Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

A Distorted Paradigm: Helmet Legislation Among Youth Detracts from a Comprehensive Attitude Towards Safety -- Anna Graves

Common wisdom within bicycle campaigns suggests that the finding of strong positive correlation between helmet legislation and head injuries supports the adoption of legislation for certain age groups (1,2). In 2005, there were 784 fatalities and an additional 45,000 injuries sustained in traffic crashes. Nearly one-fifth (18%) of the fatalities involved cyclists aged 10-20 years old; a number disproportionate to the population size (3). As such the issue of bicycle safety, especially among youth, is one that merits a concerned and thorough public health discussion. However, campaigns have failed to employ comprehensive interventions that successfully target this at-risk group.
As H. L. Mencken would say, for every complex problem, there is a solution that is simple, neat, and wrong. This paper contends that helmet legislation as the primary thrust and cornerstone of bicycle safety campaigns among youth is a cookie cutter solution for three primary reasons. First, it misplaces the focus of campaigns and detracts from other safety behaviors. Second, it is an individual-level intervention that ignores a range of societal and structural factors that increase bicycle safety. Finally, it fails to take into account the importance of youth attitudes and social dynamics as important behavioral determinants. The overall effect is a myopic paradigm with which bicycle safety is approached, and this has harmful consequences for the overall aim of campaigns.
Misplaced Focus
Legislation misplaces the focus of bicycle safety campaigns by putting helmets at the helm of the issue. Compliance with helmet laws is hailed as the primary safety behavior whilst the notion of a comprehensive attitude of safety is set on the back burner. Even non-legislative interventions such as research into helmet safety and aesthetic design, helmet giveaways, and educational programs for proper fit are spin-offs of the centrality of helmet usage. The implications of this tunnel vision are significant. The chance of an accident decreases significantly when cyclists use hand signals, are equipped with a safe bicycle and appropriate lighting equipment, travel at safe cycling speeds, and are unimpaired in their judgment by poor visibility or intoxication (4). Unfortunately, there has been a lack of emphasis upon such aspects of behavior in bicycle safety campaigns.
There is significant debate polarized around the misplaced center of helmet legislation. Opponents of legislation often argue that it constitutes unwarranted infringement of civil liberties of cyclists, and turns a pleasant leisure activity into ‘medicalized behavior (4,5).’ As a retort, proponents often portray wielders of such arguments as being unwilling to adopt relatively minor behavioral changes for the sake of safety, and dismiss them as being unreasonable (6). Such debates have tied up bicycle safety campaigns in judicial and policy-making circles, and because of the emphasis on the primacy of legislation, have precluded the widespread implementation of other measures. In addition, the political presumption that legislation is a primary solution to the problem of safety has crept into the public health domain. The issue has been defined, assessed, intervened upon and evaluated through the lens of helmet usage. In particular, evaluative studies often either control for or mention in passing a range of safety behaviors deemed confounding to the true object of study-- the efficacy of helmet legislation (1). This generates a cycle of less than optimal interventions and evaluations.
The focus on legislation may be an impediment to those who lack the self-efficacy to wear a helmet. These cyclists automatically assume themselves more prone to accidents and fail to adopt other behaviors that would greatly increase safety, even if helmets are not worn. This introduces a compounding phenomenon where the choice to not wear a helmet actually becomes a risk factor for not adopting other safety behaviors. In other words, the very population that campaigns hope to target is the same population that may feel marginalized and begin to characterize themselves as being ‘unsafe cyclists.’ This may preclude them from adopting a holistic attitude towards safety. Studies in support of this theory have shown that those who do not wear helmets are also less likely to “ride in... bicycle paths than city streets, obey traffic laws, wear fluorescent clothing and use lights at night (8).” This may be the most dangerous impact of all. While a helmet may serve as protection in the event of an accident, a behavior such as using a bicycle light may prevent an accident altogether (9). The chance of an accident relates directly to the visibility of the cyclist to motorists and pedestrians. Based on this principle, French law omits legislation pertaining to helmets, but mandates instead that retailers equip bicycles with lights and gives police the authority to stop cyclists for non-compliance with light laws (10).
Individual-Level Intervention
Helmet legislation places the responsibility for accident prevention squarely on the shoulders of the cyclist. It is an individual-level intervention that fails to highlight a range of societal and structural factors that increase bicycle safety. To begin with, the behavior of motorists is crucial to overall road safety. Significant injuries to a cyclist are 3-5 times more likely in collisions with motor vehicles as compared to bike only crashes. In most cases, both parties are at fault. Unfortunately, blame often falls on the cyclist, thanks in part to the societal expectations that they be the ones to exhibit safe behavior. The National Highway Traffic Safety Administration reinforces the importance of mutual responsibility and respect so that each party knows they are responsible for safety (4).
