Higher risk of violence exposure in men and women with physical or sensory disabilities: results from a public health survey.

The World Health Organization has declared that violence is a global public health problem. The prevalence of violence exposure among adults with intellectual and unspecific disabilities has been demonstrated in several studies, whereas only a few articles on people with sensory disabilities have been published. The aim of this study was to investigate the prevalence and risk for exposure to physical violence, psychological offence, or threats of violence in people with physical and/or sensory disabilities, compared with people with no such disabilities, controlling for socioeconomic data. Data from a public health survey were analyzed. A nationally representative sample of women and men aged 16 to 84 years had answered a questionnaire. In the present study, the whole sample, comprised of 25,461 women and 21,545 men, was used. Women with auditory disabilities were generally more often violence exposed than non-disabled women, whereas men with physical disabilities were more often violence exposed than non-impaired men. Some age groups among both women and men with visual disabilities had higher prevalence rates than women and men without disabilities. The adjusted odds ratios (ORs) were significantly higher among the auditory impairment group for exposure to physical (OR = 1.4, confidence interval [CI] = [1.1, 1.9]) and psychological (OR = 1.4, CI = [1.1, 1.8]) violence among women. Men with physical disabilities had raised odds ratios for physical violence (OR = 1.7, CI = [1.2, 2.4]) and psychological violence (OR = 1.4, CI = [1.0, 2.0]) compared with the non-disabled group. Both men and women with a physical or sensory disability showed higher odds of being exposed to violence than men and women without a disability. The results indicated that socioeconomic situation, smoking, and hazardous drinking strengthened the association between impairment and violence.

Examining quality function deployment in safety promotion in Sweden.

The first-hand needs and demands of laypersons are not always considered when safety promotion programmes are being developed. We compared focal areas for interventions identified from residents' statements of safety needs with focal areas for interventions identified by local government professionals in a Swedish urban community certified by the international Safe Community movement supported by the World Health Organization. Quantitative and qualitative data on self-expressed safety needs from 787 housing residents were transformed into an intervention design, using the quality function deployment (QFD) technique and compared with the safety intervention programme developed by professionals at the municipality administrative office. The outcome of the comparison was investigated with regard to implications for the Safe Community movement. The QFD analysis identified the initiation and maintenance of social integrative processes in housing areas as the most highly prioritized interventions among the residents, but failed to highlight the safety needs of several vulnerable groups (the elderly, infants and persons with disabilities). The intervention programme designed by the public health professionals did not address the social integrative processes, but it did highlight the vulnerable groups. This study indicates that the QFD technique is suitable for providing residential safety promotion efforts with a quality orientation from the layperson's perspective. Views of public health professionals have to be included to ascertain that the needs of socially deprived residents are adequately taken into account. QFD can augment the methodological toolbox for safety promotion programmes, including interventions in residential areas.

Can a psychosocial intervention programme teaching coping strategies improve the quality of life of Iranian women? A non-randomised quasi-experimental study.

OBJECTIVES: To assess whether a psychosocial intervention teaching coping strategies to women can improve quality of life (QOL) in groups of Iranian women exposed to social pressures. DESIGN: Quasi-experimental non-randomised group design involving two categories of Iranian women, each category represented by non-equivalent intervention and comparison groups. SETTING: A large urban area in Iran. PARTICIPANTS: 44 women; 25 single mothers and 19 newly married women. INTERVENTIONS: Seventh-month psychosocial intervention aimed at providing coping strategies. PRIMARY OUTCOME MEASURES: Effect sizes in four specific health-related domains and two overall perceptions of QOL and health measured by the WHOQOL-BREF instrument. RESULTS: Large effect sizes were observed among the women exposed to the intervention in the WHOQOL-BREF subdomains measuring physical health (r=0.68; p<0.001), psychological health (r=0.72; p<0.001), social relationships (r=0.52; p<0.01), environmental health (r=0.55; p<0.01) and in the overall perception of QOL (r=0.72; p<0.001); the effect size regarding overall perception of health was between small and medium (r=0.20; not significant). Small and not statistically significant effect sizes were observed in the women provided with traditional social welfare services. CONCLUSIONS: Teaching coping strategies can improve the QOL of women in societies where gender discrimination is prevalent. The findings require reproduction in studies with a more rigorous design before the intervention model can be recommended for widespread distribution.

