School based bicycle safety education and bicycle injuries in children: a case-control study

Perspective Commentary: The Implementation of Welfare Policies Are Not Held to the Same Ethical Standards as Research: Raising Intergenerational Health Inequality Concerns

Over the last 12 years the United Kingdom (UK) has seen the introduction of an austerity programme-a fiscal policy-with the primary goal to reduce the government's budget deficit and the role of the welfare system. Between 2010 and 2015 there was an estimated reduction of £14.5 billion in spending, attributable to decreasing the value of benefits and restricting entitlement to benefit claimants. By 2020, there had been an estimated unprecedented £27 billion less spent on welfare compared with spending in 2010. Whilst fiscally-successful at reducing spending, some implemented welfare policies have had direct consequences for people's health, increasing inequalities which have been heavily criticized. Moreover, there is growing concern that this has an intergenerational effect. In this paper, we describe the ethical principles in human research, how these have been considered in public health policy, and the existing evidence of the direct and intergenerational health and welfare consequences of some recent, nationally-implemented welfare policies. We argue that ethical principles, specifically the ethical principle of safety that is applied in all research, should be applied to all public welfare policies to stop the rising inequalities in health we are seeing across generations. We highlight that initial changes implemented to welfare policies as a response to COVID-19 demonstrate that there can be a political and societal perceived value in going further to support individuals and their families during times of adversity, and consider the ethical implications of this.

An evaluation of the effects of an innovative school-based cycling education program on safety and participation

Cycling education programs for children could play a role in promoting both cycling participation and cycling safety, and they exist in many countries - often in school settings. Evaluations have generally shown improvements in skills and knowledge, but effects on less-researched outcomes such as safety-related behaviour, crashes or injuries, cycling participation, and cycling confidence, are unclear. The present research evaluated Safe Cycle, an innovative Australian school-based program that addresses hazard awareness and overconfidence in addition to more typical content (e.g. handling skills), in terms of a comprehensive range of outcomes. Students from Years 4 to 8 (n = 108) completed online surveys in class before, immediately after, and approximately 14 weeks after, the 8-week program was delivered. Significant increases in knowledge and confidence were observed, while results also suggested increases in cycling participation. The program appeared to address illusory invulnerability effectively, but there was no evidence that the program improved safety-relevant cycling behaviours or experience of crashes. The benefits of Safe Cycle might be enhanced by including elements to increase motivation to perform safety-relevant behaviours and durability of program effects.

Recommend or mandate? A systematic review and meta-analysis of the effects of mandatory bicycle helmet legislation

If all cyclistswere wearing helmets, significant numbers of head injuries might theoretically be prevented. Mandatory bicycle helmet legislation increases helmet use but is a controversial measure. Results from 21 studies of the effects of mandatory bicycle helmet legislation on injuries among crash involved cyclists were investigated by means of meta-analysis and the effects of several potential biases were investigated. The summary effect of mandatory bicycle helmet legislation for all cyclists on head injuries is a statistically significant reduction by 20% (95% confidence interval [-27; -13]). Larger effects were found for serious head injury (-55%; 95% confidence interval; [-78; -8]). Among children, larger effects were found when legislation applies to all cyclists than when it applies to children only. There is no clear indication of the results being affected by publication bias. Publication bias may exist, but any existing biases seem to more or less outweigh each other. Results from meta-analysis do not indicate that the results are systematically affected by a lack of control for time trend bias, choice of comparison group or study design (before-after vs. case control). Summary effects may be somewhat overestimated because of a lack of control for potential confounding variables in some of the studies. However, such a bias, if it exists, is not likely to be large. Empirical evidence for the hypotheses that mandatory bicycle helmet legislation deters people from cycling and that helmet wearing leads to behavioral adaptation is mixed. In summary, mandatory bicycle helmet legislation can be expected to reduce head injury among crash involved cyclists. Some adverse effects may occur, but will not necessarily be large or long-lasting. People who may be deterred from cycling, are among those with the highest injury risk and the smallest health effects from cycling. If the overall goal is to improve safety for all cyclists and to increase cycling, mandatory bicycle helmet legislation should be supplemented by other measures, especially improved bicycle infrastructure.

