Cycle helmet wearing in 1999

Road Safety Division, Department of the Environment,

Transport and the Regions

K Bryan-Brown and N Christie

TRL Report 487

First Published 2001ISSN 0968-4107Copyright TRL Limited 2001.

This report has been produced by TRL Limited, under/as part of aContract placed by the Department of the Environment, Transportand the Regions. Any views expressed are not necessarily those ofthe Department.

TRL is committed to optimising energy efficiency, reducingwaste and promoting recycling and re-use. In support of theseenvironmental goals, this report has been printed on recycledpaper, comprising 100% post-consumer waste, manufacturedusing a TCF (totally chlorine free) process.

CONTENTS

Page

Executive Summary 1

1 Introduction and background 3

2 Review of helmet promotion initiatives 3

2.1 Introduction 3

2.2 Community based initiatives without legislation 4

2.2.1 Long term initiatives 4

2.2.2 Participation initiatives 5

2.3 Community based initiatives with legislation 5

2.3.1 Pre-legislative educational programmes 5

2.3.2 Relative effectiveness of legislation and education 6

2.4 School based promotions 6

2.5 Health based initiatives 8

2.6 Summary and conclusions 8

3 Survey of local authorities 9

3.1 Results 9

3.2 Conclusions 9

4 Methods for measuring helmet wearing rates 9

4.1 Review of sampling techniques and observation methods 9

4.2 Summary and conclusions 10

5 Results of the 1999 helmet wearing surveys 11

5.1 Methodology 11

5.1.1 Repeat observational surveys 11

5.1.1 Extended survey 11

5.1.1 Statistical significance of results 13

5.2 Results of the repeat observational surveys 13

5.2.1 Factors affecting helmet wearing in 1999 13

5.2.2 Trends in cycle helmet wearing since 1994 15

5.3 Results of the extended survey 15

5.3.1 Differences between children’s and adult’s cycling 15

5.3.2 Children’s cycling 17

5.4 Comparing the two surveys 17

5.5 Summary and conclusions 17

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6 Conclusions and recommendations 18

7 References 18

8 Acknowledgements 20

Appendix A: Helmet promotion leaflet and questionnaire 21

Appendix B: Changes in wearing rates by local authority 25

Appendix C: Data collection forms used in the repeat surveys 26

Appendix D: Data collection forms used in the extended survey 28

Abstract 30

Related publications 30

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Executive Summary

The proportion of cyclists observed wearing a helmet onthese built-up minor roads was 8.2%, significantly lessthan the 21.8% observed on the built-up major roads. Thedata showed that both adults and children were less likelyto be wearing helmets on the minor built-up roadssurveyed in the extended survey than on the major built-uproads used for the repeat survey.

The differences between the wearing rates observed inthe repeat and extended surveys are large enough to bringinto question the trend in wearing rates derived from therepeat survey alone. To establish trends in the future, bothsurveys should be undertaken.

This report reviews research into helmet promotion andreports a nationwide observational survey of cyclists,conducted in the autumn of 1999, to assess changes inbicycle helmet wearing rates since 1996. It also includesthe results of an extended survey which has been designedto improve the representativeness of the sample, inparticular increasing the number of child cyclists observed.

Literature review and local authority survey

A review of international cycle helmet promotion foundthat significant increases in helmet wearing rates have beenreported following large-scale, multi-agency, communitybased programmes. These have been designed along thelines of health promotion strategies. Large scalecommunity wide campaigns seem to be effective becausetargeting a large group can increase the probability ofchanging group norms and make helmet wearing moresocially acceptable.

Most of the apparently successful initiatives reviewedincluded helmet subsidy schemes which reduced thefinancial barriers to purchasing a helmet. The adoption ofhelmet wearing has not been particularly successful amongolder children, low-income groups or ethnic minorities,even with subsidy schemes. Because of these differences,it is essential to assess the effectiveness of an interventionrelative to different age, sex and income groups.

A survey of local authorities in England showed that,although most reported actively promoting helmets, fewhad evaluated their campaigns.

Repeat survey (built-up major roads)

A cycle helmet wearing rate study was undertaken by TRLin the autumn of 1994. Twenty seven thousand cyclistswere observed at 79 busy sites all over Great Britain, ofwhom 16% were wearing a cycle helmet. The survey wasrepeated in 1996 to measures changes in helmet wearingover the intervening two years. The wearing rate hadincreased by a small—but statistically significant—amountto 17.6%.

The repeat survey at the original sites showed thatwearing rates on built-up major roads were up by about aquarter on the 1996 rate, to 21.8%. However, this was dueto an increase amongst adult cyclists wearing helmets:there was no change amongst child cyclists.

Extended survey (built-up minor roads)

When TRL was asked to repeat the surveys for a third timein 1999, it was decided to try to include a range of quieterlocations. In particular it was hoped to boost the sample ofchildren observed as they were especially under-represented in the repeat survey and make the sample morerepresentative of the national cycling population. A reviewof the international references to sampling techniques andobservation methods was used to inform the design of thisnew extended survey.

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1 Introduction and background

A cycle helmet wearing rate study was undertaken by TRLin the autumn of 1994 (Taylor and Halliday, 1996). Twentyseven thousand cyclists were observed at 79 sites all overGreat Britain, of whom 16% were wearing a cycle helmet.

The survey was repeated in 1996 to measures changes inhelmet wearing over the intervening two years. The wearingrate had increased by a small—but statistically significant—amount to 17.6% (see Bryan-Brown and Taylor, 1997).

The surveys were not intended to produce a nationallyrepresentative wearing rate, but were meant to be used tomeasure trends over time. The sites were originallyselected for their high cycle flows, so that as large asample as possible would be achieved. This meant thatsites tended to be in busy, non-residential, urban areas. Itwas recognised at the outset of the work that this couldresult in certain groups of cyclists being under-representedin the survey.

However, the survey results have been widelymisquoted as being the ‘national wearing rate’. Althoughthis was not strictly true, the mistake was understandablegiven the lack of alternative data.

Therefore, when TRL was asked to repeat the surveys for athird time in 1999, it was decided to try to make the samplemore representative of the national cycling population. To dothis it was necessary to measure helmet wearing in differenttypes of locations, such as quieter, residential streets (where,in fact, the majority of cycling occurs). In particular thesample of children needed boosting as they were especiallyunder-represented in the survey. To inform the developmentof the extended sample the observational techniques used toestimate helmet wearing rates were reviewed.

In order that a complete picture of helmet wearing couldbe presented, TRL also maintained an ongoing review ofinternational helmet promotion schemes. This informationwas disseminated to Local Authorities, who were in turnasked about their helmet promotion activities.

This report describes work conducted between 1998 and1999 and is divided into the following main sections:

� Section 2 Review of helmet promotion initiatives.

� Section 3 Survey of local authorities.

� Section 4 Methods of measuring helmet wearing rates.

� Section 5 Results of the 1999 helmet wearing surveys.

2 Review of helmet promotion initiatives

2.1 Introduction

The promotion of helmet wearing is a contentious issue.Intuitively, the purpose of a cycle helmet is to reduce theseverity of injury to the head once an accident hasoccurred. However, Hillman claimed in 1993 that therewas no conclusive evidence that wearing a helmet reduceshead injury rates. He argued that any safety gains could beconsumed as performance benefits in that riders feel moreconfident when they were protected and therefore takemore risks. Hillman believed that greater safety would beafforded to cyclists by targeting the car driver. He arguedthat this would be ‘far more effective in lowering the

number and severity of head injuries among cyclists thanthe protection afforded by a few millimetres of polystyreneafter an accident has occurred’. In his opinion the focus ofsafety initiatives should be on the primary safety ofcyclists (avoiding the accident in the first place), ratherthan on secondary safety, that is lessening the impact of anaccident once it has occurred.

Simpson (1996) showed in her analysis of national hospitaldata (1993-1995) that 49% of pedal cyclist casualtiessustained an injury to the head or face. Mills (1989) reportedthat 53% of cyclist casualties attending Accident &Emergency departments (1984/5 data) had sustained headinjuries. Furthermore Mills estimated that if all cyclistcasualties had been wearing helmets, a saving in hospitalcosts of £80 million (1986 prices) would be made each year.Data from New Zealand supports this conclusion (Poveyet al., 1998). Helmet wearing in New Zealand rose from lessthan 40 per cent in 1989 to more than 90 per cent in 1996. Ananalysis of casualty data showed that head injuries werereduced relative to injuries to other limbs over this period.

The New Zealand evidence does not contradict Hillman’sargument that helmeted cyclists take more risks. Nevertheless,it seems sensible to assume that some level of protection isbetter than nothing, especially in avoiding injuries of minorseverity. In 1998, almost 7,000 children were injured as pedalcyclists in Great Britain with 900 killed or seriously injured(Department of the Environment, Transport and the Regions,1999). For pedal cyclists, the casualty rate (any severity) per100 million vehicle kilometres was higher than any other roaduser group except motor cycle riders.

The challenge to promote cycle helmet wearing isconsiderable. Research indicates that the rate of helmetwearing is low in Great Britain (see section 5). Youngcyclists seem very resistant to wearing a helmet because it isnot a behavioural norm: few of their peers wear helmets andwearing a helmet may arouse peer derision. Any measureimplemented which could have a negative impact on cyclingwould not be desirable, since cycling is being activelypromoted by the government’s health and transportdepartments in order to help reduce rates of coronary heartdisease and promote environmentally sustainable travel1.

A number of different approaches towards helmetpromotion can be identified in the literature, the mostpredominant being rooted in health promotion. Thefollowing approaches have been identified and will bedescribed in detail below:

1 Community based initiatives without legislation.

2 Community based initiatives with legislation.

3 School based promotions.

4 Small scale ad hoc initiatives.

Evaluation of these initiatives has involved a number ofdifferent outcome measures:

1 Observations of numbers of helmeted riders.

2 Self reported use of helmets.

3 Self reported ownership of helmets.

4 Head injury rates among cyclists from hospital data.

The evaluation methodologies used to measureeffectiveness have also been appraised.