Motala Municipality - a sustainable Safe Community in Sweden.

An extensive research project concerning injury prevention was planned and initiated in Motala Municipality in the early 1980s. This article summarises 25 years of work for injury prevention and safety promotion in Motala. Evaluation of both process and effect were conducted based on a quasi-experimental study design, as well as cost-effectiveness and cost-benefit analyses of interventions. Initial evaluations results showed an annual incidence of injuries of 118.9/1000 citizens in 1983/1984 consisting of injuries at home (35%), sports injuries (18.9%), injuries at work (13.7%), traffic-related injuries (12.8%) and other injuries (19.5%). The annual social economic costs of injuries were estimated at 116 million Swedish crowns (SEK). By 1989, after two years of preventive work, the incidence of injuries was reduced by 13%. The greatest decrease was among the moderate severity category of injuries (41%). The social economic costs were thereby reduced by 21 million SEK per year. Since then, work with injury prevention has continued and annual evaluations have shown that the incidence of injuries, with some fluctuation, has continued to decrease up to the latest evaluation in 2008. The total decrease during the study period was 37%. This study shows that community-based injury prevention work according to the Safe Community model is a successful and cost-effective way of reducing injuries in the local community.

Long-term health consequences of violence exposure in adolescence: a 26-year prospective study.

BACKGROUND: Violence victimization represents a serious risk factor for health related symptoms, for both men and women. The aim of this study was to evaluate the long-term effects of violence exposure in late adolescence and early adulthood on adult health, physical as well as mental, using a long-term prospective population-based study, with a follow up of 9, 19, and 26 years. METHODS: The primary data source is a longitudinal panel from one of the longest running social science surveys in the world, the Swedish Level-of-Living surveys (LNU). We analyzed three cohorts, individuals aged 15-19 in 1974 and 1981, and individuals aged 18-19 in 1991 which were followed up 2000. Structured interviews on childhood, family relationships, life-events, living conditions, health history and status, working conditions, behavioral, psychosocial, and demographic variables were repeatedly used in all cohorts. RESULTS: Multivariate models of violence exposures in adolescence in the 1974-91 cohorts as predictors of adult health in 2000 are reported for both men and women. Women exposed to violence had raised odds ratios for ill health, measured as heavy illness burden, and poor self rated health, after controlling for possible confounders. No such associations were found for men. CONCLUSIONS: This study's findings provide additional empirical support for the importance of policies and practices to identify and prevent violence exposure in adolescence and young adulthood and to supply treatments for adolescence exposed to violence and above all the young women.

Quality indicators for implementation of safety promotion: towards valid and reliable global certification of local programmes.

The theoretical underpinnings of safety promotion have not yet been integrated with implementation practice to ascertain between-community programme quality. This study sets out to develop a framework for verifying of the quality of community-based safety-promotion programmes in the global context. We analysed the certification indicators deployed in the international Safe Community movement in light of systems theory. Data were collected from focus group interviews with representatives from 10 certified Swedish communities and then analysed by qualitative methods. The community representatives were found to have used the present indicators mainly for marketing the safety-promotion concept to stakeholders rather than as benchmarks for safety practice. When appraised in regard to systems theory, it was found that the indicators did not cover important aspects of health-services implementation. Attainment of outcomes at the population level was not included. Consequently, that information about programme effects in high-risk groups and in risk environments could be neglected. We conclude that programme processes and outcomes at both organisational and population levels must be assessed when the quality of safety-promotion programmes is being certified. A revised set of indicators for certification of safety-promotion programmes fulfilling these criteria is presented.

