Swedish Cycle Society
- Swedish Cycling Promotion.
The Initiative Group has met at least twice a year on average and a number of working and task-force groups have been formed. A key programme strategy has been to coordinate activities between participating organizations.
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OBJECTIVES OF THE PROGRAMME |
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The group's principal strategy was to work through existing organizations. It became evident that its most urgent tasks were to: (i) review available literature on the size of the problem, in particular with regard to the effectiveness of helmet-wearing initiatives; (ii) evaluate Swedish initiatives at a local and national level; and (iii) formulate objectives for different target groups.
Based on research findings and the experience and knowledge of group members, the following principal target was established in 1991: ‘To increase the level of helmet use in Sweden in order to achieve a substantial reduction in the number of head injuries and their medical consequences by the Year 2000’ (Ekman et al., 1991).
Sub-targets were that, by the Year 2000, there should be: ‘at least 90% helmet use for children of 12 and under; at least 70% helmet use for children and teenagers 13–18, and at least 70% helmet use for adults’, and also that ‘positive attitudes towards helmet use should be created, and the factors and processes determining behaviour subjected to study’. In addition, there were certain process-oriented targets: ‘to improve and submit knowledge in the area, to examine ongoing work in Sweden and abroad, and to participate in international work within the framework of WHO Collaborating Centres’.
In 1995, the Helmet Initiative Group determined to adjust its helmet-wearing targets to those of the National Traffic Safety Programme 1995–2000, set up by Sweden's National Road Administration, the Swedish Association of Local Authorities, and the National Police Board (Sweden's National Road Administration, 1994). As shown in Table 1, targets were set at two levels.
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All available methods and data sources were utilized with regard to the following (Svanström et al., 1989
; Schelp and Svanström, 1996):
- surveillance of injuries
- provision of information and advice
- training
- supervision
- environment and product improvements, and
- legislation.
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PROCESS AND CHANGES IN INJURY PATTERN |
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Surveillance of injuries
The Initiative Group has drawn upon both national mortality data and nationwide hospital-discharge data to study trends on bicycle-related injuries before and after the start of the initiative. A number of local in-patient and emergency out-patient surveillance systems have also been used for estimating the magnitude of the injury problem.
Table 2 shows the incidence of fatal bicycle-related injuries (per 100 000) in Sweden by age group for the years 1967–1996. Table 3 shows mean incidence (per 100 000), the linear-regression parameter (ß), and the 95% confidence interval (CI) for cyclists killed (per 100 000) in Sweden over the years 1967–1996 by age group.
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There are significant differences between the three age groups in mortality for the entire study period (0.94, 0.76 and 3.46 for age groups
14, 15–64 and 65+ years, respectively). The risk of being killed due to a bicycle-related injury is estimated to be 3.7 times higher for the elderly than for the 14 years group. There were significant changes in trends for all three age groups between 1967 and 1996, equivalent to an average annual decrease of 3.3, 2.4 and 2.3%, respectively.
Table 4 shows incidence rates for bicycle-related injuries (head injuries and all diagnoses) leading to hospital in-patient care (per 1000). Table 5 shows mean incidence (per 1000), the linear-regression parameter (ß), the 95% CI, and percentage annual change.
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There are significant differences between the three age groups with regard to hospital care due to bicycle-related injury. Children of
14 years show a 2.5 times higher incidence of treatment than the age group 15–64 years, and 1.6 times higher than the elderly. For head injuries, the corresponding increments are 3.3 and 3.8, respectively.
There are significant changes in trend between 1985 and 1996 for the two age groups 14 and 15–64 years. There was an average annual decrease for children of 2.2% for all diagnoses, and of 3.4% for head injuries, and corresponding increases of 3.4 and 4.6% for the age group 15–64 years.
An analysis of 15 years of regional and national programmes on bicycle helmet promotion demonstrated positive developments for various programme components (including child health care, staff and parental information/education, helmet-discount schemes, and general community-safety programmes). Repeated information appears to give results in the long term, but is most effective when combined with legislation and multi-faceted training and helmet-discount programmes. Favourable results were also observed when all of these components were incorporated into a comprehensive, community-oriented safety-promotion programme (the ‘Safe Community’ model) (Ekman et al., 1997).
A regional study showed significant differences between incidence rates for bicycle-related injuries in rural and urban areas, with incidence higher in rural areas (Welander et al., 1999).
Evaluation of national and local programmes has been performed by the Initiative Group (Ekman et al., 1997). Finding that a large number of elderly bicyclists sustained head injuries prompted the establishment of a task force on bicycle safety for the elderly within the Initiative Group.
Provision of information and advice
To coordinate the work of the group, a secretariat was established in 1992 as part of a collaboration contract between the National Safety Promotion and Injury Prevention Programme of the Swedish National Institute of Public Health and the Skaraborg Institute (information available at http://www.safetyandhelmets.nu/). The Secretariat was granted WHO status through its links with the Karolinska Institutet and the Institute's WHO Collaborating Centre on Community Safety Promotion (Ekman and Welander, 1998). Its staff provide advice, supply information materials, and organize conferences and seminars. Approximately 1 000 000 brochures with evidence-based facts, posters and videos, mainly designed for families, pre-school and school children, adults and the elderly, have been ordered from around Sweden. Orders came mainly from district nurses/ child health care centres, local medical care centres, compulsory schools and high schools, universities, parent organizations, pensioners' organizations, traffic-safety authorities in municipalities, the police force, labour unions, safety inspectors, trade, commerce and industry, the National Association for Road Safety and other voluntary traffic-safety organizations, and also the general public.