1 The National Cycling Strategy aims to quadruple the number of trips bycycle by the end of 2012 (Department of the Environment Transport andthe Regions, 1996).

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2.2 Community based initiatives without legislation

2.2.1 Long term initiativesThe Seattle intervention (DiGuisseppi et al., 1989 andBergman et al., 1990)) is often identified as the model ofgood practice. The intervention aimed to increase parentalawareness of the need for helmets, promote use by childrenand reduce financial barriers to purchasing a helmet.

A full-time health educator co-ordinated the activitieswhich began in 1986 and increased year on year. Publicservice announcements were broadcast on television, radioand at local baseball games. Press conferences werearranged and pamphlets distributed to physicians andhealth departments. A school based safety programme wasimplemented in Seattle in 1988, and posters and stickerswere distributed to children via schools. Incentives to wearhelmets were introduced, including free tickets to baseballgames and free French fries for helmet wearers. Discountschemes for helmet purchase were also introduced andimplemented via different agencies including ParentTeacher Associations (PTAs).

The intervention was evaluated using a pre-test post-testnon randomised control group. Seattle was the interventioncity and a demographically comparable city, Portland, wasthe control city. Observations of helmet wearing weremade before and 4, 12 and 16 months after the campaignbetween 1987-1988. Helmet use increased from 6% to16% in Seattle and from 1% to 3% in Portland. Theincrease in helmet wearing rate was significantly greater inSeattle than the increase in Portland. Predictors of helmetuse identified in the analysis were:

� Being observed as being of white ethnic origincompared to non-white ethnic origin.

� Riding a geared cycle compared to a non-geared cycle.

� Riding in playgrounds, parks or cycle paths compared tocity streets.

� Riding with adults or other children who wore helmetsthan when alone, or with other unhelmeted adults orchildren.

Although no income effect was reported it seems likelythe effectiveness of the intervention varied with socio-economic group. The ethnic effect and the cycle geareffect may both be indicators of an income effect. i.e.children of a non-white ethnic origin may be more likely tobelong to a low income group compared to their whitecounterparts, and children who ride a cycle without gearsmay come from families who cannot afford a geared cycle.

In a follow up to the evaluation of the Seattleexperiment Rivara et al., (1994) noted that between 1987and 1992 medically treated bicycle related head injuriesdecreased by 67% among 5-9 year olds and 68% among10-14 year olds.

Over the same period helmet wearing increased from4% for all children under 15 to 54% among 5-9 year oldsand 38% among 10-14 year olds.

However, without data on changes in the number ofchildren cycling it seems difficult to assess the directimpact of the intervention.

Farley et al., (1996) assessed the effectiveness of afour-year programme of bicycle helmet promotiontargeted at 380 elementary schools containingapproximately 100,000 children (aged 5-12 years) in oneregion of Quebec. The programme comprised persuasivecommunication and multiple intervention strategiesinvolving community and school based activities. Morethan 200 hundred schools and 250 agencies participatedin the programme each year. The campaign was clearlystructured and involved a number of components:

1 A preliminary study was carried out to identify factorslikely to influence the intention of cyclists to use helmetsand in order to identify the appropriate messages.

2 The campaign ran between April and August yearlyfrom 1990 to 1993.

3 School based activities, including poster designs,pamphlets, word association games and role play (toencourage attitudinal, belief and value change regardinghelmet wearing) were carried out between May-Juneeach year.

4 Community based activities involving setting updiscount schemes and disseminating information onregulations regarding helmet use.

5 An organising committee co-ordinated activitiesenlisting the support of teachers, police officers, socialclubs etc.

The study group was selected from a sample of childrenfrom one region of Quebec exposed to the programmewith a comparable control group of children selected froma matched region also in Quebec not exposed to a similarintervention.

Analysis showed that helmet use increased from 1.3%before the programme to 33% in 1993 in the municipalitiesexposed to the programme. In the control municipalitieshelmet wearing had also increased. Analysis found thatwearing a helmet was predicted by:

� being a girl compared to a boy;

� being in the younger age group compared to the olderage group;

� cycling on bike paths compared to local streets;

� being in an area exposed to the programme compared tothe control area.

Although Farley et al. argued that the programme wasclearly effective in most cycling circumstances and forvarious groups of children there was some variation inprogramme effectiveness according to socio-economicgroup. Children in ‘poor’ communities riding on localstreets in the intervention area were 1.76 times more likelyto be wearing helmets than similar child cyclists in thecontrol population. However, the programme was threetimes more effective in ‘average rich’ municipalities thanin ‘poor’ areas with these children being 5.72 times morelikely to wearing a helmet compared to the control group.

Ekman et al., (1997) found that it is possible to reducethe incidence of injuries through the provision ofinformation on helmet wearing. Ekman et al. evaluated theimpact of a four-year helmet promotion programme which

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began in 1987, in Skaraborg, Sweden. The interventionwas targeted at pre-school children and comprised a‘helmet prescription’ and a discount voucher to purchase ahelmet at half price, and information campaigns aimed atparents, pre school organisations and local residents.

Cyclist casualties were monitored between 1978-1989 infive counties in Sweden, including Skaraborg. The resultsshowed that bicycle injuries for children under the age of 15fell by 48% between 1978 and 1993. Comparison of headinjuries pre- (1978-1980) and post-campaign (1987-1989)showed that concussions decreased by 37% and other headinjuries decreased by 57% compared to decreases of 6% ofconcussions and 13% of head injuries in Sweden as a whole.

A household survey found that 90% of pre-schoolchildren reported wearing a helmet. However, Ekmanidentified a number of problems with the evaluationmethodology. In particular the results may have beenconfounded by the impact of environmentalimprovements. e.g. the extension of safe cycle lanenetworks, and changes in the transport structure whichmay have reduced exposure to risk. Also, registration ofin-patient data may have been affected by admissionpolicies and no information was available on outpatients.

2.2.2 Participation initiativesStevenson and Lennie (1992) described a two yearcommunity based action research programme to developstrategies for increasing helmet wearing by children from arural town in Queensland, Australia. The initiative wasbased on the model provided by Elliot and ShanahanResearch (1986) who argued that the deterrence andlegislative strategies do not change well-entrenched attitudesand behaviours. Alternatively, a social environment needs tobe created in which people are encouraged to ‘....voluntarilyadopt safe behaviours without external controls byrewarding safe behaviour, punishing unsafe behaviour,encouraging people to take personal responsibility for theirbehaviour and making non-compliance an anti-social act’.

The children were encouraged to become activeparticipants in the research and develop their own practicalstrategies to increase helmet wearing. The intervention wasbased on an ‘action research’ approach. ‘The aim of actionresearch is to combine the knowledge of a community orgroup seeking change with the expertise of researchers tofind practical solutions to problems’, enabling people to‘....investigate and understand their own situation, thusempowering them to change their social environment’. Theintervention involved a co-ordinator who supervised allcomponents of the research.

Although the initiative was not evaluated, the outcomesof the student workshops indicated that helmet promotionshould:

� show helmet wearing to be trendy;

� encourage adults to set an example;

� target younger students;

� implement media campaigns showing injuries as a resultof not wearing a helmet;

� encourage riders to wear helmets all the time;

� make wearing compulsory, accompanied by measures tomake helmets affordable for less well off families.

Winn et al., (1992) describe an innovative interventionaimed at increasing cycle helmet use among childrenliving in economically depressed inner city areas in EastWheeling, West Virginia, which had a predominantlyblack population. The intervention comprised a bicyclesafety module (BSM) and was aimed at children agedbetween 6 and 14 attending a day camp. The specificobjectives of the BSM were to improve children’sknowledge of bicycle and helmet safety, increase use ofhelmets on and off site, and gain anecdotal accounts ofimprovements in attitudes to cycling and helmet safety ingeneral. The BSM provided opportunities for students toimprove practical riding skills and cycle maintenance,learn about high-risk situations and traffic law, and to userole-play to develop resistance to peer pressure againstusing a helmet.

The intervention involved 152 students, but theevaluation was carried out among only 23 students whohad attended every component of the BSM course. Thesestudents were administered a 16 item test (no details given)about various aspects of cycling safety pre and postintervention. Observations of cyclists were made pre,during and post intervention. The results indicated thatthere was a significant improvement in cycle safetyknowledge among the 23 children who attended the entirecourse, cycle helmet use rose from zero to over 90%during the intervention, falling to only 80% afterwards.The intervention seemed to be quite popular with children.

Winn et al. claimed that the approach was valuablebecause it was creating an environment ‘rich with rolemodels’ which encouraged children to adopt saferbehaviours, but the lack of detail about the evaluationmethodology makes it difficult to assess the impact of theintervention.

2.3 Community based initiatives with legislation

2.3.1 Pre-legislative educational programmesThere has been considerable interest in the role of pre-legislative educational campaigns on the effectivecompliance with the law. Often such campaigns have beeninitiated over several years using the community basedhealth promotion approach. In the USA, Howard County,Maryland was the first jurisdiction to mandate helmetwearing for children younger than 16 in 1990. Cote et al.,(1992) reported that the helmet-wearing rate in HowardCounty was the highest documented for US children andthat can in part be attributed to the pre-legislative campaigninvolving police and health workers. Scheidt et al., (1992)attributed the success of the Howard County legislation tofollowing the Seattle model of helmet promotion in thepre-legislative stage.

Evaluation of the Howard County campaign was carriedout by Dannenberg et al., (1993) and Gielen et al., (1994).Evaluation of the relative effectiveness of legislative andeducation strategies was carried out in three AmericanCounties:

� Howard County, which mandated helmet wearing forchildren under the age of 16 in 1990 and was supportedby a considerable education campaign.

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� Montgomery County, which had an educationalprogramme only and no legislation.

� Baltimore County, which had only minimal educationalactivity and no legislation.