A national study of the prevalence and correlates of domestic violence among women in India.

This article estimates the national prevalence rate of domestic violence in India and examines the demographic and socioeconomic status of the victims of domestic violence. The study used the Indian National Family Health Survey 3, a cross-sectional national survey of 124 385 ever-married women of reproductive age from all the 29 member states. χ(2) Analysis and logistic regression were used. Lifetime experiences of violence among respondents were as follows: emotional violence, 14%; less severe physical violence, 31%; severe physical violence, 10%; and sexual violence, 8%. Women of scheduled castes and Muslim religion were most often exposed to domestic violence. Women's poorer economic background, working status, and husband's controlling behavior emerged as strong predictors for domestic violence in India. Elimination of structural inequalities inherent in the indigenous oppressive institutions of religion, caste, and the traditional male hierarchy in society could prevent domestic violence.

The impact of child safety promotion on different social strata in a WHO Safe Community.

BACKGROUND: The objective of the current study was to evaluate outcomes of a program to prevent severe and less severe unintentional child injuries among the different social strata under WHO Safe Community program. Specifically, the aim was to study effectiveness of Safe Community program for reducing child injury. METHODS: A quasi-experimental design was used, with pre- and post-implementation registrations covering the children (0 -15 years) in the program implementation area (population 41,000) and in a neighboring control municipality (population 26,000) in Ostergotland County, Sweden. RESULTS: Boys from not vocationally active households displayed the highest pre-intervention injury rate in both the control and intervention areas. Also in households in which the vocationally significant member was employed, boys showed higher injury rates than girls. Households in which the vocationally significant member was self-employed, girls exhibited higher injury rates than boys in the intervention area. After 6 years of program activity, the injury rates for boys and girls in employed category and injury rates for girls in self-employed category displayed a decreasing trend in the intervention area. However, in the control area injury rate decreased only for boys of employed families. CONCLUSIONS: The study indicated that almost no changes in injury rates in the control area suggested that the reduction of child injuries in the intervention area between 1983 and 1989 was likely to be attributable to the safety promotion program. Therefore, the current study indicates that Safe Community program seems to be successful for reducing child injuries.

Residents' perspectives on safety support needs in different types of housing areas.

BACKGROUND: Knowledge about conditions that are understood to support safety is important for planning residential safety promotion in interactions with residents. How residents themselves perceive and reason about their own safety needs has seldom been investigated in Scandinavia. AIM: To identify factors perceived to be necessary to feel safe by residents in areas with blocks of flats and detached houses. METHODS: Residents in a Swedish municipality were asked an open-ended question on the research topic by a mail survey; 787 residents provided narrative data that were fed into a summative qualitative and quantitative content analysis. RESULTS: A stable social structure in the housing area was perceived to be the central factor in a safety-supportive residential environment. Whereas maintenance of good and reassuring relations was emphasised in detached housing areas, support for management of poor or even fear-provoking neighbour relations was requested from areas with blocks of flats. This finding emphasises the need to reduce the differential exposure to safety-related factors in the living environment. CONCLUSIONS: The results of our study encourage the continued use of a setting-orientated safety promotion approach in which residents and other stakeholders are involved. The policy recommendation that can be drawn from the study is that both the subjective and objective dimensions of safety should be identified and considered when developing local safety promotion interventions in community contexts.

Physical and psychological symptoms and learning difficulties in children of women exposed and non-exposed to violence: a population-based study.

OBJECTIVES: To analyse the association between violence against mothers and the health of their children as reported by the mothers. METHODS: The data originate from a multistage sampling health-questionnaire survey, distributed to a representative sample of women in Sweden. The health of 283 children (aged 0-18 years), as reported by women who had been exposed to violence at home or outside home during the past 12 months, was compared with that of 4,664 children of non-exposed mothers. RESULTS: Odds ratios regarding most registered physical symptoms showed that children of violence-exposed mothers had a significant higher risk of ill health than children of non-exposed mothers. Regarding psychological symptoms and learning difficulties, the odds were raised for girls for most symptoms, but not for boys. A twofold increase in health-care utilisation and an overall general increase in the risk of pharmaceutical consumption were shown for both girls and boys of exposed mothers. CONCLUSIONS: This population-based study shows an increased risk of poorer health amongst boys and girls aged 0-18 years, as reported by mothers exposed to violence.

