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close windowDuval County, Florida
Stephen M. McCloskey, Program Manager, The Injury Prevention Program Office, Duval County Health Department, Jacksonville, FL
Radley C. Remo, M.P.H., Coordinator for the Center for Health Statistics, Duval County Health Department, Jacksonville, FL
Carol Conroy, MPH, PhD., Director of Epidemiology Division, Duval County Health Department, FL
Preliminary research on bicycle-related injury mortality and morbidity was conducted by the Florida Department of Health’s Injury Prevention Program Office (TIPPO) in Duval County during the end of 1994 and the beginning of 1995. Early assessment revealed a disproportionately high incidence of bicycle injuries among the 5- to 14-year-old age population in Duval County. This population group ranked number one with 35 percent of all nonfatal bicycle-related injuries during 1994. Only four of the 115 injured children in the same age group were wearing helmets during the crash event (1). This represents only a 3 percent helmet use rate for the nonfatal injured group and no helmet use among the four fatalities that year.
In 1996 the Florida Department of Transportation approved a grant for Florida State University to conduct a Florida Bicycle Helmet Use Survey (2), which included Duval County. The 1996 survey revealed the overall bicycle helmet use rate for all ages in Duval County to be 19 percent (the second lowest rate among the eight counties in the study). The same report revealed a 14 percent observed helmet use rate for the 5- to 14-year-old age group in Duval County — the same population group that experienced the highest injury rate.
With the problem clearly defined, Florida Department of Health’s Injury Prevention Program Office (TIPPO) in Duval County drew up a project design with the aim of increasing helmet use among 5 to 14 year olds in the county as its primary goal. Our goal was formalized and reads, “To increase use of bike helmets in Duval County Public Elementary Schools’ aged children to at least 50 percent by December 1999 as measured by baseline and annual observational surveys.” A work plan with scheduled milestones and activities was then drafted to track the implementation progress. Three countermeasures to apply to the at-risk population group were chosen based on efficacy studies found in the literature. The three countermeasures were:
To accomplish our objectives, we knew we would need broad community support and a strong coalition of working partners. We were fortunate to gain successful, progressive buy-in from a vast array of disciplines with an interest in mitigating the problem of bicycle-related injuries to children. Both direct financial, and in-kind support, including staff salaries, were and are an important part of this program.
Primary underwriting has come from the Florida Department of Transportation State Safety Office with approximately 50 percent of the monetary support over the eight-year history of this project. The second largest cash commitment to the project came from Brooks Health Foundation which is affiliated with Brooks Rehabilitation Hospital. (A cumulative summary of the financiers of the project is listed on the last page.)
The second critical fiscal support element for this project is in-kind donations. The Duval County School Board and the Duval County Health Department carry the lion’s share of day-to-day staff allocation by providing project administration staff and teachers for the bicycle safety curriculum at the 103 elementary schools and 26 middle schools in Duval County, Florida, over the past eight years.
A pivotal position to keep the implementation process in the schools going is the school board’s bike contact/project coordinator. This person works full time on making sure that the schools are implementing the bike safety curriculum, scheduling the trailers, conducting instructor trainings, and acts as a liaison for communications between all the core partners. In addition, the Fleet Management Division of the school system is invaluable to the project because they store and transport all the equipment the schools need to conduct the project at their individual schools.
A third level of support was sought in the form of coalitions, single organization champions and support groups that would be responsive to the cause of reducing bike injuries in Duval County. At the local level, TIPPO has become an active member in three coalitions that have vested interests in the bicycle-injury problem. These groups are the Jacksonville Pediatric Injury Control System, Duval County Community Traffic Safety, and The Bicycle/Pedestrian Advisory Committee within the mayor’s office. These groups provide expertise in the areas of injury prevention among children, traffic-related injury prevention knowledge, and a connection to the local governing body.
The other champions on the local scene are too numerous to mention, but are no less important to the whole mission. They comprise individuals with a passion for the problem, private enterprises that are sensitive to giving back to the community in this form, bike clubs, the housing authority, bike shops, the Jacksonville Jaguars football team’s foundation, hospitals, service clubs, the city parks and recreation department, law enforcement agencies, rehabilitation hospitals and clinics, brain injury associations, medical associations, law firms, academia, physical education associations, and public health associations.
Statewide organizations and state and national agencies including The National Highway Traffic Safety Administration, the Federal Highway Administration and the Center for Disease Control & Prevention have also supported this effort.