On the use of naturalistic methods to examine safety-relevant behaviours amongst children and evaluate a cycling education program

School-based cycling education programs aim to improve cycling safety and participation amongst children. Available research suggests that typical programs, which focus on bicycle manoeuvring skills, have limited effects on behaviour observed on a track or planned route. The current study uses theoretically more valid, naturalistic cycling data, to evaluate Safe Cycle, a program that incorporates hazard and self-awareness training. Soon after Safe Cycle was delivered at treatment schools, research bicycles instrumented with a rearward- and a forward-facing camera were loaned to six children from treatment schools and six children from (waitlist) control schools. In each group half the children were in Year 6, and half were in Year 7/8. Each child was instructed to ride the research bicycle instead of their own bicycle for the 1-2 weeks that they had a research bicycle. Video data were reduced using a purpose-designed coding scheme that identified whether participants performed specific safety-relevant behaviours in appropriate circumstances. While the participants controlled their bicycles well, gave way appropriately to traffic at intersections, and stopped at red lights, participants frequently removed one or both hands from the handlebars, and seldom signalled turns, conducted over-shoulder-checks when changing lanes, or looked in multiple directions at intersections (except when crossing a road). While aspects of design and small sample sizes limited evaluation findings, this research demonstrated the feasibility and potential of naturalistic data to support cycling education program evaluation. Further, the study substantially extended available naturalistic study of children's cycling behaviour to highlight behaviours which might be targeted by cycling safety initiatives.

An Intervention to Reduce Bicycle Injuries among Middle School Students in Rural China

This study aimed to evaluate the effectiveness of an intervention to reduce bicycle injuries among rural middle school students in China. A one-year cluster-randomized controlled trial was conducted with seventh grade students from six middle schools in two towns in rural Chaoshan, China. The two towns were randomly assigned to either the intervention or control group. Road safety education materials, two lectures on road safety, and a series of health education activities were delivered to 1312 students in the intervention group over one year, and the content of the intervention included traffic safety knowledge, methods of preventing bicycle injury and management of bicycle injuries. Questionnaires weere administered to the two groups before and after the intervention to measure the incidence, cognitions, and behaviors related to bicycle injuries. The pre-intervention incidence of bicycle injuries exhibited no significant difference between the two groups, while the difference reached significance after the intervention (χ² = 13.409, p < 0.001). In the intervention group, the incidence decreased significantly after the intervention (χ² = 8.137, p = 0.004), while no significant change was observed in the control group. Publicity and education intervention measures have certain short-term effects on the prevention of bicycle injuries among rural middle school students; we should approach intervention measures according to the characteristics of traffic injuries in different areas.

Risk Factors for Bicycling Injuries in Children and Adolescents: A Systematic Review

CONTEXT

Child and adolescent bicycling is beneficial, but injuries occur and can be severe and costly.

OBJECTIVE

To systematically review the individual and environmental factors associated with bicycling injury risk in children and adolescents.

DATA SOURCES

Fourteen electronic databases were searched.

STUDY SELECTION

Two authors independently assessed potentially relevant articles for eligibility. The inclusion criteria were as follows: bicyclists younger than 20 years old; examined individual and environmental characteristics of bicycling crashes; compared injured and uninjured bicyclists or bicyclists with different types or severity of injury; study designs with a predetermined comparison group; and published in English from January 1990 to May 2015. The exclusion criteria were outcomes related to helmet use, helmet legislation, or mountain biking, and comparisons of census-based injury rates.

DATA EXTRACTION

Data on study design, setting, population, injury definitions, injury risk factors, and results were extracted. Risk of bias was assessed by using the Newcastle-Ottawa Scales.

RESULTS

Fourteen articles were included. Lower socioeconomic status, riding on the road, riding in rural compared with urban areas, and riding on the sidewalk were associated with bicycling injury. Bicycling safety education did not protect children against future injury. Injuries related to a motor vehicle collision were more severe than other bicycling injuries.

LIMITATIONS

Study heterogeneity prevented meta-analyses. Study quality was affected by inadequate definitions of study groups and self-reported data.

CONCLUSIONS

Lower socioeconomic status and riding location were associated with bicycling injury and severity increased with motor vehicle collisions. The bicycling environment is a promising avenue for prevention.

The impact of cycle proficiency training on cycle-related behaviours and accidents in adolescence: findings from ALSPAC, a UK longitudinal cohort

BACKGROUND

Cycle accidents are a common cause of physical injury in children and adolescents. Education is one strategy to reduce cycle-related injuries. In the UK, some children undertake National Cycle Proficiency Scheme [NCPS] training (now known as Bikeability) in their final years of primary school. It aims to promote cycling and safe cycling behaviours but there has been little scientific evaluation of its effectiveness.