Playground injuries in children.

BACKGROUND: Rapid urbanization and unplanned population development can be detrimental to the safety of citizens, with children being a particularly vulnerable social group. In this review, we assess childhood playground injuries and suggest safety mechanisms which could be incorporated into playground planning. METHODS: Inclusion criteria were "children" as the focus group, "playground" as the main field of study, and "unintentional injury" and "safety" as the concepts of study. The keywords used for the PubMed search were "playground", "children", and "injury". Initially we 182 articles. After screening according to inclusion criteria, 86 articles were found, and after reading the abstracts and then the full text, 14 articles were finally included for analysis. The papers reviewed included four case-control studies, three case studies, three descriptive studies, two interventional studies, one retrospective study, one cross-sectional study, and one systematic review. RESULTS: Playground-related fractures were the most common accidents among children, underscoring the importance of safety promotion and injury prevention in playgrounds, lowrisk equipment and playing hours (week days associated with higher risk), implementation of standards, preventing falls and fall-related fractures, and addressing concerns of parents about unsafe neighborhoods. With the exception of one study, all of the reviewed papers had not implemented any practical safety plan. Safe engineering approaches were also ignored. CONCLUSION: We recommend a systematic safety approach based on the "safety circle" which includes three main areas, ie, equipment, environment, and children.

Correlates of local safety-related concerns in a Swedish Community: a cross-sectional study.

BACKGROUND: Crime in a neighbourhood has been recognized as a key stressor in the residential environment. Fear of crime is related to risk assessment, which depends on the concentration of objective risk in time and space, and on the presence of subjective perceived early signs of imminent hazard. The aim of the study was to examine environmental, socio-demographic, and personal correlates of safety-related concerns at the local level in urban communities. The specific aim was to investigate such correlates in contiguous neighbourhoods in a Swedish urban municipality. METHODS: A cross-sectional study design was used to investigate three neighbourhood settings with two pair-wise conterminous but socially contrasting areas within each setting. Crime data were retrieved from police records. Study data were collected through a postal questionnaire distributed to adult residents (n = 2476) (response rate 56%). Composite dimensions of perceived residential safety were derived through a factor analysis. Logistic regression analysis was used to examine associations between high-level scores of the three safety-related dimensions and area-level crime rate, being a victim of crime, area reputation, gender, age, education, country of birth, household civil status and type of housing. RESULTS: Three composite dimensions of perceived residential safety were identified: (I) structural indicators of social disorder; (II) contact with disorderly behavior; and (III) existential insecurity. We found that area-level crime rates and individual-level variables were associated with the dimensions structural indicators of social disorder and existential insecurity, but only individual-level variables were associated with the dimension contact with disorderly behavior. Self-assessed less favorable area reputation was found to be strongly associated with all three factors. Being female accorded existential insecurity more than being a victim of crime. CONCLUSION: We have identified environmental, socio-demographic, and personal correlates of safety-related concerns in contiguous neighbourhoods in a Swedish community. The results of this study suggest that residents' self-assessed area reputation is an important underlying mechanism of perceived safety. We also found a difference in crime rates and safety-related concerns between areas with blocks of flats compared with small-scale areas although the neighbourhoods were close geographically.

Infrastructural requirements for local implementation of safety policies: the discordance between top-down and bottom-up systems of action.

