I was back on the bike, making my way to the OSU campus to complete the weekend with a heavy dose of linear regression, after an evening of slightly heavier socializing than I normally enjoy these days (friends of ours had a combined Kentucky Derby/Cinco de Mayo party; you can imagine what combinations of mint juleps and maragaritas can do). Or perhaps it was last night's 'super moon' that was making me feel a bit fuzzier than usual. Biostatistics, bourbon, or big, big moon: regardless of cause, the effect was to make me feel a bit like the character in Kris Kristofferson's song.
I wonder how the people on the cycle tavern are feeling this morning? I biked by their contraption as I was going home yesterday, and they were already deep into their own celebrations.
It's a beautiful day here in Columbus. It sure is easy to be outside and active when it's like this. Even the urban down and out areas I bike thorough as I travel out of Bexley have some charm on a day like today. The shuttered heavy industrial plants, the railroad tracks, the vacant lots, all are decorated with yellow dandelions, purple chickory, pink sweet peas (I think their sweet peas).
This is the kind of weekend day I can only hope there are plenty of kids out on their bikes. And I hope they are wearing helmets. Safety is a big interest of mine, of course. It's my occupational myopia as a physician and a public health practitioner. I'm still surprised at how many people I encounter around town who are biking without helmets. I wear a helmet for the same reason I get a flu shot: I do it 'for the kids.' When grown ups model behavior, the kids are likely to mimic it; so if it's good behavior we want to foster in our children, we have to be on our best behavior. I alluded to as much in my recent blog post where I reviewed the data showing the strong association of parental encouragement and co-play and the amount of time their children will spend in outdoor activity.
Wearing a helmet is good for me, of course; but to be honest, I might try to get away without doing so if I didn't know how important it is for kids to wear helmets when biking, skateboarding, etc. Our own Center for Research Injury and Policy at Nationwide Children's Hospital states that 10 000 children are hospitalized in the United States every year because of bicycle-related accidents, and a third of those events result in traumatic brain injuries. The good news is that bicycle helmets are judged in some studies to be 88% effective at reducing traumatic brain injuries.
The book Moments in Leadership: Case Studies in Public Health Policy and Practice profiles a great example of a physician spearheading a local movement to increase use of helmets in young bicyclists, with a demonstrable decrease in traumatic brain injuries. In Seattle, Dr. Abraham Bergman began a campaign to increase bicycle helmet use in the 1980s. Many local governments, including our city of Columbus, work through a punitive model to enforce bicycle helmet wear: in 2008 Columbus made helmet wear mandatory for use in bicyclists under age 18. In neighboring Bexley, beginning in 2010, parents could be fined if their biking youngsters weren't wearing lids.
Dr. Bergman took a different approach, reasoning his best line of attack would come largely through motivating individuals to ‘do the right thing’ “I like to use motivation rather than education. How do you get people to do things? The masters of that are advertising people," he is quoted as saying in the book.
Dr. Bergman applied a systems approach to achieve his goal of increasing bicycle helmet usage in children. He collaborated with his partner Dr. Frederick Rivara and other health care practitioners. He identified several key ‘players’ who would need to participate for his vision to bear fruit: local news agencies; local and international manufacturers and distributors; and local retailers. Then he went to work.
He needed to get out the message to motivate parents and children, and he did this by having local news crews interview the families of injured children. He needed to address the barrier of cost: for many families, the contemporaneous cost of $80 (1980's dollars) for a helmet was far too expensive. He worked with a local company, Mountain Safety Research, as well as international manufacturing units in Taiwan to produce a low cost helmet. He then worked with a local retailer, Fred Meyer, as well as a national one, Toys ‘r Us, to ensure that these helmets would be sold. Using this systems approach, Dr. Bergman achieved a cost-effective intervention, locally available: the end price of $15 for a helmet was within reach for most families.
Bergman and Rivara then set out to measure the success of their campaign. They took advantage of a ‘natural experiment,’ in which a similar community of Portland, Oregon could be compared with their community of Seattle: in Portland, there was no such campaign at the time to induce families and children to use helmets. The case study reports that the baseline rate of helmet use was 3% in both communities, and over the time the researchers conducted their evaluation that proportion rose to 65% in Seattle and only 12% in Portland. This dramatic increase was achieved without legislation; one can infer that the change was attributable to the Bergman campaign.
Dr. Bergman’s modeling of exemplary public health practices did not end there, however. The gold standard for a primary prevention intervention is to prove that you have reduced morbidity and mortality of a disease. In other words, one might prove that more children were wearing bicycle helmets, but does this result in the outcome one was hoping for: the reduction of head injuries in children?
Indeed, Bergman and Rivara went on to conduct just such an epidemiologic study. (Rivara et al., 1994) From 1987 to 1992 they and their team monitored helmet use and head injury admissions rates for children in a large health maintenance organization in Seattle. During the five years of this study they saw helmet use rates rise in school aged children from 5.5% to 40.2%. During this same period, they observed admission rates for bicycle-related head injuries decrease by 66.6% in 5- to 9-year olds and by 67.6% in 10- to 14-year olds.
This case, the "Seattle Children's Bicycle Helmet Campaign," inspires me. A clinician, like me, observed negative health outcomes in patients, and he was not willing to accept the status quo. Certainly, he could have continued caring for these children one by one: treating a concussion here, sewing a laceration there, and possibly even seeing a family through the grief of a death. Dr. Bergman did not stop there. He became a leader in public health and helped bring a product to production and motivate people to use it. He went on to assemble a team to assess the results of his intervention. In applying principles of good public health practice, leadership, and systems analysis, Dr. Bergman went far beyond the boundaries of clinical medicine and impacted literally hundreds to thousands of individuals. I can only hope I could achieve a small portion of this in my career.
So, if you're inspired, first: get outside and have fun. Second, if you're going to your bicycle, put on your helmet! And third, make a small public health promotional gesture and visit my friends at the Ohio chapter of the American Academy of Pediatrics, who run a fantastic campaign called 'put a lid on it'. 'Like' their Facebook page, and learn how you, too, can promote safe activity for the kids in your life whom you love.
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