METHODS

The sample (n = 5415) were participants in the Avon Longitudinal Study of Parents and Children who reported whether or not they had received NCPS training. Outcomes were self-reported at 14 and 16 years: cycling to school, ownership of cycle helmet, use of cycle helmet and high-visibility clothing on last cycle, and involvement in a cycle accident. An additional outcome, hospital admittance due to a cycle accident from 11 to 16 years, was also included for a subsample (n = 2222) who have been linked to Hospital Episode Statistics (HES) data.

RESULTS

Approximately 40 % of the sample had received NCPS training. Trained children were more likely to cycle to school and to own a cycle helmet at both 14 and 16 years, to have worn a helmet on their last cycle at age 14, and to have worn high-visibility clothing at age 16, than those who had not attended a course. NCPS training was not associated with self-reported involvement in a cycle accident, and only six of those with HES data had been admitted to hospital due to a cycle accident. Irrespective of training, results indicate very low use of high-visibility clothing, very few girls cycling as part of their school commute, and less than half of helmet owners wearing one on their last cycle.

CONCLUSIONS

Our results suggest cycle training courses for children can have benefits that persist into adolescence. However, the low use of cycle helmets, very low use of high-visibility clothing, and low levels of cycling to school for girls, indicate the further potential for interventions to encourage cycling, and safe cycling behaviours, in young people.

Database improvements for motor vehicle/bicycle crash analysis

Background

Bicycling is healthy but needs to be safer for more to bike. Police crash templates are designed for reporting crashes between motor vehicles, but not between vehicles/bicycles. If written/drawn bicycle-crash-scene details exist, these are not entered into spreadsheets.

Objective

To assess which bicycle-crash-scene data might be added to spreadsheets for analysis.

Methods

Police crash templates from 50 states were analysed. Reports for 3350 motor vehicle/bicycle crashes (2011) were obtained for the New York City area and 300 cases selected (with drawings and on roads with sharrows, bike lanes, cycle tracks and no bike provisions). Crashes were redrawn and new bicycle-crash-scene details were coded and entered into the existing spreadsheet. The association between severity of injuries and bicycle-crash-scene codes was evaluated using multiple logistic regression.

Results

Police templates only consistently include pedal-cyclist and helmet. Bicycle-crash-scene coded variables for templates could include: 4 bicycle environments, 18 vehicle impact-points (opened-doors and mirrors), 4 bicycle impact-points, motor vehicle/bicycle crash patterns, in/out of the bicycle environment and bike/relevant motor vehicle categories. A test of including these variables suggested that, with bicyclists who had minor injuries as the control group, bicyclists on roads with bike lanes riding outside the lane had lower likelihood of severe injuries (OR, 0.40, 95% CI 0.16 to 0.98) compared with bicyclists riding on roads without bicycle facilities.

Conclusions

Police templates should include additional bicycle-crash-scene codes for entry into spreadsheets. Crash analysis, including with big data, could then be conducted on bicycle environments, motor vehicle potential impact points/doors/mirrors, bicycle potential impact points, motor vehicle characteristics, location and injury.

Bicycle Promotion as a Response to Climate Change

Increased use of bicycles and other human-powered cycles for transportation is one way to slow climate change while providing health and economic benefits. HF/E professionals can make valuable contributions to this effort through research on actual and perceived barriers to utility (transportation) cycling and on effective means to reduce these barriers.

Prevention of bicycle-related injuries in children and youth: a systematic review of bicycle skills training interventions

BACKGROUND

Bicycling is a popular means of recreation and transportation for children; however, it is a leading cause of recreational injury. Bicycle skill development and safety education are important methods of bicycle injury prevention.

OBJECTIVE

To determine the effectiveness of bicycle skills training programmes in reducing bicycle-related injuries in children and youth.

METHODS

Sixteen databases were systematically searched to include studies involving children less than 19 years of age who participated in interventions that targeted bicycle skills and safety education. Outcome measures included injury, behaviour, knowledge and attitudes. Data extraction included study characteristics, intervention and outcomes. Quality of evidence was assessed using the Downs and Black criteria.

RESULTS

Twenty-five studies, including both observational (ie, case-control) and experimental (ie, randomised controlled trials) designs met the inclusion criteria. Overall, there was no statistically significant intervention effect on measures of injury. Eight of 16 studies measuring knowledge reported significant knowledge gains as a result of the intervention. Of 13 studies evaluating behavioural and attitude changes, five reported significant improvement. There was no significant difference in quality index scores between studies that showed an improvement in knowledge or behaviour (61%, 95% CI 49% to 74%) and studies that did not (57%, 95% CI 48% to 66%).