The evaluation was conducted in 1991 among 4th, 7thand 9th grade students from a stratified sample of publicschools. A questionnaire was administered, which askedabout helmet wearing a year previously, compared to inthe previous month. Other measures included bicycleownership and use, awareness of helmet law, sources ofinformation about law, the effect of peer pressure andaccident history. Of the 7,217 students canvassed, 48%(3,494) responded to the questionnaire. The response rateswere similar over the three counties and 85% of therespondents owned a cycle. The results indicated that selfreported helmet-wearing rates had increased by the most inHoward County (with intervention and legislation)—from11% to 37%. Rates had also increased in Montgomery(with education only)—from 8% to 13%. BaltimoreCounty with only minimal education activity saw a smallerincrease, from 7% to 11%.

Analysis of the data indicated that key predictors ofhelmet use were having peers that wore them, being in thefourth grade (the youngest group) and using car seat beltsregularly.

Cote et al., 1992 conducted observations of cyclistsunder the age of 16 in the three counties pre and postlegislation/education campaign. Observations were madein a number of census tracts to represent middle incomeand upper middle income tracts (no low-income tractswere selected) and, within these two types of tracts,different types of sites were selected to cover areas nearschools, recreation centres/pools, county thoroughfares,residential streets, parks and bicycle paths.

The results indicated that helmet wearing in HowardCounty had increased from 4% to 47%. In MontgomeryCounty helmet wearing and had increased from 8% to 19%.In Baltimore County helmet wearing had decreased from19% to 4%. The combination of education and legislationseemed most effective in increasing helmet-wearing rates.

In Victoria, Australia a programme of helmet promotionhas been ongoing since 1984, involving a community widemulti-agency approach, similar to the Seattle campaign, and,a helmet subsidy scheme. Legislation requiring helmetwearing was enacted in 1990. Cameron et al., (1994) haveevaluated the Victoria programme by observations of helmetwearing, epidemiological surveillance of cyclist headinjuries, insurance data for ‘no fault’ accidents involvingcyclists and by monitoring cyclist exposure in terms of timespent cycling. Observations were made at specific sites inFebruary and March each year between 1983-1991 inmetropolitan areas of Melbourne.

Helmet wearing rates increased steadily to around 30%in 1989. With the introduction of mandatory legislation therates increased further to 75% in 1990 and again to 85% in1992. Concurrently, head injuries to cyclists decreased by70% compared to pre-law levels. Cameron et al. arguedthat these findings ‘...confirm that if the communityunderstands the benefits of a safety measure, and a

reasonable proportion has already been persuaded toadopt it voluntarily, then considerably increased use canbe achieved through a law even with relatively moderatelevels of enforcement’. There was a substantial reduction inbicycle usage by children especially those aged between12-17, and this may have accounted for part of the increasein the helmet-wearing rate (Finch et al., 1993).

Epidemiological surveillance of head injuries indicatedthat all types of road accident trauma decreased by 26%,which may also have influenced results. Furthermore, it isarguable that the exposure studies carried out in twomonths can give an accurate picture of cycling throughoutthe year and the early surveys of helmet wearing werebiased toward the school journey. There is no informationon whether the initiative was effective irrespective of thesocio-economic status or ethnic origin of the cyclists.

2.3.2 Relative effectiveness of legislation and educationMacknin et al., (1994) looked at the association betweenbicycle helmet legislation, bicycle safety education, anduse of bicycle helmets in children under the age of 16. Ananonymous questionnaire survey was carried out amongelementary school children in the classroom inpredominantly white, upper middle class suburbs of Ohio.Direct observations of helmet wearing were also carriedout. One location had bicycle helmet legislation and aneducation programme, another had only bicycle helmetlegislation and the remaining two had no legislation orsafety education.

The education programme included school based safetytalks and videos, and letters sent to parents with an offer ofdiscount helmets. The PTA also purchased helmets forchildren who could not afford them. Issues of helmetsafety were integrated into normal curriculum activities,such as designing posters in art lessons.

In the questionnaire the questions on helmet use wereembedded among other questions about safety e.g. seatbelt use. Observations of cyclists were only made in thelegislation/education area by one observer over an 11 hourperiod on residential streets, main roads, recreation sitesand on all school grounds in the school district.

The results indicated that self reported wearing of ahelmet ‘always’ was significantly higher in the legislation/education area (68%) than in the law only area (37%) or inthe other two ‘control’ sites (18% and 22%). 85% ofcyclists observed in the legislation/education area werewearing their helmet. There were no details on the actualnumbers observed though it seems from the discussion thatit was less than a hundred. The evaluation methodologyrelied heavily on self-reported data and did not provide acomparative estimate of actual rates of helmeted cyclists.

2.4 School based promotions

School based initiatives share much in common with thecommunity wide initiatives in that they have used healthpromotion principles in the intervention design.

Morris and Trimble (1991) compared the effectiveness ofan education programme alone and a programme combinedwith a helmet subsidy among elementary school children.

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Three elementary schools were involved in the evaluation,one received education, one education and a helmet subsidyscheme and the other school acted as a control.

The education intervention comprised a short classroombased talk involving discussion about helmets and the risksof cycling, followed by a video on cycle safety and helmetuse. Various school wide activities were arranged,including poster competitions and a leaflet about the risksof cycling and benefits of helmets was issued. In theeducation and subsidy school this leaflet contained acoupon for the purchase of a helmet at a reduced price.

The results showed that only the school that receivedboth the educational programme and subsidy showed asignificant increase in the proportion of children wearinghelmets. The number of cyclists per school was very small(less than 30) and it is difficult to draw firm conclusionsfrom this study. However, the authors argued that ‘thesubstantial subsidy was the factor that made a differencethat was both clinically and statistically significant’. Whatis rather disappointing was that 72 helmets were purchasedduring the scheme, but only six cyclists were actuallyobserved wearing them. This confirms that ownership andwearing rates do not correlate highly.

Watts et al., (1997) aimed to look at the relativeeffectiveness of a school based cycle helmet promotionprogramme with and without free helmet distribution. Theoutcome variable was self-reported intention to wear theirhelmet ‘always’ when cycling in the local area. The studytook place in an American state which had mandatoryhelmet requirements.

After the intervention, reported helmet wearing hadsignificantly increased from 38% (total pre test) to 46%(total post-test). There was a significant increase inreported helmet use by children at the school in which freehelmets had been distributed. There was no significantincrease at the school that did not have the free helmetscheme. Furthermore, children who were given freehelmets were significantly more likely to report wearing ahelmet than those children who already owned one.

Pendergrast et al., (1992) carried out a study in the USAto investigate the difference between an experimental,intensive, school based initiative and a traditional schoolbased information campaign for promoting cycle helmetuse. They argued that the influence of peer pressure onhelmet use suggested that a school based, peer ledinitiative would be an important first step in anintervention. The first objective was to test the hypothesisthat creating a school and peer environment in whichhelmet wearing was the norm would result in a significantincrease in helmet use. The second objective was to assessthe social, familial and behavioural correlates of childhelmet use, with particular emphasis on the relationshipbetween parental and child attitudes.

The initiative was aimed at elementary school childrenin suburban areas, and comprised two types ofintervention. A survey was carried out regarding bicycleinjuries and helmet use. All children received literatureabout bicycle safety and a discount coupon for helmetpurchase. The ‘experimental’ school was then the target ofan intensive safety campaign conducted mainly in the

classroom including the formation of school cycle clubs,and demonstrations of the importance of helmets by aprofessional stunt rider.

At post test children in the experimental school weresignificantly more likely to believe that helmets wereprotective, but did not differ on any other variables.Analysis showed that the following factors were associatedwith parental intent for the child to use a helmet: siblinghelmet ownership; parental helmet ownership; and lowersocial barriers to helmet use perceived by parents. Theresponse rate was poor among parents. The intensivecampaign showed no statistically significant effect in termsof intention to wear a helmet. Of the total (combined)sample 85% of children reported that they had no intentionto wear a helmet on their next ride. Helmet non-use waspredicted by non-use by a cycling parent or sibling. Theintensive programme was not successful in enlisting thesupport of parents.

Parkin et al., 1993 evaluated the effectiveness of anotherschool based intervention programme in Canada. Theevaluation was designed to take into account any seculartrend in helmet use and control for income levels and thelocation where the cycling was carried out.

The intervention was aimed at four elementary schoolsin an urban Canadian community; two from a high-incomearea and two from a lower income area. Eighteen schoolswere selected for the control group comprising a mixtureof high, middle and low-income schools.

The intervention used health nurses as facilitators tohelp schools set up action plans to promote the use of cyclehelmets. This involved setting up planning committees,identifying goals and targets, setting up links with parents,student education initiatives, bike rallies and educationalweeks entitled ‘Be Bike Smart’. 20% discount vouchersfor helmet purchase were also available.

The main dependent measure was observation of helmetwearing carried out at randomly selected sites pre-intervention (June and October 1990) and post intervention(April and September 1991), between 2-5 months after theintervention had been initiated. The observation sites wereselected to represent high, middle and low-income areas andwithin these to represent recreational and school journeys

The results showed an increase in the secular trend inhelmet use between 1990 and 1991. Comparison of helmetwearing rates by income level showed that in high-incomeareas, there was a significantly greater increase (32%) inhelmet wearing in the intervention area than in the controlarea (11%). However, there was no such statisticallysignificant effect in the low income areas: in theintervention area, wearing rates increased from 1% to 7%between pre- and post-test; in the control area theyincreased from 3% to 13%.

It is thought that this ‘income effect’ could be related tolow observational counts at schoolyard locations becausesome schools in low-income areas actively discouragedcycling to school. The main reasons for this policy werelack of cycling facilities at schools, and because theschools were often situated in areas of high traffic density.Once again the positive influence of helmeted peers orparents was noted in this study.

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Weiss (1992) reported that there is evidence that theoverall helmet-wearing rate has decreased among cyclistsin Arizona. Weiss (1992) compared the helmet wearingrates of school age cyclists in 1985 and again in 1990 inTucson, Arizona. The sample comprised four elementaryschools, three middle schools, three high schools and oneuniversity campus. The same schools were used for the1985 and 1990 observations and no formal cyclecampaigns were carried out between the surveys.Observations were 90 minutes before school started until15 minutes after school had begun. Observations weremade on sunny, autumn days. All the schools were situatedin middle class neighbourhoods. The number of cyclistsobserved was small.