The speed at which vehicles are traveling greatly impacts safety. Trial zones in which 20mph limits were enforced had significantly lower incidence of injuries and fatalities than their control counterparts (11). Injury criteria to the head (79%), chest (30%), and pelvis (16%) were reduced with a 6 mph decrease in speed (12). In this particular intervention, legislation may be a powerful tool to increase road safety.
Structural factors also play an important role in reducing the chance of collision. The 2006 NHSTA Bicycle Report shows that 66% of fatalities occur in urban areas between the hours of 5 and 9 p.m, the busiest hours of traffic. It recommends the addition of additional bike paths and lanes in urban environments that limit the co-mingling of traffic and bikes. As a stark example of the successes of bicycle-specific road constructs, there were 225 bicyclist fatalities In New York City between 1996 and 2005, but only one of these occurred when a bicyclist was in a marked bicycle lane (13). Other important structural contributors to safety are “Share the Road” signs and up kept roads.
One of the most serious accusations leveled at helmet legislation is that it decreases the number of cyclists on the road and thereby increases risk per remaining cyclist—whether or not they are compliant with the enforced laws. The Safety in Numbers theory proposes that the incidence of fatalities and injuries does not increase linearly with the number of cyclists. Instead, it follows a power curve whereby the risk of collision decreases by roughly -0.6 the power of the number of people cycling. Thus a two-fold increase in numbers of cyclists would cause collisions to only disproportionately increase by a 32% and summarily benefit everyone (14). In societies where a larger proportion of society actively participates in cycling, motorist are more likely to be cyclists themselves and be more aware of other cyclists, hence avoiding more accidents (9).
Youth Culture and Attitudes
Youth, especially those who deliberately engage in dangerous cycling activities, are inevitably bound to the youth culture. As such, interventions need to be developed in a culturally sensitive and competent manner (15). This is particularly true given that youth between the ages of 11 and 20 years have the lowest helmet usage rates (16). Among youth, attitude is a particularly strong behavioral determinant. The Truth campaign, a highly successful anti-smoking intervention directed at Florida youth, was based on the premise that adolescents want to be told the facts and then left to make their own educated decisions (17). Safety helmet legislation may come across as being restrictive and dogmatic, inciting some youth to respond negatively and potentially participate in more dangerous behaviors as a means of resisting authority.
Rebellious attitudes aside, many youth have logical and practical reasons for their choice to not wear helmets. Research on college-aged youth has showed that they think helmets are uncomfortable (20%), restrict the natural feeling one gets from riding a bike (23%), make them look silly (36%) or are a nuisance to store between rides (33%) (11). Some of these perceptions may seem trivial but are apparently significant barriers to helmet use. While it must be conceded that legislation may be the positive tipping-point factor in the decision to wear a helmet, the manner in which youth reach the decision is crucial. It will inevitably effect how they frame the issue in their discussions with peers and how they will behave in the absence of enforcement or once they reach an age that excludes them from jurisdiction. Importantly, a choice that is self-initiated is more likely to be maintained. A detailed report comparing pre- and post-legislation counts concluded that youth were particularly resistant to changes not self-enforced. In the year following helmet legislation, teenagers registered a 44% drop in helmet usage compared to a 29% drop in adults (18). It is therefore crucial that youth be viewed in the context of their own youth culture, and that they be viewed as rational individuals. Interventions that take these considerations into account will lead to safe behavior being internally motivated rather than a forced.
Social Dynamics
Social dynamics also play crucial roles in decisions youth make about their behavior. A recent study based on social psychological models showed the subjective norm to be the strongest predictor of the intention to use a bicycle helmet (18). Only one in four students would not mind wearing a bicycle helmet even if friends did not wear them, leaving the other three to depend on the opinions and decisions of their friends (19). Instead of viewing this trend as an impediment to the encouragement of safety behaviors, campaign project researchers should embrace a community-based approach that positively incorporates social dynamics. Change should be instituted at a grassroots level instead of using the legislative thrust. A highly successful campaign at the University of Southern Carolina coupled this approach with social marketing. The student-initiated campaign developed the slogan “The Grateful Head” and succeeded in raising the helmet use across campus from a baseline mean of 27.6% to a mean of 49.3% by the last weak of intervention (20).