BACKGROUND: Safety promotion is planned and practised not only by public health organizations, but also by other welfare state agencies, private companies and non-governmental organizations. The term 'infrastructure' originally denoted the underlying resources needed for warfare, e.g. roads, industries, and an industrial workforce. Today, 'infrastructure' refers to the physical elements, organizations and people needed to run projects in different societal arenas. The aim of this study was to examine associations between infrastructure and local implementation of safety policies in injury prevention and safety promotion programs. METHODS: Qualitative data on municipalities in Sweden designated as Safe Communities were collected from focus group interviews with municipal politicians and administrators, as well as from policy documents, and materials published on the Internet. Actor network theory was used to identify weaknesses in the present infrastructure and determine strategies that can be used to resolve these. RESULTS: The weakness identification analysis revealed that the factual infrastructure available for effectuating national strategies varied between safety areas and approaches, basically reflecting differences between bureaucratic and network-based organizational models. At the local level, a contradiction between safety promotion and the existence of quasi-markets for local public service providers was found to predispose for a poor local infrastructure diminishing the interest in integrated inter-agency activities. The weakness resolution analysis showed that development of an adequate infrastructure for safety promotion would require adjustment of the legal framework regulating injury data exchange, and would also require rational financial models for multi-party investments in local infrastructures. CONCLUSION: We found that the "silo" structure of government organization and assignment of resources was a barrier to collaborative action for safety at a community level. It may therefore be overly optimistic to take for granted that different approaches to injury control, such as injury prevention and safety promotion, can share infrastructure. Similarly, it may be unrealistic to presuppose that safety promotion can reach its potential in terms of injury rate reductions unless the critical infrastructure for this is in place. Such an alignment of the infrastructure to organizational processes requires more than financial investments.

What promotes sustainability in Safe Community programmes?

BACKGROUND: The theory and practice of safety promotion has traditionally focused on the safety of individuals. This study also includes systems, environments, and organizations. Safety promotion programmes are designed to support community health initiatives taking a bottom-up approach. This is a long-term and complex process. The aim of this study was to try to empirically identify factors that promote sustainability in the structures of programmes that are managed and coordinated by the local government. METHODS: Four focus group sessions with local government politicians and administrators in designated Safe Communities were conducted and analyzed using qualitative content analysis. RESULTS: Collaboration was found to be the basis for sustainability. Networks, enabling municipalities to exchange ideas, were reported to positively influence the programmes. Personal contacts rather than organizations themselves, determine whether collaboration is sustained. Participants reported an increase in cross-disciplinary collaboration among staff categories. Administrators and politicians were reported to collaborate well, which was perceived to speed up decision-making and thus to facilitate the programme work. Support from the politicians and the county council was seen as a prerequisite. Participants reported an increased willingness to share information between units, which, in their view, supports sustainability. A structure in which all local authorities' offices were located in close proximity to one another was considered to support collaboration. Appointing a public health coordinator responsible for the programme was seen as a way to strengthen the relational resources of the programme. CONCLUSION: With a public health coordinator, the 'external' negotiating power was concentrated in one person. Also, the 'internal' programme strength increased when the coordination was based on a bureaucratic function rather than on one individual. Increased relational resources facilitated the transfer of information. A regular flow of information to policy-makers, residents, and staff was needed in order to integrate safety programmes into routines. Adopting a bottom-up approach requires that informal and ad hoc activities in information management be replaced by formalized, organizationally sanctioned routines. In contrast to injury prevention, which focuses on technical solutions, safety promotion tries to influence attitudes. Collaboration with the media was an area that could be improved.

Effectiveness of community-based injury prevention. Long-term injury rate levels, changes, and trends for 14 Swedish WHO-designated Safe Communities.

This study investigates the injury rate levels, changes, and trends between 1987 and 2002 for the 14 Swedish municipalities designated as WHO Safe Communities. The injury rate was defined as the number of injured patients discharged from hospital per 1000 persons. Injury rates were age standardised. Each municipality was compared with its respective municipality group, according to a classification of Sweden's 288 municipalities into nine groups based on numerous structural parameters. The average injury rate levels for the 14 WHO-designated Safe Community municipalities ranged from 11.54 to 19.09 per 1000 population during the study period, which was defined as the time period during which a municipality's injury prevention program has been operational. Eleven of 14 municipalities had higher levels than their corresponding municipality groups. Five of the 14 municipalities "outperformed" their respective municipality groups and achieved a greater relative injury rate decrease during the study period. The trends for the 14 municipalities in relation to their municipality groups showed an inconsistent pattern, with only four municipalities exhibiting overall favourable trends for the study period.