TIPPO selected a bike safety curriculum developed by the University of Florida because of its strong emphasis on skills training, a highly rated peer-reviewed curriculum, its perspective on bicycle safety in the context of all traffic safety (pedestrian to pre-drivers education), its two-day certification requirement for all instructors, and the proximity of the University for technical support. The curriculum, the Florida Traffic and Bicycle Safety Education Program is grade-specific and is meant to build on the previous years knowledge and skills base (see http://www.dcp.ufl.edu/centers/trafficsafetyed/ for more information). The ultimate project vision and mission is that the knowledge and skills learned in the early years will also transfer to safe motor vehicle driving behaviors when the children get older.
Since 1995, over 175 physical education teachers and school resource officers have been trained and certified with the classroom and the on-bike skills qualifications needed to deliver the curriculum to the children during physical education classes in the 103 schools.
Thirteen custom-designed (by TIPPO) transportable self-contained training modules (trailers) were purchased to house bicycles, helmets, street signs, videos, P.A. systems, curricular manuals, teaching aids, etc. to service and rotate among the 103 elementary schools in the county. The fleet management division of the school system provides transport of the trailers to and from the elementary and middle schools. A school warehouse is used to store equipment between deliveries to the various schools and during school breaks. The school system provides the maintenance of most of the project equipment, but some bicycle repairs are contracted out to local bike shops.
In 1996, TIPPO provided statistical data, cost of injuries, and cost benefit analysis of helmets to inform and educate the state legislators before their vote on bicycle helmet legislation. Florida passed bicycle helmet legislation for children under the age of 16, which took effect in 1997. TIPPO also drafted a Helmet Proclamation, which was adopted and signed by the Duval County School Board President and superintendent of schools. The proclamation then was posted at all elementary schools in 1997. The injury prevention staff worked with the Duval County public school curriculum writers to craft a bicycle safety education standard that served as a countywide mandate to provide the health department’s bike safety project in all 103 elementary schools. In 1998 the city of Jacksonville passed a City Council Resolution recognizing the health department’s bike safety project.
Over 20,000 helmets have been sold and distributed with “hands-on” proper fit training throughout the elementary schools of Jacksonville in the last seven years. A unique system of helmet acquisition was designed to be self-contained and modular like the educational trailer component. Twenty-two kits were assembled that contained samples of the helmets, three types of sales procedures, order forms, and measuring instructions. TIPPO then processes the schools’ helmet orders and arranges direct shipment from the vendor to the individual schools. Scholarship programs were also designed for each school, and included in the helmet kit. The health department was able to purchase helmets at low cost through its competitive bid process. Rather than give the helmets away free, helmets were sold to the children for $4 to $5, about half the price that the health department paid. Subsidizing the helmet cost rather than giving them away, enabled the County to provide low-cost helmets to more of the County’s at-risk population, approximately 50 percent instead of 25 percent that would have been possible with free helmets.
Other project reinforcement over this period has included:
All of the above activities and products are specifically planned to raise community awareness of bicycle safety and injury prevention. Therefore, an intensive multifaceted project aimed at the highest risk population combined with a multi-level awareness campaign aimed at creating a community bike safety norm.
There have been 115,000 children (the target population is about 64,000 children in any given year) educated and trained in proper helmet fit and pedestrian and on-bike safety skills. Many of these children have received annual bike safety training throughout their elementary and middle school grades. Program reviews and audits suggest that the number of children educated has actually been underestimated.
About 75 percent of the elementary schools have participated in the project at least once, and some annually, while an estimated 25 percent of the schools have not participated in the bike safety curriculum or helmet distribution. Further study to determine possible barriers to school participation, and to gain higher compliance to reporting protocols, are part of TIPPO’s on-going quality improvement goals.
We evaluated data from pre- and post-intervention annual observational surveys (1996–2002) to determine if the intervention (bicycle helmet sales and bicycle safety education) increased the use and proper use of bicycle helmets. We also compared experimental schools (exposed to the intervention) against control schools (not exposed to the intervention). Although data were collected on other bicycle safety behaviors (such as scanning, signaling and wearing bright visible clothing), this case study focuses only on helmet use and proper use.
Data were collected at school locations for approximately 45 minutes before school started or immediately after school ended. To maximize the number of observations, schools were observed during the school year’s warm weather months (April through June). Three Duval County Health Department employees and one Duval County School Board employee collected the data.
In 1996 there were a total of 735 children observed at school sites. Of those a total of 93 wore a helmet (12.7 percent), an even lower percentage than the results from the statewide observational survey. Over the next six years, the bicycle helmet usage rates ranged from as high as 63.9 percent in 1998 to as low as 43.8 percent in 2001. All of these years have shown a greater helmet use rate than the baseline. The number of bicyclists observed for those same years ranged from 409 to 582, each a smaller sample than the baseline year. The methodology used for the surveys was the same year-to-year except for modification of age groups over different years. Middle school children are included in the yearly results even though they were not exposed to the curriculum until 2001. The observed increases in helmet use might, therefore, be understated, although it remains to be seen if middle school students will show the same degree of increase in helmet use as the elementary-aged children.