Another useful social theory is the Diffusion of Innovations Theory. It offers the concept of “early adopters”-- individuals who pick up on the benefits of a certain innovation and through social contacts, ideally spread the acquisition of the innovation. Using this model as a critique of current campaigns, it may be said that potentially beneficial sources of social influence are seldom incorporated. For instance, some bicycle interest groups appeal to youth and their subcultures but do not explicitly endorse helmet usage among their following. They often organize and compete in local competitions wherein incentives for the most popular bikers to speak up for bicycle safety could have widespread ripple effects. Bicycle retail shops are also often rider run, and because they already have a profit-driven motive to sell safety equipment, they are potentially an important voice for pushing bicycle safety. As a final note, campaigns should more actively employ the arm of media advocacy. Hip cycling or extreme sport personalities could be portrayed as early adopters of safe behaviors and encourage their following to do likewise. Therefore, a consideration of social dynamics among youth may open up a potential goldmine of interventions that could replace the lagging benefits of legislation.
Conclusion
The health benefits and environmental friendliness of cycling are undeniable. Bicycle safety campaigns strive to decrease in mortality and rate of injury while simultaneously increasing access to the cycling-- a task particularly challenging with regard to the younger generation. This paper suggests that the use of helmet legislation as a primary thrust of bicycle safety campaigns has been deleterious to their overall aims.
Instead, a bicycle safety needs to be approached with a much more comprehensive attitude. This will reduce the skew of interventions towards helmet usage and place greater emphasis on the societal and structural factors that factor into safety. In addition, such an attitude will demand a revision of the approach towards understanding the target audience of youth. This may involve the soliciting of youth specialists, the extensive use of sociological models, and the observation of youth trends and cultural shifts. Campaigns should be assured that such efforts will not go unrewarded as positive decisions internally motivated are likely to carry on into adulthood and so confer long-lasting impact. To reach this aim, significant reforms need to be made to the paradigm through which bicycle safety is viewed.
REFERENCES
1. Macpherson AK, To TM, Macarthur C, Chipman ML, Wright JG, Parkin PC. Impact of mandatory helmet legislation on bicycle-related head injuries in children: A population-based study. Pediatrics 2002; 110:e60.
2. Attewell RG, Glase K, McFadden, M. Bicycle helmet efficacy: a meta-analysis. Accid. Anal. Prev. 2001; 33:345-352.
3. NHTSA’s National Center for Statistics and Analysis. Bicyclists and other cyclists. Traffic Safety Facts 2005, DOT HS 810 617, http://www-nrd.nhtsa.dot.gov/Pubs/810617.PDF.
4. London Cycling Campaign. Cycle helmets. London: LCC, 1999.
5. Skrabenek P. The death of human medicine and the rise of coercive healthism. London: Social Affairs Unit, 1994.
6. Sheikh A, Cook A, Ashcroft R. Making cycle helmets compulsory: ethical arguments for legislation. J R Soc Med 2004; 97:262-265.
7. Cook A, Sheikh A. Trends in serious head injuries among cyclists in England: analysis of routinely collected data. BMJ 2004; 321:1055.
8. Lajunen T, and Rasanen M. Can social psychological models be used to promote bicycle helmet use among teenagers? A comparison of the Health Belief Model, Theory of Planned Behavior and the Locus of Control. Journal of Safety Research 2004; 35:115-123.
9. Williams J, and Boyd H. Howard Boyd on: In training England’s cyclist. Interview of Howard Boyd, Bicycle Forum 1982; 8:24-31.
10. Osberg JS, Stiles SC, Asare OK. Bicycle safety behavior in Paris and Boston. Accid Anal. and Prev. 1998; 30: 5:679-687.
11. Geffen R. Portsmouth, Newcastle and Southwark to become 20mph zones. Cycle Digest 2006; 48:4.
12. Robinson DL. Reasons for trends in cyclist injury data. Injury Prevention 2004;10:126-127.
13. New York Department of Health and Mental Hygiene, 2005. Bicyclist Fatalities and Serious Injuries in New York City. www.nyc.gov/html/dot/downloads/pdf/bicyclefatalities.pdf.
14. Jacobson PL. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Injury Prevention 2003; 9:205-209.
15. Rosenfeld SL, Fox DJ, Keenan PM, Melchiono MW, Samples CL, Woods ER. Primary care experiences and preferences of urban youth. Journal of Pediatric Health Care 1996; 10:4:151-160.
16. Rodgers GB. Bicycle helmet use patterns in the United States: A description and analysis of national survey data. Accid. Anal. and Prev. 1995; 27:1:43-56.
17. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
18. Hagel BE, Pless B. A critical examination of arguments against bicycle helmet use and legislation. Accid. Anal. Prev. 2006; 38:2:277-278.
19. Everett A, Price JH, Bergin DA, Groves BW. Personal goals as motivators: predicting bicycle helmet use in university students. Journal of Safety Research 1996; 27:1:43-53.
20. Ludwig TD, Buchholz C, Clarke SW. Using social marketing to increase the use of helmets among bicyclists. Journal of American College Health 2005; 54:1:51-58.

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2 Comments:

  • At December 14, 2007 at 9:09 AM , Anonymous Anonymous said...

    This year the VeloCity cycling conference in Munich included details of my helmet paper. The ECF are the leading cycling organisation in the world, therefore my article has been peer reviewed by the world's leading cycling body. I believe the article "The case against cycle helmets and legislation" details many concerns and shows that helmet legislation can do more harm than good. The report can be viewed (some inserts are not provided) at

    www.ctcyorkshirehumber.org.uk/campaigns/velo.htm

    or a pdf copy with inserts can be obtained by emailing

    Colin@vood.freeserve.co.uk

    or viewed at

    http://cyclingedinburgh.files.wordpress.com/2007/10/colin-clarke-velo-city.pdf


    It provides useful additional information about helmet safety aspects and legislation. It contains many details not provided in other reports and provides an estimate of the harm that can result from introducing enforced helmet legislation.




    Regards Colin Clarke
    Honorary Secretary CTC
    Yorkshire and Humber Region
    York UK
    Colin@vood.freeserve.co.uk

     
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