Only in elementary schools was there a significantincrease in helmet wearing (from 2% to 17%) and this wasattributable to a special programme on cycle helmets inone particular school. Weiss noted that there was aconsiderable decrease in absolute numbers of childrencycling, even though there was no change in the size ordemographic characteristics of the school samples whichmay have been able to explain this effect. He concludedthat small-scale interventions might be successful inimproving helmet use though it is difficult to judgewhether effects are sustained over time.

2.5 Health based initiatives

Small-scale interventions carried out in the context of thehealth service have met with some success.

McEvoy (1996) carried out a small-scale project inConnecticut where, although there have been mandatorylaws compelling helmet wearing for children under the age13 since 1993, there was not a high level of compliance.The study involved 20 children who did not own a helmetwho were having routine health checks whilstaccompanied by a parent. The parents were givencounselling and leaflet about helmet use, and a coupontowards a purchase of a helmet for those children who didnot already own one. A follow up survey one month laterindicated that all but one of parents had redeemed theirvouchers and the parents reported that their child was nowwearing the helmet.

Cushman et al., (1991) evaluated helmet promotion in arandomised trial targeting children aged 5 to 18 presentingat primary care settings for routine care. The interventioninvolved the physician counselling the child and parent onthe importance of cycle helmets, and giving them leafletsto take home. The sample comprised 167 children in theintervention group and 172 in a control group. A follow uptelephone call was made 2-3 weeks later to assess theimpact of physician counselling on reported helmetpurchase. There was no significant difference in theproportion of helmets purchased between the control andintervention group. This led the researchers to concludethat physician counselling had not had an impact on thetarget audience.

However, there is a growing move for GPs in theprimary care setting to increase their role in the promotionof health and safety at a local level (e.g. Ward and Christie,2000). Towner et al., (1998) argued that professionals in

paediatric health are well placed to act as a focus for multi-agency prevention campaigns as they have:

� experience of caring for head injured children;

� have access to local data to provide a sound researchbase to the programme;

� can collaborate with other professionals to develop acampaign;

� disseminate information at a local level.

With increasing emphasis placed on the role of primarycare with respect to prevention of accidental injury, someconsideration needs to be given to the feasibility ofpromoting helmet wearing in this setting.

2.6 Summary and conclusions

It is difficult to compare the impact of the various helmetpromotions described largely because different evaluationmethodologies have been used.

Significant increases in helmet wearing rates have beenreported for large-scale, multi-agency, community basedprogrammes designed along the lines of the healthpromotion strategies. Large scale community widecampaigns seem to be effective because targeting a largegroup can increase the probability of changing groupnorms and make helmet wearing more socially acceptable.This approach is necessary. Much qualitative research hasshown that the main reason for not wearing a helmet is thatit is not the norm among young cyclists. It would also beinteresting to explore whether observations of children atschool locations provide an accurate indication of generallevels of cycling. It is possible that, with increasing traffic,children may be less likely to travel to school during peaktraffic periods (early morning) and switch to riding theircycles more at weekends or after school. Further researchis required to look at the relationship between cycling onschool journeys and other forms of recreational cycling.

Most of the initiatives reviewed included helmet subsidyschemes which reduced the financial barriers to purchasinga helmet. The adoption of helmet wearing has not beenparticularly successful among older children (aged 12-17),low-income groups or ethnic minorities, even with subsidyschemes. Because of these differences, it is essential toassess the effectiveness of an intervention relative todifferent age, sex and income groups.

A central problem in reviewing helmet promotionschemes relates to the evaluation methodologies,especially to the outcome measures. Several studies haveused direct observations of helmeted cyclists as theoutcome variable using census data to cover geographicareas stratified in terms of factors like socio-economicstatus and number of resident children. Observation siteshave been selected to cover different types of journey (e.g.school/recreation) and different types of location (e.g.junctions/school yards). With regard to schools, it wasnoted in one study that differences in the schools policytowards cycling might have influenced cycling levels.

Given that helmet wearing is likely to vary with socio-economic group it is important to establish whetherobservations within different socio-economic areas

9

provide an accurate measure of the distribution of socio-economic status among cyclists. Most of themethodologies described make the assumption that thechild cyclist is near to their home and it is difficult to knowhow valid this assumption is. It is likely that older andmale children travel further from home than youngerchildren and female children.

Some studies have used cyclist casualty data as one ofthe outcome measures but the number of cyclist casualtiesmay vary according to several factors :

� hospital policies on admissions;

� clinical definitions of head injuries;

� changes in levels of cycling;

� changes in the cycling infrastructure which improvesafety for cyclists.

None of the studies have taken into account the possibleinfluence of all these factors.

Studies of self-reported cycle helmet wearing are difficultto evaluate because there seems to be a low correspondencebetween self reported and observed behaviour.

There is little research on how helmet-wearingbehaviour varies according to the weather or season. It ispossible that helmets may be more likely to be worn inwinter to protect the cyclist’s head from adverse weatherand less likely to be worn in the summer because it is toohot and uncomfortable. It is also unknown to what extent acyclist’s assessment of risk (which may influence thehelmet-wearing decision) is affected by the weather /season. For these reasons, seasonal variation must beconsidered when designing evaluations.

3 Survey of local authorities

Following the literature review described in section 2,good practice guidelines on cycle helmet promotion weredeveloped and disseminated in a leaflet distributed to alllocal authorities in Great Britain (see Appendix A). Itaimed to inform road safety practitioners on the relativeeffectiveness of cycle helmet initiatives ranging from smallscale, single agency promotions to large scale, multi-agency approaches.

A questionnaire was designed to assess the extent ofsafer cycling activities in the area. It was produced as adetachable section of the leaflet. The questionnaire wasdivided into six sections:

� child cyclist training;

� local authority cycling initiatives;

� target group and messages aimed at promoting safercycling;

� involvement with other agencies;

� design of any evaluation;

� campaign costs.

3.1 Results

The main results of the survey were that, of the 140 localauthorities which responded:

� 134 provided cyclist training;

� 125 had mounted cycle use promotion campaigns, 117of which included the promotion of cyclist safety;

� 95 of the authorities had promoted cyclist safety as aseparate campaign.

In total, 125 authorities had run cyclist safetycampaigns, either as part of a campaign to promote cycleuse or as a separate campaign, or both. Of these 125authorities:

� 87% promoted conspicuity;

� 84% promoted helmet wearing;

� 85 authorities did not evaluate their campaigns.

3.2 Conclusions

Taken at face value, this survey indicated a high level ofcycle helmet promotion, along with the promotion of othercycle safety issues.

However, it is recognised that distributing thequestionnaire as an integral part of a leaflet givinginformation about cycle helmets may have biasedresponses. Clearly it alerted respondents to DETR interestin helmet publicity: it may have led some respondents tobelieve that the survey was only interested in campaignsthat included helmet promotion.

4 Methods for measuring helmetwearing rates

A number of the research studies reviewed in section 2 haveobserved a mismatch between owning and actually wearinga cycle helmet. Also, there were indications that people gavesocially desirable responses when asked about owning/wearing a helmet. This could result in reported helmet usebeing greater than actual helmet wearing. Therefore,considerable importance must be attached to accurate waysof observing helmet wearing among cyclists.

However it seems generally difficult to observe a sampleof cyclists which is representative of the general cyclingpopulation. In each of the helmet-wearing surveysconducted in 1994 and 1996 in Great Britain (reported inTaylor and Halliday, 1996 and Bryan-Brown and Taylor,1997) over 26,000 cyclists were observed. Howevercyclists aged under 16 were under-represented by almost afactor of four. This is probably because the observationsites were mainly located at major, built up locations andnot where most children cycle.

It was therefore decided that, for the 1999 repeat survey,additional sites would be surveyed in order to try toimprove the representativeness of the sample. To informthe development of this survey, a review of samplingtechniques and observation methods was performed.

4.1 Review of sampling techniques and observationmethods

Womack (1995) developed an observational method inorder to evaluate initiatives to increase helmet wearingamong children aged 5-14. The aim of this study was to

10

report on a method for achieving a baseline measure ofhelmet wearing. Observational surveys of bicycle helmetuse were carried out in six cities. Three were targeted byan intervention programme which aimed to increasebicycle helmet wearing in the age group 5-14 years. Theother three cities were selected as control cities.

Observation zones in each city were designated usingcensus data for school attendance zones merged withgeographic files. School attendance zones in target andcontrol cities were matched for ethnicity and socio-economic characteristics. Observations in school areaswere taken between July and September 1994. Four highschools were selected randomly within four geographicquadrants from the total population of high schools in eachtarget city. After the schools had been selected a map ofthe school attendance zone was obtained from the schooldistrict and each road way in the zone was observed.

Observations in school areas were made in at least twosocio-economically diverse neighbourhoods. Observerscanvassed each observation zone by car covering as manypublic roads as possible. Observations were made on oneweekend day and three-week days. On non-school daysobservations were made between 9.30 am and 12 noon,and from 2 pm until dark. On school days observationswere from 7 am until 9 am and from 2.30 pm until 4 pm,and were concentrated around primary schools.

For each cyclist observed the following measures wererecorded:

� helmet use or non-use;

� correct or incorrect use (i.e. whether or not fastenedproperly);

� gender;

� age (estimated in years);

� ethnicity;

� rider or passenger;

� location (street identifier);

� on road or off road;

� time of day.

Overall, 1,485 cyclists were observed. In each study areathe number of cyclists was between 200-350. Wide variationsin helmet use were found, ranging from 3% to 22%. Theresults showed that the number of observations was fargreater in the afternoon than the morning and that there werelarge variations in each city. Helmeted riders were more oftenobserved in areas with higher median income levels andlower percentages of Black or Hispanic households. Nogender differences were observed, but cyclists were morelikely to wear a helmet if travelling with someone else than ifalone. Cyclists riding on the road were more likely to wear ahelmet than those cycling off road were.