There was a significant increasing trend in helmet use across all locations (see figure 1). Only children in elementary and middle schools observed riding to or from school are included in this figure. Figure 1 shows a rapid increase from baseline to the next immediate year then shows the rates start to level off at about 44 percent for 2001 and 2002.
Data on proper use of helmets were available from 1997 to 2002. Because the data were not disaggregated by age group and observation location, proper helmet use was analyzed for the total sample (including children and adults) and not by observation location. Baseline data were from the 1996 observational survey conducted by school board transportation specialists. Proper use as a percent of total use among all ages dropped dramatically from baseline to 1997 and then again from 1997 to 1998, from 87 percent to 47 percent (figure 2). Proper use remained about the same for several years, and then climbed dramatically for 2001 and 2002 to 73 and 77 percent, respectively. Although total use peaked in 1998 and gradually leveled off, proper use showed a somewhat counter-trend. If school-aged children showed similar trends to the all-ages data, then the overall result would be an increase in the proportion of children properly wearing helmets from about 11 percent at baseline to 34 percent in 2002. It is likely, however, that children wear helmets improperly somewhat more often than do all ages. Nevertheless, the results are encouraging that there has been an increasing trend in proper helmet use.
Figure 1. *Note: Bicycle Helmet Use was calculated for both elementary and middle schools over all years even though the first five years of this project targeted only elementary school children. Proper Bicycle Helmet Use, is calculated as percentage of those wearing helmets. 1996 was the baseline year; data from observational survey. Middle school children were not exposed to the intervention until 2001 (2002 survey results).
Figure 2. *Note: Proper helmet use is calculated as the percent of those using helmets, for both elementary and middle schools over all years, although the first five years of this project was aimed only at elementary school children. Middle school children were not exposed to the intervention until 2001 (2002 survey results). 1996 is the baseline year.
These results suggest that our multi-faceted bicycle safety program has been successful in increasing helmet use among children. Observations indicate substantial increases in helmet use among children riding to and from school, although rates have leveled off since 1998, possibly due to less enforcement of the helmet law in recent years. The evaluation relates to the effect of implementing a safety program in a community (Duval County) and does not address whether there were changes in behavior in the individual children receiving the safety training. Therefore, additional evaluation aimed at comparing individual changes in behavior (e.g., use of helmets, proper use of helmets, safe riding skills) among children receiving the training and those not trained needs to be completed to more precisely measure the success of the safety program.
Additionally, because there were several components to the intervention (distributing low cost helmets, helmet use education, fitting instruction, and riding safety) it is important to evaluate the different components. There may be other factors, including a helmet law that went into effect January 1, 1997, and a school proclamation endorsing helmet use that also contributed to the increase in helmet use. Considering these factors would be an important next step to evaluate the success of this safety program.
The results of the comprehensive community-wide effort are promising and illustrate the need to continue the safety program while conducting a more rigorous evaluation.
From 1995 to the present, the health department’s Injury Prevention Office has gained a progressive list of collaborators who are making a difference that likely would not have been achieved by any single agency or entity. All the contributors, great and small, are equally important to the success of this project. Our philosophy is that the smallest contributor could be the difference between life and death with a child that they directly or indirectly affected.
| FDOT Grants (1995-2002) | $440,000 |
| TIPPO Project Director (DCHD In-kind) | $75,000 |
| TIPPO Project Implementation (DCHD In-kind) | $43,000 |
| BROOKS Health Foundation Donation | $100,000 |
| Helmet Sales Revenue (1995-2002) | $93,000 |
| Duval County School Board (in-kind) | $140,000 |
| Centers for Disease Control Grants | $60,000 |
| Port of Jacksonville Pilot Club | $5,000 |
| Misc Donations | $20,000 |
| Grand Total | $976,000 |
Note: Duval County Health Department and Duval County School Board in-kind figures are conservative estimates. Helmet sales revenues are reinvested for continuous helmet procurement. Miscellaneous donations include, but are not limited to, such support materials as surgical caps for prevention of lice transmission, field markers, volunteer service hours, etc.
Stephen M. McCloskey
Project Director
Duval County Health Department
The Injury Prevention Program Office
900 University Blvd. N., STE 210 D
Jacksonville, FL 32211
(904) 665-2308
Stephen_McCloskey@doh.state.fl.us