Swedes Document Injury Reduction
From A Helmet Program
(our copy is undated, but the date should be early 1991)
A Study of the Effectiveness of Bicycle
Safety Helmets Among Children
in Skaraborg County, Sweden
Ekman, R and Welander, G.
Karolinska Institute, Department of Social Medicine, Kronan Health Center and Skaraborg County Council, Department of
Health Promotion, Sit Olafsgatan 46, S-52135 Fallioping, Sweden
The County of Skaraborg is situated in the centre of western Sweden, and has an area of 8 210 square kilometers. The
landscape is very flat with a few table top mountains. There are 17 rural municipalities, the smallest one containing 6
000 inhabitants and the largest with 47 000 inhabitants. The whole county comprises 273 000 inhabitants. 20.4 % are aged
0-14 years, slightly higher than the average level of Sweden. The average temperature is 6 degrees C. The county is well
decentralized with a large amount of small density populated area and eight larger towns. The main Stockholm-Gothenburg
road (E3) runs through the county, as well as the main railway line connecting Stockholm-Gothenburg. The county is both
agricultural and industrial, consisting of heavy and light industry farming, forestry and tourism. There are three major
hospitals, a primary health service with local health centres in every municipality, each having its own child health
unit. The county has developed an accident prevention programme with special inter- section task groups in 10
BACKGROUND AND INTRODUCTION
Bicycle accidents with resulting head injuries lay claim to a large portion of hospital resources and the individual
suffers heavily. Between 70 and 120 cyclists die per year in Sweden (1). The Skaraborg county council decided in 1987 to
subsidised cycle helmets for the counties four year old children. The goal for research was to map out and evaluate the
effect of subsidized cycle helmets to four years olds and the impact it may have had on reduction of head injuries
resulting from cycling.
MATERIAL AND METHOD
The study comprises partly a survey of attitudes regarding the use of child safety helmets based on an random sample of
750 families, and partly data from the hospital's discharge register for children aged 0-14 years over a period of eleven
years for bicycle accidents, single or due to collision with cars. All diagnoses have been studied with special focus on
concussions. The response rate was 90 %.
The survey shows that almost 80 % of the children cycled before the age of five. The child health care organization
recommended that children should not cycle before the age of five or six years: 40 % of the parents had the opinion that
the price reduction of cycle helmets should be offered in safe areas for children below the age of four years old. This
opinion is shared by the district nurses responsible for child safety information. 79 % of the surveyed children use
cycle helmets and more than 50 % have used the County Council's subsidies of 70 SEK per helmet.
The studied group was very positive to the helmet subsidies. 94 % were positive to the use of helmets on small
The study of the hospital discharge register over eleven years on children (bicycle accidents) showed that the percentage
was 40 % lower 1987-1989 than 1978-1980. The total reduction of hospital care cases for concussion was 121: 223 cases
during the first period 1978-1980 and 102 during the later period 1987-1989. The reduction of in-patient care days due to
cycle-accidents during the period 1987-1989 in comparison to 1978-1980 was 36 %. Parallel to this, the reduction of
nursing days in hospital was 61 % for the same period. A comparison between the years 1989 and 1986 showed that the
number of concussions per 1 000 children had been reduced by 25% from 50 to 37. Note that during this period, traffic
work and speed had increased (2). After 1986 the use of cycle helmets among children increased distinctly and according
to in care patient statistics it could be noted that injury cases of police reported accidents with personal injuries
1982-1989 in Skaraborg were above the national average and increased during the end of the period (3). The report showed
the opposite, a decrease in the number of head injuries to children during this period. During the period 1978-1980 the
average number of hospital care days for children 0-14 years (injured in cycle accidents) in Skaraborg was 434 at a cost
of 995,000 SEK. During a comparable period 1987-1989 the cost was reduced to 336,000 SEK for 153 nursing days in
hospital, a reduction of 619,000 SEK (9). The effect of better care and treatment, child safety information and the
helmet campaign etc had led to a reduction of the total amount of nursing days in hospital by 238, for children involved
in bicycle accidents during the period 1978-1989. Even such facts as weather, cycle sales, environmental improvements
(separation of cycle and motor traffic) etc had a probable effect on the reduction of injuries caused by accidents (4, 5,
6). Head injuries earlier looked upon as rather slight are very expensive to treat, and can result in long term problems
with concentration difficulties, aggressiveness, headaches, balance problems, light and sound sensitivity problems for
years ahead (7).
The National Board of Traffic Safety estimates that there will be approximately 120,000 more children in the age bracket
0-15 by the year 2000, compared to 1989 for the whole of Sweden (2). For Skaraborg the estimation would be about 4,100
more children by the year 2000. With the present ambition on child safety work, we estimate higher costs for community
and hospital care in the future. Approx. 10% of hospital care in Sweden is used for treatment of accidental injuries. A
large proportion of the specialized resources and high cost units as neuro- and thorax surgery clinics and orthopedic
units and intensive care units are needed for traffic accidents (8). To this date the helmet subsidy scheme in Skaraborg
County has amounted to approx SEK 250,000 per year. For this amount one could provide hospital care for four severely
head-injured children, 28 days for each. If the child is severely injured and requires regional hospital care the cost
would increase from SEK 2,200 per day to SEK 5,700 at a neurological clinic (9, 10). The county administrative board of
traffic safety has estimated that the total costs for all types of traffic accidents on the state roads of the county are
for 1988 SEK 740 million in human and material loss (11). A study from Lidkoping community shows that only 10-31% of road
traffic accidents are reported by the police authorities, which means the total costs are much more than those stated
Against the background of the above study one can see the importance of stimulating and increasing traffic safety
measures such as early usage of safety helmets, especially when 80% of children two, three and four years old use
two-wheelers in traffic situations. This should mean that the County Council's subsidy on helmets should be reformed to
cover even age groups under the age of four.
Small children have become more frequent in traffic situations, even as passengers on adult cycles. A fact to keep in
mind is that the subsidy system has the effect that a large group of children, is given a leading role as trend-setters
using good head protection while cycling. An expansion would mean a strengthening of this behaviour. From the parents
responses one can conclude that most children with helmets use them. In most cases when children have been involved in
traffic accidents, the helmet has probably prevented or reduced the extent of injury. The study s conclusion is that
extended investment in cycle safety for all children is worth its price. It reduces, human suffering, reduces costs for
the individuals, hospital care and community. Production losses due to parents care of their injured children are also
reduced. Preventative measures lead to reduction of care-related costs for the County Council and enable other important
health programs to become possible. The National Home and School Alliance (Hem och skola) has expressed its support for
extensive use of cycle helmets in line with this study (13). The County Council decided 1990-10-01 with this study as a
base for its decision, to extend the helmet campaign (subsidy offer) to cover two additional groups: nine-month-old
children and two-and-a-half-year-olds. This offer is a combined effort of the Skaraborg Traffic Safety Association and a
local insurance company in Skaraborg.
Work is under way with an extensive study followed by a final report. This study will be extended with data from a number
of control areas (other County Councils) and national statistics referring to cycle accidents involving children and
statistics from the hospital district register. Even other facts that may have affected the accident situation will be
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