The study by Joshi et al., (1994) suggests that cyclinginfrastructure is a highly important factor affecting cyclehelmet wearing rates and must be considered whenselecting sites: In Oxford, there are exceptionally highrates of cycling among teenagers but helmet wearing ratesare low. It should not be assumed, however, that non-wearers are irresponsible cyclists. Two thirds use cycle

routes where they were available, and more than half altertheir routes to avoid heavy traffic and go out of their wayto avoid potential points of conflict such as roundaboutsand major intersections.

This suggests that cycling infrastructure may offer goodsites to measure cyclist activity. However, it is necessary tounderstand the relationship between helmet wearing andperceived safety of route as it may be that designated cycleroutes are perceived as safer than ordinary highways andtherefore helmets may be thought less necessary.

Whilst it is important to provide an accurate picture ofthe number of helmeted riders to evaluate the effectivenessof an initiative, it is also important to monitor the absolutenumbers of cyclists. This is important because helmetinitiatives may draw attention to the risks of cycling andthereby turn people away from cycling. Thus theproportion of helmeted cyclists may be greater than beforethe intervention, but this may be because there are fewerunhelmeted cyclists rather than more helmeted.

Observational techniques used to evaluate the impact oflegislation have had to consider this problem. It wasargued by Cameron et al., (1994) that the introduction ofhelmet legislation in Victoria, Australia was associatedwith a decrease in the absolute numbers of cyclists,especially teenage cyclists (12-17 years). This estimatewas based on exposure studies carried out by Finch et al.,(1993). However, the number of teenagers observed at 64sites in Metropolitan areas of Melbourne was small,around 600 in the 1991 and 1992 surveys, compared with1,000 at the 1990 pre-legislation survey. Each survey wasconducted for only two weeks in May and June eachsurvey year. This period seems far too short and wassensitive to the effects of weather and other events, such asa bike rally during one observation period.

4.2 Summary and conclusions

In summary an evaluation design needs to take intoaccount the following factors:

� Self-reported measures (through questionnaires) enableconsiderable detail to be obtained about the cyclist, theirexposure, demographic details, and qualitative factorsrelated to their reported helmet wearing

� However, the research has found a mismatch betweenreported ownership, reported use and actual wearingrates. Direct observations of helmet wearing may bemore reliable than self-reported measures.

� Observations of child cyclists need to be conducted insites representing both school and recreational journeysin a sample of census tracts stratified to berepresentative of different socio-economic and ethnicgroups. This can be done using census data and schooldistrict or catchment information.

� Child cyclists are unlikely to be observed where trafficdensity is high or at locations perceived to be risky.Observation sites may need to be placed away frommajor junctions/ heavy traffic areas. As the number ofchild cyclists are likely to be inversely proportional tothe traffic density.

11

� Observations of cyclists should be undertakenthroughout the year to take into account seasonalvariations in exposure or helmet wearing. Alternatively,if repeat surveys are required (to measure on-goingtrends), they should be conducted at the same time ofthe year each time.

� Observation sites should take into account the existingcycling infrastructure i.e. cycle paths, routes, facilities,etc. which may influence levels of cycling, especially ifthey are changed part way into the evaluation.

� Observation sites on cycle routes and paths may providegood opportunities to measure child cyclist activity.

� School policy toward cycling to and from school, andthe facilities they provide for cyclists, need to be takeninto account, as observations have been affected byschools which actively discouraged cycling because ofthe traffic density in the district.

5 Results of the 1999 helmet wearingsurveys

5.1 Methodology

5.1.1 Repeat observational surveysThe survey design was kept as close to the 1994 and 1996surveys as possible, using the sites shown in Figure 1. Therelevant local authorities (listed in Appendix B) wereasked to conduct the surveys on TRL’s behalf.

The local authorities were asked to conduct the surveysat the same times and on the same day of the same week ofthe year as they had in 1996. They were sent a supply ofdata collection forms (see Appendix C) and instructionsand examples of how to complete them. Followingcomments from some of the survey teams in 1996, theforms were improved, so that only ticking boxes wasrequired.

The survey teams were asked to collect the followingdata on each passing cyclist:

� sex;

� whether wearing a helmet;

� type of bicycle ridden (racing / touring, mountain/BMX,traditional town or ‘other’);

� age (child, under 16 or adult, 16 or over);

� if more than one cyclist riding together, number in thegroup.

5.1.1 Extended survey5.1.1.1 Sampling methodThe aim of this survey was to ‘boost’ the sample of childcyclists and to be more representative of the types ofcycling that children do.

The main considerations were to observe a large sampleof children in an economical way, ensuring a geographicalspread, across all socio-economic groups. The questionwas how to find compact areas (about 1km square) wherelarge numbers of child cyclists could be observed.

Published National Travel Survey data give an

indication of cycling levels by region, but the samples arenot large enough to be broken down into the small areasneeded for the proposed sampling procedure. It wastherefore decided to use child cycle casualty rates(STATS19) as a proxy for cycling levels.

Previous studies (see section 2) have shown that socio-economic status of the area affects helmet wearing levels.The DETR’s Index of Local Deprivation (see GovernmentStatistical Service, 1999) was used as a measure of areawealth. This Index was based on 12 indicators, includinglevel of unemployment, low educational attainment, crimelevel, overcrowded housing and derelict land.

Districts were ranked by child cyclist casualty rates andby Deprivation Index. Districts were sampled from thosewith high cycling activity (ie. casualties), ensuring a goodmix of wealth and geographical areas. The sample isshown in Table 1. The casualty data were analysed toidentify 1km squares within each district where cyclinglevels could be expected to be especially high. (ie. casualty‘black sites’.)

Table 1 Sample of locations

Child cyclist casualties1

per 100,000 Level ofDistrict name DETR region population deprivation2

Coventry West Midlands 17.7 1Crewe & Nantwich North West 18.4 4Doncaster Yorkshire & The Humber 17.3 1Eastleigh South East 21.7 5Fareham South East 27.2 5Gloucester South West 22.6 2Ipswich Eastern 17.1 2Kingston-upon-Hull Yorkshire & The Humber 28.7 1Kingston-upon-Thames London 18.1 4Lincoln East Midlands 26.8 1Liverpool North West 19.9 1Milton Keynes South East 21.0 4Peterborough Eastern 22.2 2Portsmouth & Gosport South East 18.3 2Slough South East 17.8 2Taunton Deane South West 28.8 4Wigan North West 22.2 2Wirrall Merseyside 17.8 1Wolverhampton West Midlands 17.3 1Worthing South East 28.1 4

1 1998 casualty figures.2 DETR Index of Local Deprivation split into five equal groups, where

‘1’ is very deprived and ‘5’ is the least deprived.

Previous studies (see section 2.2) have used movingobservers to try to maximise the numbers of cyclistsobserved and it was decided to use this method. For each1km square selected within each area a route was mappedout, covering as many roads within the square as possible.

Public Attitude Surveys Ltd (PAS) conducted theextended surveys on TRL’s behalf. They were asked tosurvey each area on one weekday (either from 7am until1pm, or from 1pm until 7pm) and on one weekend day(from 1pm until 7pm). PAS were provided with datacollection sheets designed by TRL (see Appendix D).

Observers were asked to drive around the prescribedroute continuously for the whole survey period, and record

12

Key

1 Aberdeen2 Glasgow (8)3 Edinburgh4 Newcastle5 Darlington6 Stockton (2)7 Barrow8 York (2)9 Beverley10 Hull11 Scunthorpe12 Grimsby13 Doncaster (2)14 Liverpool (2)15 Warrington (2)16 Manchester (2)17 Stockport (2)18 Crewe19 Stafford20 Derby21 Nottingham (2)22 Newark23 Boston (2)24 Wolverhampton25 Loughborough26 Leicester27 Coventry28 Warwick29 Rugby30 Northampton31 Peterborough (2)32 Cambridge (4)33 Bedford (4)34 Norwich35 Lowestoft36 Ipswich37 Colchester38 Chelmsford (2)39 London (3)40 Reading41 Oxford (3)42 Ridgeway – Oxford43 Swindon44 Cheltenham45 Gloucester46 Cardiff47 Bristol48 Bristol-Bath Cycle Route (2)49 Bournemouth50 Portsmouth

Figure 1 Repeat cycle helmet observation survey sites

13

for each cyclist they observed:

� type of area (residential, shops, school or other);

� sex of cyclist;

� age group (infant 0-6, junior 7-10, secondary 11-16 oradult);

� helmet (on head, carrying but not worn on head, no);

� riding position (road, pavement, other);

� type of bike (racer, mountain, traditional town, other).

Observers were also asked to indicate if the cyclist was achild in school uniform or someone doing a paper round.A comments column was also provided where they couldrecord other visible safety aids (or lack of) or behaviours(eg. two children on one bike).

5.1.1 Statistical significance of resultsThroughout Sections 5.2, 5.3 and 5.4 there are tablesshowing differences between groups of cyclists. eg.children versus adults, repeat survey versus extendedsurvey. Significant differences between groups areindicated by asterisks, as follows:

NS not significant at the 5% level* significance of at least 5%** significance of at least 1%*** significance of at least 0.1%

In the main body of text, significance levels are quotedas a p level. ie. a p value of 0.05 or less means that theresult is significant at at least the 5% level. In some cases,data are missing and so sample sizes are given, whereappropriate.

5.2 Results of the repeat observational surveys

In the 1999 survey 26,2302 cyclists were observed at thesites previously surveyed. Of these cyclists 21.8% werewearing helmets. The large sample size means that one canbe 99% certain that this figure is within 0.7% of the helmetwearing rate of the population who cycle on built-up majorroads on weekdays.

This means that the wearing rate is up by almost aquarter on the 1996 level of 17.6%. However, as shown in

Table 2, this rise is due to increased numbers of adultcyclists wearing helmets: there has been no statisticallysignificant change in child wearing rates.