Economic analysis of injury prevention--applying results and methodologies from cost-of-injury studies.

Injuries pose an economic problem of immense proportion to communities in every society. The economic burden from injuries can be quantified through cost-of-injury studies, using techniques adopted from cost-of-illness research. This study explores the feasibility of applying results and methodologies from existing cost-of-injury studies in economic analyses of injury prevention interventions and programmes. The literature on cost-of-injury studies and economic appraisals of injury prevention efforts was examined to elicit studies that calculated injury costs. Studies were accepted for inclusion if they included an analysis of the costs of all injuries occurring in a geographical area (community, region or country) during a specific time period, employed a societal perspective and an incidence-based costing approach and were conducted in industrialized countries. There were 12 studies that met the inclusion criteria. The average total cost per injury case was USD $3536, while the average share of indirect to total cost per injury case was 71%. However, the cost figures showed wide variation across the studies. Based on the limited similarity of findings from the studies, it was concluded that it is not feasible to apply results and methodologies from existing cost-of-injury studies. The cost estimators described in this study could possibly be adapted for use as reference points in economic analyses of existing programmes, but any other uses should be approached with caution. Locally obtained data are needed for reliable economic analyses of injury prevention interventions and programmes.

Strategies and goals of community-based injury prevention programmes--a mixed-methods study of 25 Scandinavian WHO Safe Communities.

Documentation and analysis of prevention goals and interventions employed by community-based injury prevention programmes is vital to advance the knowledge and understanding of synergistic multi-strategy injury prevention programmes. This study examined the goals and interventions of 25 Scandinavian community-based injury prevention programmes in WHO-designated Safe Communities. Collection and analysis of quantitative data from survey questionnaires to the programme coordinators was followed by collection and analysis of qualitative data from structured interviews with programme coordinators from eight of the programmes. The results demonstrated that the programmes under study predominantly relied on "intuitive" and subjective methods for selecting interventions. The programmes largely failed to transform injury surveillance data into information and knowledge that could prioritize community safety strategies and measures, due to insufficient time and personnel resources. The results demonstrated the importance of combining passive approaches with active interventions. Educational efforts were considered essential to the programmes. The programmes preferred to rely on broadly stated goals rather than specific objectives.

Can screening and simple written advice reduce excessive alcohol consumption among emergency care patients?

AIMS: Emergency care patients have an overrepresentation of risky drinkers. Despite the evidence on the effectiveness of a short feedback on screening or self-help material, most studies performed so far have required considerable time from staff and thus been difficult to implement in the real world. The present study evaluates the effect of the screening and whether simple written advice has any additional effect on risky drinking. METHODS: An alcohol screening routine was implemented among injury patients in a Swedish emergency care department. Over 12 months, two cohorts were invited to answer an alcohol screening questionnaire in the waiting room. In the first 6 months, 771 patients were screened without any written advice (cohort A) and in the following 6 months, 563 were screened and in addition received simple written advice about sensible drinking (cohort B). None of the patients received one-to-one feedback. Six months after the screening, a follow-up interview by telephone explored the changes in drinking. RESULTS: In cohort A 182 (24%) of the patients were defined as risky drinkers and in cohort B 125 (22%). Reached at follow-up after 6 months were 81 (44%) risky and 278 (47%) non-risky drinkers in cohort A, and 40 (32%) risky and 220 (50%) non-risky drinkers in cohort B. The number of patients with heavy episodic drinking decreased significantly in cohort A from 76 (94% of the risky drinkers) to 49 (59%). In cohort B a similar change was seen from 37 (92%) to 27 (68%). Only in cohort B, was a significant increase in readiness to change drinking habits seen [from 3 (8%) to 9 (23%)]. The reduction in heavy episodic drinking was comparable with previous reports from more extensive interventions. However, at the time of follow-up, drinking among non-risky drinkers at baseline had increased. When considering the greater numbers of non-risky drinkers, the total consumption in the study group increased during the study period. CONCLUSIONS: Owing to the reported difficulties of integrating more time-consuming alcohol interventions in emergency departments, it is suggested that at least screening for drinking should be implemented as routine in emergency departments. More research is needed in order to establish the optimal balance between effective alcohol intervention, and acceptable time and effort requirement from staff.