Training
The strategy has been to participate in existing training programmes and to organize conferences and seminars. All seven ‘National Injury Prevention’ conferences and 10 ‘Safe Community’ conferences during the last decade have included presentations from members of the Initiative Group. Group members have also participated in numerous international events, to share their ideas and experiences and to learn from the experiences of others. Group representatives also give lectures to students on mainstream university courses in Sweden (at departments of public health sciences, social medicine, economics, etc.), and also to students on MPH (Master of Public Health) and PhD courses in public health sciences. The task force on bicycle safety for the elderly has organized training events for pensioners’ organizations throughout Sweden. More than 10 scientific studies on the epidemiology, implementation and evaluation of members of the Initiative Group have been published in international journals.
Via contacts with colleagues, universities, nursing schools, high schools and compulsory schools, students are encouraged to develop their skills with regard to traffic safety through the writing of reviews and essays.
Supervision
Each year, Sweden's National Road Administration reports the annual rate of helmet use on the basis of a sample of 4000 households. Furthermore, since 1988, the Swedish Road and Traffic Research Institute (VTI) has published annual reports on helmet use based on observation studies of cyclists in 21 municipalities.
Table 6 shows some results of these observation studies from 1988, 1998 and 1999. The use of bicycle helmets has increased in all age groups. Children aged 10 years now have a usage rate of 49.6% (1999), compared with 20.2% in 1988. There are wide variations in helmet usage between age groups and geographic areas. Also, gender differences in helmet use in the 65+ group (males 10.8%, females 18.7%; 1998) have been observed (Nolén, 1999).
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Another form of supervision is the local use of specially designed age-related checklists distributed by Sweden's child health care organization.
Environment and product improvements
One of the policies of the Initiative Group is to use helmet campaigns to complement environmental change and the development of safer vehicles (bicycles). Extensive efforts are made to extend the network of safe-cycle lanes and to implement safety-promoting changes in transport structure, particularly in high-risk rural areas. The National Institute of Public Health is also promoting safe cycling as part of its strategy to encourage physical activity.
There are reasons to believe that the quality of bicycles has to be improved. For example, children's bicycles without pedal-operated foot-brakes have been introduced. The technical quality and safety of bicycles has been shown to be highly variable.
As a guide for consumers, Sweden's National Board for Consumer Policies issued a report on the 12 helmets on the market in 1987. (Eight years later, in 1995, there were about 70 models available.) So far, nobody has written an overview of the market situation.
Legislation
The Swedish Bicycle Helmet Initiative agreed that a multi-faceted strategy would be needed to achieve their objectives—a conviction based on experiences from the strategies of the Swedish National Safety Promotion and Injury Prevention Programme (Svanström et al., 1989; Schelp and Svanström, 1996). Although legislation was not originally envisaged as a tool for outcome achievement, the positive findings from Australia and New Zealand convinced the Initiative Group that Swedish Government targets would not be achieved within the time stipulated. For this reason, in later years, the Initiative Group has adopted the strategy of promoting mandatory helmet-wearing legislation, but in combination with information and educational efforts for all age groups. Therefore a special task force group on legislation has been established within the Initiative Group. The Group has approached the Ministry of Transport, argued for legislation in the press, and organized seminars and conferences (with, for example, invited speakers from Australia). Through the National Road Administration, a special memorandum was sent to the Minister of Transport. The response to the idea of legislation was positive—‘but not now’. The Swedish Parliament, through the national ‘Zero Vision’, has now adopted the goal of mandatory helmet-wearing, but has left it to the government to decide when this should be implemented.
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CONCLUSION: IMPLICATIONS FOR INJURY PREVENTION |
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Both Swedish and international studies demonstrate the positive effects of wearing bicycle helmets (Cass and Gray, 1989
; Thompson et al., 1989; Kroon, 1990; Schelp and Ekman, 1990; Leicester et al., 1991; Björnstig et al., 1992; Coté et al., 1992; Baker et al., 1993; Olkkonen, 1993; Cameron et al., 1994; Rivara et al., 1994; Henderson, 1995; Rodgers, 1995a; Rodgers, 1995b; Svanström et al., 1995; Thompson et al., 1996; Ekman et al., 1997; Welander, 1999; Scuffham et al., 2000). There is evidence that the incidence of head injuries among helmet users is 60–80% lower than that among non-helmet wearers (Thompson et al., 1989; Thompson et al., 1996). Injury data demonstrate to a considerable extent bicycle-related mortality risk for the elderly compared with children, who in turn show a higher mortality risk than 15- to 64-year-olds. This confirms the findings of earlier studies (Kingma, 1994; Larsen et al., 1995). The Initiative Group has been active for a decade. It is unanimous in its conviction that long-term strategies are needed to reach its long-established targets. Target levels remain the same, but the time frame needs to be revised. Levels of helmet use have been increasing continuously, but not at the rate at which the Group had anticipated or hoped.
Our 10 years' of experiences from a bicycle helmet promotion programme lead to the conclusion that there is a case for mandatory helmet-wearing, as one of the most important strategies on the national level. But regional and community-based efforts will still need to be more comprehensive. Besides this, efforts must be made to intensify the activities of parties already involved in prevention programmes. New target groups must be approached, such as immigrants, vulnerable social groups and teenagers. Sustainability of the Swedish Bicycle Helmet Initiative Group, including continued participation of group members and organizations, is the key—in the long term—to protecting Swedish bicyclists against head injuries.
More research needs to be done with regard to traffic-injury patterns. The previous decade marked the establishment phase of the Swedish Bicycle Helmet Initiative Group. There is more to come in the new millennium.
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