AppendixB shows a breakdown of wearing rates andcyclist counts by local authority area.

5.2.1 Factors affecting helmet wearing in 19995.2.1.1 Age and sex of cyclistThe 1999 adult wearing rate of 22.2% was significantlygreater than the 15.0% observed amongst children(p<0.001). The small difference observed between malesand females was not significant at the 5% level.

When the 1999 wearing rates were disaggregated by ageand sex (as shown in Table 3), it appeared that there maybe an interactive effect between age and sex. In order toinvestigate this further, a statistical technique calledlogistical regression was used. This method estimates theparameters of an equation to predict the level of a bivariatevariable (in this case wearing or not wearing a helmet)from the values of a set of independent variables (ie. ageand sex). The significant interaction terms revealed by thisanalysis represent the inter-relationships between theindependent variables.

Table 2 Changes in wearing rates between 1994, 1996 and 1999

Wearing rates (sample sizes in brackets) Significance of1996 / 1999

Category of cyclist 1999 1996 1994 difference

All cyclists 21.8% (26,230) 17.6% (27,783) 16.0% (27,417) ***

Males 21.7% (18,975) 17.4% (19,793) 15.5% (19,660) ***Females 22.1% (7,243) 18.3% (7,973) 17.2% (7,757) ***Missing 16.7% (12) 16.7% (6) – – –

Children 15.0% (1,549) 14.4% (1,741) 17.6% (1,425) NSAdults 22.2% (24,599) 17.0% (24,879) 15.9% (25,992) ***Missing 42.7% (82) 37.2% (1,152) – – NS

Table 3 Wearing rates by age group and sex

Children Adults

Wearing rate Sample size Wearing rate Sample size

1999 surveyMales 12.7% (1,122) 22.2% (17,794)Females 20.9% (426) 22.2% (6.794)

1996 surveyMales 13.3% (1,326) 16.7% (17,545)Females 17.6% (415) 17.5% (7,328)

1994 surveyMales 16.0% (1,036) 15.5% (18,624)Females 21.9% (389) 17.0% (7,368)

2 A further 83 cyclists were observed without their helmet status recorded.They were excluded from the analysis.

The observed variation in children’s and adult’s wearingrates was explained by the interaction between age andsex. This indicated that female children were not any lesslikely than adults to wear a helmet, but that male childrenwere much less likely.

14

5.2.1.2 Type of bicycleThe most popular types of bike were mountain bikes andBMXs, which were ridden by 37% of those observed. Thetype of bike with the highest wearing rate was racing bikes,as shown in Table 4. Further analysis using logisticalregression showed that, whilst some of this difference wasexplained by the proportions of males / females and children /adults riding each type of bike, bike type alone also affectedhelmet wearing rate.

Weather data were missing for 1,031 cyclists, most ofwhich were in one local authority area where the wearingrate was low. This has caused the ‘wet’ and ‘dry’ rates toeach be more than the overall rate of 21.8%.)

This effect was also found in the 1996 survey, thoughnot in 1994. Note that in the 1999 survey weather wasrecorded for each 15 minute period, rather than hourly.

5.2.1.5 LondonThe wearing rate at the London sites was 43.5% in the1999 survey, significantly higher than outside London(19.9%, p<0.001). This was an increase on the 1996 figurewhich was 39.2% (p<0.005).

The characteristics of cyclists observed in London weredifferent from elsewhere: there were no children observedat all, whereas they made up an average of 6.5% of thesample elsewhere (p<0.001). Also, more of the samplewere male in London: 79.8% compared with 71.7%elsewhere (p<0.001).

5.2.1.6 Recreational routesCyclists were surveyed on a Sunday afternoon on theRidgeway cycle track and the Bath to Bristol cycle route.More cyclists wore helmets on these routes than at theother sites. Table 5 shows how the characteristics of cyclistat recreational sites differ to other locations.

Table 4 Different types of bikes

% riding bike type

Bike type (n=26,230) Wearing rate

Mountain / BMX 37.4 20.7%Traditional town 27.9 17.9%Racing / tourer 9.2 31.5%Other 2.0 24.4%Missing 23.5 24.2%

5.2.1.3 TimeFigure 2 shows the wearing rate by hour of day forchildren and adults. The lines have been ‘smoothed’ bytaking hourly averages. eg. 0800 on the graph indicates theaverage wearing rate between 0800 and 0859 hours.

For adults, peaks in wearing rates are observed in themorning and again in the afternoon, presumably associatedwith the work journey. For children, however, wearingrates are higher during the ‘off-peak’ period, between noonand 3pm.

The wearing rate was lowest during the weekday off-peakperiod (15.0%) and highest at the weekend (38.4%)3. The rateduring the weekday peak period was 26.0% (p<0.001). (Peakwas defined as 0700 – 0959 hours and 1600 – 1859 hours.)

5.2.1.4 WeatherOf the 474 hours of surveys carried out 27.5 hours at 20sites were recorded as ‘wet’. Of the 853 cyclists observedin the wet, 27.1% were wearing a helmet, significantlymore than the 22.0% when it was not wet (p<0.001). (NB.

0

10

20

30

40

0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800Time of day

Wea

ring

rate

, % (m

ean

over

hou

r)

children adults

Figure 2 Wearing rates by time of day

Table 5 Recreational routes

Recreational Other SignificanceCharacteristic routes sites of difference

% wearing a helmet 38.4% 21.6% ***% children 20.7% 5.8% ***% females 38.2% 27.5% ***% riding in a group 55.5% 4.3% ***

3 Based on a small sample at recreational sites only.

However, no weekday recreational route data areavailable and so this effect is indistinguishable from anyweekend effects (see section 5.2.1.3).

15

5.2.1.7 Local cycling levelsAs shown in Figure 3, there is evidence to suggest that wearingrates are highest where there are low levels of cycling, asmeasured by 1991 census cycling to work data (see Office ofPopulation Censuses and Surveys, 1993). This could be due tothe lack to safe cycling facilities or other cyclist provision inthese areas. The notable exceptions are Oxford and Cambridgewhich both have high levels of cycling and high wearing rates.

The 1996 survey found that, when analysed by area, anincrease in helmet wearing was associated with a fall in thenumber of cyclists observed. This effect was not found in the1999 survey, indicating that this effect has not continued.

5.2.2 Trends in cycle helmet wearing since 1994The increase in helmet wearing rates observed on built-upmajor roads between 1994 and 1999 has not been uniformacross gender and age groups.

Figure 4 shows how the helmet wearing rate has variedover the three survey years. The wearing rates for adultshave increased steadily: for men the rate has increased by afactor of 1.43 over the five years 1994-1999, and forwomen the rate has increased by a factor of 1.31.

For children the wearing rate fell between 1994 and 1996.Since 1996 the girls’ wearing rate has increased and almostreached 1994 levels, but for boys there has been no suchsign of any recovery. The figure shows quite clearly that theboys’ wearing rate is about two thirds the girls’ rate.

5.3 Results of the extended survey

In total 3,407 cyclists were observed on built-up minorroads, of whom 8.2% were wearing a cycle helmet. A

greater proportion of children than adults were wearing ahelmet. The small sample of children aged under 7revealed a wearing rate of over one in five.

The time when wearing was greatest was during theweekday peak hours4. Cyclists were found to be morelikely to wear a helmet if they were riding on the road(rather than on the pavement, or somewhere else). As inthe repeat survey a higher proportion of cyclists worehelmets in wet weather. However in the extended surveythe difference between wet and dry was not statisticallysignificant.

Table 6 gives a summary of sample sizes and wearingrates split by the main independent variables.

It was anticipated that some cyclists would be carrying ahelmet but not wearing it. For example, hanging from thehandle bars of their bike. Only 20 cyclists in total wererecorded as doing this. They were analysed together withthe non-wearers, as this sample is too small to analyse inisolation.

5.3.1 Differences between children’s and adult’s cyclingMore children than adults were observed wearing helmets(p=0.033). Other differences between child and adultcyclists are summarised in Table 7. It can clearly be seenthat the distributions of type of area observed in, type ofbike ridden, riding position and day / time vary betweenchildren and adults.

Adults were more likely to wear a helmet when ridingon the road than on the pavement (8.2% versus 4.8%,

Scunthorpe

y = -7.8141Ln(x) + 28.763R2 = 0.2907

0

5

10

15

20

25

30

35

40

45

50

0 5 10 15 20 25 30

% who cycle to work (1991 census)

1999

hel

met

wea

ring

rate

Cambridge

Oxford

York

Edinburgh

Westminster

BathGlasgow

NewcastleManchesterBristol

Gloucester

Norwich

Portsmouth

BostonHull

PeterboroughDarlingtonStockton

BedfordBarrow-in-Furness

4 ‘Peak weekday hours’ are defined as 0700 to 0959 hoursand 1600 to 1859 hours.