CONCLUSIONS

There is a paucity of high-quality research in the area of bicycle skills training programmes. Educational and skills training bicycling programmes may increase knowledge of cycling safety, but this does not seem to translate into a decrease in injury rate, or improved bicycle handling ability and attitudes.

Cycling crashes in children, adolescents, and adults--a comparative analysis

OBJECTIVE

To compare rates, circumstances, and outcomes of cyclist crashes between children (aged 0-9 years), adolescents (aged 10-19 years), and adults (aged 20 years and over) in Victoria, Australia.

METHODS

A retrospective analysis of cyclist crashes in police records and the Victorian Admitted Episodes Dataset during the period 2004-2008.

RESULTS

Adolescent cyclists had the highest rates, per 100 000 people, of police-reported (32.6, 95% confidence interval [CI]: 30.7-34.5) and hospitalized cyclist crashes (71.6, 95% CI: 68.7-74.4). Police-reported helmet use at the time of the crash was lowest among children (57.1%, 95% CI: 49.5-64.8) compared to 60.2 percent (95% CI: 57.3-63.1) in adolescents and 77.7 percent (95% CI: 76.5-78.8) in adults. This was reflected in the hospital data, which indicated that more than one third of cyclist hospitalizations among children (37.4%) resulted in head injuries compared to around 1 in 4 hospitalized cyclist crashes in adolescents (26.8%) and adults (23.7%). Cyclists emerging off a footpath into the path of a vehicle as well as cyclists struck by vehicles emerging form a driveway were the most frequent types of police-reported crashes involving children (73.9%) and adolescents (48.1%). In contrast, most adult cyclist crashes occurred on the roadway, mainly at intersections.

CONCLUSIONS

Programs to improve the safety knowledge and behavior of children and adolescent cyclists, particularly focusing on helmet use, should be part of a comprehensive approach that encompasses legislative and environmental changes, including appropriate cyclist facilities and reduced speed limit in residential areas.

Myths concerning alpine skiing injuries

There are many commonly discussed myths about ski safety that are propagated by industry, physicians, and skiers. Through a review of the literature concerning 12 such topics, this article demonstrates that the following are untrue: (1) Broken legs have been traded for blown-out knees. (2) If you know your DIN (a slang term for release indicator value), you can adjust your own bindings. (3) Toe and heel piece settings must be the same to function properly. (4) Formal ski instruction will make you safer. (5) Very short skis do not need release bindings. (6) Spending a lot of money on children's equipment is not worth the cost. (7) Children need plenty of room in ski boots for their growing feet. (8) If you think you are going to fall, just relax. (9) Exercise can prevent skiing injuries. (10) Lower release settings can reduce the risk of anterior cruciate ligament injury. (11) Buying new ski equipment is safer than renting. (12) Skiing is among the most dangerous of activities. It is important for the skiing public, physicians, and all those interested in improving skiing safety to verify the measures they advocate. The statements analyzed here are simply untrue and have the potential to cause harm if taken as fact by those exposed to these unsupported opinions.

Advances in the prevention of children's injuries: an examination of four common outdoor activities

PURPOSE OF REVIEW

Injuries remain the leading cause of death for children. Experts in paediatrics and child health have a current interest in promoting children's healthy active living. This review highlights findings from recent literature regarding the prevention of injuries from four common outdoor activities: bicycling, snowboarding and skiing, walking and playground activity.

RECENT FINDINGS

There is sound evidence for the effectiveness of bicycle helmets, the promotion of bicycle helmets at a community level and through physician counselling, and legislation; for the effectiveness of helmets for skiing and snowboarding; for the effectiveness of implementing playground safety standards; and for the effectiveness of modifications to the pedestrian physical environment.

SUMMARY

The science of injury prevention has advanced considerably. The highest level of evidence, including systematic reviews, is now available regarding the effectiveness of protective measures, engineering approaches to the environment and legislation. Healthcare providers caring for children play a leading role in injury prevention through child and family counselling, advocacy and research.

Water safety: age-specific changes in knowledge and attitudes following a school-based intervention

OBJECTIVES

To explore whether an intervention during mandatory schooling can lead to age-specific changes in water safety knowledge and attitudes.