Bicycle helmet use in Sweden during the 1990s and in the future.

This paper describes how the use of bicycle helmets in Sweden has changed for different categories of cyclists from 1988 to 2002, and it also estimates future trends in voluntary wearing of bicycle helmets up to the year 2010. Observational studies of the use of bicycle helmets were conducted once a year from 1988 to 2002 at 157 sites in 21 cities. The subjects observed were children cycling to school (average n = 5471/year) and in their free time (average n = 2191/year), and adults cycling to workplaces and on public bike paths (average n = 29 368/year). The general trend in helmet use from 1988 to 2002 was determined by linear regression analysis, and the results were also employed to estimate future helmet wearing for the period 2003-2010. Differences in helmet use according to gender and size of city were analysed by chi-square tests. From 1988 to 2002, all categories of cyclists showed an upward trend in helmet use (p < 0.01, p < 0.001). Helmet wearing increased from about 20 to 35% among children (< or =10 years) cycling during free time, from approximately 5 to 33% among school children, and from around 2 to 14% in adults. Total average helmet use rose from about 4 to 17%. However, during the last 5 years of the study period (1998-2002), none of the categories of cyclists studied showed an upward trend in helmet wearing. It is estimated that approximately 30% of cyclists will wear helmets voluntarily by the year 2010, if helmet promotion activities are continued at the same level as previously. The results suggest that Sweden will probably not reach its official goal of 80% helmet use unless a national bicycle helmet law is passed.

A local bicycle helmet 'law' in a Swedish municipality - the effects on helmet use.

The municipality of Motala in Sweden introduced a local bicycle helmet 'law' on May 1, 1996. This is not a legally enacted ordinance, but instead a legislated recommendation backed up by information and education. Formally, the law applies to children (aged 6-12 years), although the intention is to increase helmet use by all cyclists. The objective of the present study was to quantitatively evaluate the impact of the Motala helmet law on observed use of helmets by children and adults. Bicycle helmet use was monitored in Motala (n = 2,458/year) and in control towns (n = 17,818/year) both before and after adoption of the helmet law (1995-1998). Chi-square tests showed that helmet wearing 1995-1998 increased in Motala among all bicyclists (from 6.1% to 10.5%) and adults biking on cycle paths (from 1.8% to 7.6%). Helmet use by school children aged 6-12 increased during the first 6 months after introduction of the law (from 65.0% to 75.7%) but then progressively decreased to the pre-law level. Considering children cycling on cycle paths and for recreation in housing areas, there was a tendency towards increased helmet use during the first post-law year, but this was followed by a reduction to a lower level in 1998 than in 1995. Logistic regression analysis taking into account data from the control towns indicated that the helmet law had a positive effect on children cycling to schools during the first 6 months, and a weak delayed but more long-term positive effect on adult cyclists on cycle paths. There were no positive effects on children in housing areas and on cycle paths. The Motala helmet law probably would have had greater and more lasting effects on helmet use by bicyclists, if certain problems had been avoided during the initiation phase. Moreover, although it did have a positive influence on both school children and adults, it is not legally binding, and hence no penalties can be imposed. Presumably, compulsory legislation would have a more substantial impact on helmet wearing than a non-mandatory helmet 'law' such as that introduced in Motala.