Figure 3 Relationship between helmet wearing and local levels of cycling

16

p=0.006). This was not the case amongst children, manymore of whom were observed riding on the pavement.Maybe surprisingly, neither children or adults were anymore likely to ride on the pavement during peak hours,

The proportion of girls in the 11-16 year old sample(17.7%) was smaller than the proportion of females in the

10%

15%

20%

25%

1994 1996 1999

Year of survey

Wea

ring

rate

on

maj

orbu

ilt-u

p ro

ads

male children female children

male adults female adults

Table 6 Sample sizes and wearing rates

% wearing SampleVariable Category helmets size Significance

Age group 0-6 years 22.6 (53) **7-10 years 9.2 (174)11-16 years 8.8 (725)Adult 7.4 (2,354)

Child 16 or under 9.7 (952) *Adult over 16 7.4 (2,354)

Sex Male 8.2 (2,558) NSFemale 8.1 (750)

Area type City / town centre 10.5 (1,321) ***Urban – out of centre 6.6 (2,009)

Location type Residential 7.1 (1,855) ***Shops 7.3 (958)School 22.4 (49)Other 13.4 (432)

Day / time Weekday peak 10.8% (1,032) ***Weekday off-peak 8.1% (817)Weekend 6.4% (1,481)

Weather during Dry 8.0 (2,482) NS15 minute period Raining 11.0 (210)

Mixed 6.7 (239)

Type of bike Racer / tourer 12.0 (200) ***Mountain 10.3 (1,767)Traditional town 4.4 (1,163)Other 5.2 (172)

Riding position On road 9.1 (2,097) *On pavement 6.4 (1,039)Other 5.9 (102)

School journey Child in uniform 18.2 (88) **Child not in uniform 8.9 (866)Adult 7.4 (2,352)

Figure 4 Changes in wearing rates 1994-1999

Table 7 Characteristics of child and adult cyclists

Significanceof difference

betweenchildren

Variable / category Children Adults and adults

% wearing helmet 9.7% 7.4% *

% female 20.6% 23.4% NS

Type of area Residential 64.8% 52.9% ***Shops 21.8% 31.7%School 3.1% 1.0%Other 10.3% 14.4%

Type of bike Mountain 73.0% 45.3% ***Traditional town 16.0% 43.1%Others 11.0% 11.5%

Riding position On road 40.9% 74.4% ***On pavement / other 59.1% 25.6%

Day / time Weekday peak 29.7% 31.6% ***Weekday off-peak 13.4% 29.5%Weekend 56.9% 38.9%

Table 8 Wearing rates by day/time and age group

Children Adults

Wearing Sample Wearing Samplerate size rate size

Weekday peak 10.4% 280 11.0% 735Weekday off-peak 21.5% 121 5.5% 692Weekend 6.7% 551 6.0% 927

other age groups: 30.4% of children aged under 11 and23.4% of adults. This points to a decline in cyclingamongst females during their teenage years (p<0.0001).

As shown in Table 8, wearing rate day/time patternsvaried between children and adults: children were morelikely to wear a helmet during weekday off-peak hours,whilst the adult wearing rate was highest during weekdaypeak hours.

17

5.3.2 Children’s cyclingPeaks in the numbers of child cyclists were observed inthe morning and afternoon, presumably associated withtravelling to and from school. However, as shown inTable 8, helmet wearing amongst children was greatestduring off-peak hours.

There was no significant difference in wearing ratesbetween children on the school journey wearing anidentifiable school uniform and those not.

Children’s helmet wearing varied by type of bike ridden(p=0.004). Wearing rates were:

� 11.5% for mountain bike riders;

� 4.6% for traditional town bike riders;

� 3.8% for riders of other bikes.

A quarter of children wore helmets when it was raining,compared with 8.0% when it was ‘dry’ and 5.7% when itwas ‘mixed’ (p<0.001).

5.4 Comparing the two surveys

The results presented in the previous two sections showlarge differences between wearing rates on built-up majorroads (repeat survey) and wearing rates on built-up minorroads (the extended survey). This section examines theseresults further in order to suggest reasons for this difference.

Table 9 shows that the characteristics of the samplesvary across each of the variables measured. Does thedifference in wearing rates arise because of differences inthe composition of the survey samples (the extendedsurvey sample included a high proportion of children) orbecause of some underlying difference in helmet wearingbetween groups in the two surveys?

In order to investigate this further, the logistic regressionmethod was used (see section 5.2.1.1). Table 10 shows thesignificant terms in the model.

Table 9 Compare characteristics of two samples (sample sizes in brackets)

Built-up major roads Built-up minor roads Significance of differenceCharacteristic (repeat survey) (extended survey) between surveys

% wearing helmet 21.8% (26,230) 8.2% (3,330) ***

% child 5.9% (26,148) 28.8% (3,306) ***

% adults wearing helmets 22.2% (24,599) 7.4% (2,354) ***% children wearing helmets 15.0% (1,549) 9.7% (952) ***

% female 27.6% (26,218) 22.7% (3,308) ***

Peak-time Weekday peak 59.2% 31.0%Weekday off-peak 39.6% 24.5% ***Weekend 1.2% (26,230) 44.5% (3,330)

type of bike % racer 12.1% 6.1%% mountain 48.9% 53.5% ***% traditional town 36.4% 35.2%% other 2.7% (20,054) 5.2% (3,302)

% observed in Dry weather 92.4% 84.7%Wet weather 3.4% 7.2% ***Mixed weather 4.2% (25,199) 8.2% (2,931)

Table 10 Terms in the comparison of survey model

Interaction Significance

Survey by age by peak-time ***Age by peak-time ***Survey by age NSAge ***Peak-time ***Survey ***

This shows that the difference in the wearing ratesobserved is partly due to the different make-up of the twosamples (the differences in age and proportions observedat peak time) and partly to different behaviours betweenthe two surveys (indicated by the survey, survey by ageand survey by age by peak-time interactions).

The differences in observed wearing rates arose because:

� there were more children observed in the extendedsurvey;

� both children and adults are less likely to wear helmetson quiet roads than on busy roads;

� wearing rates in peak, off-peak and weekend periods donot vary uniformly across child and adult cyclists.

5.5 Summary and conclusions

The 1999 repeat observational surveys showed that helmetwearing on built-up major roads increased by a quarter on1996 figures. This increase was greatest amongst adultcyclists. The girls’ wearing rate also increased, but wearingamongst boys went down.

Since the first survey in 1994 the proportion of cyclistswearing a helmet has increased in each survey. Betweenthe 1994 and 1996 surveys the proportion of childrenwearing a helmet fell. Since 1996 the proportion of girlswearing a helmet has almost recovered to the 1994 level,but the proportion of boys wearing a helmet remains atabout the 1996 level.

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As in the 1996 survey, helmet wearing was found to behigher in places where overall cycling levels were lower(as defined by the Census ‘cycling to work’ indicator). It isnot altogether surprising that these cyclists could feel moreat risk and therefore choose to wear a helmet. For example,there may be fewer engineering measures to help cyclists.Where cyclists are more commonplace, drivers may beused to sharing the road space with them and thereforetreat them with more consideration, thereby reducingcyclists’ perceptions of risk.

In the analysis of the 1996 survey (see Bryan-Brown andTaylor, 1997), it was suggested that an increase in the wearingrate was associated with a fall in the number of cyclistsobserved, implying that helmets may discourage people fromcycling. This effect has not continued into 1999.

The extended survey attempted to improve therepresentativeness of the sample by observing cyclists onbuilt-up minor roads. The sampling methodologydeveloped under this project provided a reasonablyefficient way of detecting child cyclists. An average of 4.0children were observed per hour of survey, compared with3.3 for the repeated surveys on built-up major roads.

The proportion of cyclists observed wearing a helmet onbuilt-up minor roads was 8.2 per cent, significantly less thanthe 21.8 per cent observed at the built-up major sites. Thedata show that both adults and children were less likely to bewearing helmets on the minor roads than on the major roadsused for the repeat survey. The differences between the twosurveys confirm that the repeat surveys on busy roads onlyare not representative of the whole cycling population. Theyalso suggest that wearing rates vary greatly and by manyexternal factors, some measurable or ‘observable’, othersnot. For example, if cyclists make choices based upon theirperceived level of risk then this would explain why fewercyclists wear a helmet on quieter roads.

6 Conclusions and recommendations

This research has found that, although increasing steadily,helmet wearing rates in this country are still low. Majorincreases in helmet wearing rates will not be achievedwithout a large-scale, multi-agency, community basedprogramme, along the lines of the health promotionstrategies. A survey of local authorities showed that,although most reported actively promoting helmets, fewhad evaluated their campaigns. The literature review foundthat the main reason for young people not wearing ahelmet was that it was not seen as the norm and theyfeared peer derision. It is unclear what effect school policyhas on helmet wearing and, furthermore, whether it affectscycling levels within the school.

The international review of cycle helmet surveysconfirmed the need for observations of cyclists in order todraw as clear a picture as possible of the national wearingrate. Self reported measures have thrown up inconsistenciesbetween claiming to own a cycle helmet, claiming to wearon a frequent basis and actually wearing it!

It is recommended that the repeat surveys are continuedas an ongoing measure of helmet wearing trends on built-up

major roads. The extended survey, developed andconducted on built-up minor roads for this first time, hasconfirmed that the repeat survey alone does not representan overall picture of the nation’s helmet wearing.

Furthermore, the differences between the wearing ratesobserved on major and minor roads in built-up areas arelarge enough to bring into question the trend in wearingrates derived from the repeat survey alone. For example,helmet wearing on built-up major roads (as indicated bythe repeat survey) could increase, whilst wearing on minorroads (estimated from the extended survey) may decline.To establish trends such as this in the future, both surveysshould be undertaken.

7 References

Bergman A, Rivara F P, Richards D D and Rogers L W(1990). The Seattle children’s bicycle helmet campaign.AJDC Vol. 144, June 1990.

Bryan-Brown K and Taylor S (1997). Cycle helmetwearing in 1996. TRL Report TRL286. Crowthorne: TRLLimited.

Cameron M H, Vulcan A P, Finch C F and Newstead S V(1994). Mandatory bicycle helmet use following a decadeof helmet promotion in Victoria, Australia—an evaluation.Accid. Anal and Prev. Vol. 26 No. 3, pp. 325–337.

Cote T R, Sacks J J, Lambert-Huber D A,Dannenberg A L, Kresnow M, Lipsitz C M andSchmidt E R (1992). Bicycle helmet use among Marylandchildren: effect of legislation and education. PediatricsVol. 89 No. 6, June 1992.

Cushman R, James W and Waclawik H (1991).Physicians promoting bicycle helmets for children: arandomized trial. American Journal of Public Health.Vol. 81, No. 8, pp. 1044–6

Dannenberg A L, Gielen A C, Beilenson P L, Wilson M Hand Joffe A (1993). Bicycle helmet laws and educationalcampaigns: an evaluation of strategies to increasechildren’s helmet use. American Journal of Public HealthMay 1993 Vol. 83, No. 5.