METHODS

Age-specific questionnaires were distributed to 202 kindergarten and grade one pupils, 220 elementary school pupils and 337 pupils attending the first three high school grades in Greater Athens. The information was used to design an educational package that was subsequently presented to pupils of the same grades and similar socio-demographic profiles attending different schools in the same area. One month later, a post-exposure evaluation was conducted using the initial questionnaires, in which 115, 205 and 321 pupils from the respective grade categories provided their responses. In order to compare the performance of pupils exposed to the educational intervention with that of pupils who participated only in the initial assessment, mean differences in scores measuring overall knowledge and attitudes were estimated within each of the three grade groups adjusting for age, gender, sibship size, maternal education and swimming knowledge.

RESULTS

Among kindergarten and grade one pupils, those who received the intervention scored significantly higher for knowledge (17.40%, 95% CI 6.41% to 28.39%) and attitudes (23.64%, 95% CI 4.48% to 42.79%). Among elementary school pupils the gains in knowledge were less evident (14.58%, 95% CI -3.05% to 32.21%)) and almost null in attitudes (5.64%, 95% CI -11.47% to 22.77%). Further advancement of age showed no improvement in knowledge (-0.15%, 95% CI -5.30% to 4.99%) and a minimal, insignificant increase in attitudes (6.32%, 95% CI -1.87% to 14.52%) among exposed high school pupils.

CONCLUSION

The school-based intervention resulted in considerable positive changes in knowledge and attitudes among very young pupils. Elementary schooling seems to provide meagre opportunities to simply improve knowledge. Alternative/complementary approaches should be sought in any attempt to modify behavior.

Making evaluation an integral part of injury programme implementation

Uncertainty about the nature of evaluation can lead to injury prevention programme evaluations being poorly resourced and poorly conducted. The aim of this paper is to demystify programme evaluation and, by stressing its function, offer a perspective on evaluation that may encourage its more widespread integration in the general activity of injury prevention and control. Programme evaluation is best understood simply as the process of getting answers to essential questions about a programme. Methodology used in evaluation needs to be based in empirical science but is otherwise unrestricted except by the chosen question and the practical circumstances relating to the programme and the community in which it is implemented. Discussion about which methodology is appropriate for evaluation research is (unwittingly) a debate about 'which questions should you be asking?'. If the right people ask the right (and properly formulated) questions and build the means of obtaining the information to answer these questions (using appropriate methodology) into the conduct of the programme then evaluation will no longer be a problem but an essential component of the overall effort to reduce the community burden of injury.

Looking for the evidence: a systematic review of prevention strategies addressing sport and recreational injury among children and youth

OBJECTIVES

To examine evidence on the effectiveness of current injury prevention strategies in selected sport and recreational activities, determine the applicability of the evidence to children and youth and discuss the implications related to policy, programming and future research.

METHODS

Research questions and relevance criteria were developed a priori. Potentially relevant studies were located through electronic and hand searches. Two independent assessors assessed articles for first relevance and then quality. Relevant articles were abstracted and synthesised for activities that had three or more relevant articles.

RESULTS

A total of 21,499 articles identified through database and manual searching yielding 117 that met inclusion criteria. The majority of the studies (93 or 89%) involved eight activities: baseball, basketball, cycling, football, ice hockey, rugby, alpine skiing and soccer. Children and youth were identified as the specific target group in 45% of the studies and another 12% included children in their sample. Studies addressed a range of intervention strategies and varied on quality of evidence.

CONCLUSIONS

Surprisingly few well-designed and controlled studies investigating strategies to prevent injuries were found and an even smaller number evaluated strategies to reduce injury in children and youth. As governments in developed countries continue to focus on increasing physical activity among children and youth, thought must be given to the issue of risk of injury and the relative lack of evidence of effective preventive measures.

Cycling: the risks

On average, 140 cyclists are killed each year on Britain’s roads and a further 22 785 injured. About a third of those injured are children. This review examines the nature and circumstances of cycling injuries and contrasts them with the risks associated with other modes of transport. It looks at the effectiveness of cycle helmet use and suggests other measures to best reduce cycling injuries.

Childhood injury prevention at home and play

Unintentional injuries are the leading cause of death for children and adolescents in the United States, and they create a significant burden of disability and financial cost. If motor vehicle-associated injuries are not considered, children are most commonly injured in their home and play environments. The reduction over the past 20 years in childhood deaths related to motor vehicle injury has been significant, but rates of childhood death due to other causes, such as firearms, have increased. This review focuses on several categories of injuries other than motor vehicle injuries and highlights a few recent successful community- and practice-based injury-prevention programs. In addition, recent epidemiologic studies describing risk factors for injury-related death are discussed. Injuries due to interpersonal violence and motor vehicles are covered elsewhere.