Department of the Environment, Transport and theRegions (1999). Road traffic statistics:1998. TransportStatistics Report SB (99) 20.

Department of the Environment, Transport and theRegions (1996). Cycling in Great Britain. TransportStatistics Report. London: The Stationery Office.

DiGuisseppi C G, Rivara F P, Koepsell and Polissar T D(1989). Bicycle helmet use by children. Evaluation of acommunity wide helmet campaign. JAMA October 27 1989Vol. 262 No. 16, pp. 2256–61.

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Ekman R, Schelp L, Welander G and Svanstrom L (1997).Can a combination of local, regional and nationalinformation substantially increase bicycle-helmet wearingand reduce injuries? Experiences from Sweden. Accid.Anal and Prev Vol. 29 No. 3, pp. 321–328, 1997.

Elliot and Shanahan Research (1986). An exploratorystudy of high school students’ reaction to bicycle helmets.Victoria: Road Traffic Authority

Farley C, Haddad S and Brown B (1996). The effects ofa 4-year program promoting bicycle helmet use amongchildren in Quebec. American Journal of Public Health.Vol 86. No. 1, pp. 46–51.

Finch C F, Heiman L and Neiger D (1993). Bicycle useand helmet wearing rates in Melbourne, 1987-1992: theinfluence of the helmet wearing law. VICROADS, Australia.

Gielen A, Joffe A, Dannenberg A L, Wilson M E H,Beilenson P L and Deboer M (1994). Psychosocialfactors associated with the use of bicycle helmets amongchildren in counties with and without helmet use laws. TheJournal of Paediatrics February 1994.

Government Statistical Service (1999). Regional trends 34.London: The Stationery Office.

Hillman M (1993). The case for and against promotingcycle helmet wearing. PTRC 21st Summer Meeting,Proceedings of Seminar C 13-17 September 1993.

Joshi M S, Beckett K and Macfarlane A (1994). Cyclehelmet wearing in teenagers—do health beliefs influencebehaviour? Archives of Disease in Childhood 1994;Vol. 71 No. 6, pp. 536–539

Macknin M L, Vanderbrug S and Medendorp S (1994).Association between bicycle helmet legislation, bicyclesafety education, and use of bicycle helmets in children.Arch. Pediatr Adolesc Med/Vol. 148, March 1994.

McEvoy M (1996). Increasing bicycle helmet use amongschool age children. Nurse Practitioner. Vol. 21, No. 4,pp 14–6, 150.

Mills P J (1989). Pedal cycle accidents—a hospital basedstudy. Research Report RR220. Crowthorne: TRL Limited.

Morris B A P and Trimble N E (1991). Promotion ofbicycle helmet use among schoolchildren: A randomisedclinical trial. Canadian Journal of Public Health, Vol. 82No. 2, pp. 92–4.

Office of Population Censuses and Surveys (1993). 1991Census. County report part 2. London: The Stationery Office.

Parkin P C, Spence L J, Hu X, Kranz K E, Shortt L Gand Wesson D E (1993). Evaluation of a promotionalstrategy to increase bicycle helmet use by children.Paediatrics Vol. 91 No. 4, pp. 772–7.

Pendergrast R A, Asworth C S, DuRant R H andLitaker M (1992). Correlates of children’s bicycle helmetuse and short-term failure of school-level interventions.Pediatrics Vol. 90 No. 3, pp. 54–8.

Povey L J, Frith W J and Graham P G (1998). Helmeteffectiveness in New Zealand. Road Safety Research,Policing and Education Conference 1998, Vol. 2.Wellington: Land Transport Safety Authority.

Rivara F P, Thompson D C, Thompson R S, Rogers L W,Alexander B, Felix D and Bergman A B (1994). TheSeattle children bicycle helmet campaign: Changes inhelmet use and head injury admissions. Paediatrics Vol. 93No. 4, April 1994.

Scheidt P C, Wilson M H and Stern M S (1992). Bicyclehelmet law for children: A case study of activism in injurycontrol. Paediatrics Vol. 89 No. 6, June 1992.

Simpson H (1996). Comparison of hospital and policecasualty data: a national study. TRL Report TRL173.Crowthorne: TRL Limited.

Stevenson T and Lennie J (1992). Empowering schoolstudents in developing strategies to increase bicycle helmetwearing. Health Education Research Theory and PracticeVol. 7 No. 4, pp. 555–566.

Taylor S B and Halliday M E (1996). Cycle helmetwearing in Great Britain. TRL Report TRL156.Crowthorne: TRL Limited.

Towner E, Carter Y and Hayes M (1998). Implementationof injury prevention for children and young people. InjuryPrevention 1998; 4 (suppl): S26-S33; BMJ.

Ward H and Christie N (2000). Strategic review ofresearch priorities for accidental injury. Department ofHealth. www.doh.gov.uk/research/documents/rd3/accidental_injuries_report.pdf

Watts D, O'Shea N, Ile A, Flynn E, Trask A andKelleher D (1997). Effect of a bicycle safety program andfree bicycle helmet distribution on the use of bicyclehelmets by elementary school children. Journal ofEmergency Nursing Vol. 23 No. 5, pp. 417–9.

Weiss B D (1992). Trends in bicycle helmet use by children:1985 to 1990. Pediatrics Vol. 89 No. 1, pp. 78–80.

Winn G L, Jones D F and Bonk C J (1992). Taking it tothe streets. Helmet use and bicycle safety as components ofinner city youth development. Clinical PaediatricsNovember 1992.

Womack K N (1995). Bicycle helmet use evaluation usingcomparison-site observation. Transportation ResearchRecord No.1538 Safety and Human Performance,pedestrian and bicycle Research. Transportation Research,Board National Research Council.

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8 Acknowledgements

The authors would like to thank Gordon Harland, TRL’sQuality Audit and Review Officer, for his help andguidance, and also Pam Lewis who contributed greatly tothe project. Thanks also to Andrea Scott for entering thedata, to the contributing local authorities and their surveyteams, and Phil Bowring and the PAS survey staff forconducting the extended surveys.

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Appendix A: Helmet promotion leaflet and questionnaire

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1999 1996 1994

Authority Rate % Count Rate % Count Rate % Count

Aberdeen City 22.1 104 21.0 176 25.7 136Bath & NE Somerset 36.6 298 24.0 537 24.9 554Bedfordshire 6.4 565 5.9 706 5.6 587Berkshire 20.5 449 23.4 380 18.9 428Bournemouth 9.1 594 7.9 762 6.9 725Bristol City 29.8 514 19.5 159 18.0 194Cambridgeshire 24.0 6,122 20.1 5,684 19.2 5,238Cardiff 22.2 243 53.8 156 18.3 323Cheshire County 9.4 212 4.2 285 6.4 171Coventry 19.8 162 16.3 160 18.7 203Cumbria County 4.2 404 5.9 340 5.2 539Darlington Borough 7.0 71 12.8 39 3.2 31Derbyshire 10.0 401 9.1 464 8.1 446Doncaster 13.9 158 19.2 130 13.6 125East Riding of York 6.9 102 6.7 149 9.1 88Edinburgh City 46.5 654 42.5 320 35.9 412Essex 8.6 521 7.0 628 6.5 589Glasgow City 34.2 1,318 38.8 1,232 21.4 1,584Gloucestershire County 14.2 549 7.3 578 7.2 748Greater Manchester 30.9 265 22.3 287 21.1 356Kingston upon Hull 2.0 507 2.9 787 2.2 734Leicestershire 17.5 794 15.7 1,042 12.2 951Lincolnshire County 0.9 338 2.7 298 0.0 373Liverpool City 21.2 189 11.2 152 10.5 153Newcastle City 33.7 205 31.8 198 24.2 211Norfolk County 21.5 261 10.6 908 15.0 381North East Lincolnshire 5.7 331 5.8 345 9.7 299North Lincolnshire 3.9 382 6.2 421 3.1 295Northamptonshire County 20.8 154 8.8 102 22.6 53Nottingham City 21.7 757 14.5 888 14.9 803Nottingham County 5.2 516 0.6 650 0.9 585Oxford County 27.7 2,834 23.5 3,155 21.2 3,180Peterborough 4.1 676 4.2 836 4.2 956Portsmouth City 15.9 334 17.2 274 16.2 328Staffordshire County 10.1 99 10.1 138 6.1 214Stockton-on-Tees BC 8.1 86 8.5 71 6.7 90Suffolk 13.1 191 8.0 576 10.4 712Swindon Borough 11.2 205 6.5 275 4.2 331Warrington Borough 14.6 89 4.4 91 10.8 102Warwickshire 11.0 327 11.9 328 19.5 128Westminster 43.5 2,177 39.2 1,975 38.1 1,986Wolverhampton MBC 8.9 135 11.9 135 7.0 171York City 12.6 937 7.6 955 5.2 904

Total 21.8 26,230 17.6 27,772 16.0 27,417

These figures are for interest only and are not intended to representoverall wearing rates within each local authority area, as they arebased only on a small number of sites.

Appendix B: Changes in wearing rates by local authority

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Appendix C: Data collection forms used in the repeat surveys

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Appendix D: Data collection forms used in the extended survey

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Abstract

This report reviews research into helmet promotion and reports a nationwide observational survey of cyclists,conducted in the autumn of 1999, to assess changes in bicycle helmet wearing rates since 1996. It also includes theresults of an extended survey which has been designed to improve the representativeness of the sample, in particularincreasing the number of child cyclists observed.

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TRL286 Cycle helmet wearing in 1996 by K Bryan-Brown and S Taylor. 1997 (price £25, code E)

TRL214 The effectiveness of child cycle training schemes by T Savill, K Bryan-Brown and G Harland.1996 (price £35, code H)

TRL156 Cycle helmet wearing in Great Britain by S B Taylor and M E Halliday. 1996 (price £25, code E)

PR76 International literature review of cycle helmets by M Royles. 1994 (price £25, code E)

RR220 Pedal cycle accidents – a hospital based study by P J Mills. 1990 (price £20, code B)