Prevention of bicycle-related head injuries

Each year in the United States, bicycling accidents cause approximately 1,300 deaths and 60,000 injuries. The death and injury rates are particularly high among children. The death rate from bicycle injuries in children exceeds the death rate from accidental poisonings, falls, firearm injuries, and many major illnesses. Head trauma is the most frequent cause of death and serious injury among bicyclists. Bicycle helmets have the potential to decrease the frequency and severity of bicycle-related head injury. Unfortunately, however, most bicyclists do not use a helmet. The helmet-use rate is extremely low among children. The failure of bicyclists, particularly children, to use bicycle helmets presents an opportunity for prevention of thousands of the traumatic head injuries that occur annually in the United States. Helmet use could be encouraged by schools, community safety programs, and office-based education by physicians.     

Effectiveness of a state law mandating use of bicycle helmets among children: an observational evaluation.

In spring 1999, the authors evaluated the effectiveness of a 1997 Florida law requiring helmet use by all bicyclists younger than age 16 years. Sixty-four counties in Florida had enacted the bicycle helmet-use law, while the other three counties had opted out. Using a cross-sectional study design, the authors conducted unobtrusive observations at bicycle racks at public elementary schools statewide. Florida children riding bicycles in counties where the state helmet-use law was in place were twice as likely to wear helmets as children in counties without the law. In counties where the state law was in place, 16,907 (79%) of 21,313 riders observed wore a helmet, compared with only 148 (33%) of 450 riders in counties where no such law was in place (crude prevalence ratio = 2.4, 95% confidence interval: 2.1, 2.8). Helmet use by children of all racial groups exceeded 60% under the law. No significant difference in use by gender was found. These data support the positive influence of a law on bicycle helmet use among children. The data reinforce the Healthy People 2010 objective that all 50 states adopt such a law for children in order to increase helmet use and consequently reduce brain injury.     

Helmet use among motorcyclists who died in crashes and economic cost savings associated with state motorcycle helmet laws--United States, 2008-2010

In 2010, the 4,502 motorcyclists (operators and passengers) killed in motorcycle crashes made up 14% of all road traffic deaths, yet motorcycles accounted for <1% of all vehicle miles traveled. Helmet use consistently has been shown to reduce motorcycle crash-related injuries and deaths, and the most effective strategy to increase helmet use is enactment of universal helmet laws. Universal helmet laws require all motorcyclists to wear helmets whenever they ride. To examine the association between states' motorcycle helmet laws and helmet use or nonuse among fatally injured motorcyclists, CDC analyzed 2008-2010 National Highway Traffic Safety Administration (NHTSA) data from the Fatality Analysis Reporting System (FARS), a census of fatal traffic crashes in the United States. Additionally, economic cost data from NHTSA were obtained to compare the costs saved as a result of helmet use, by type of state motorcycle helmet law. The findings indicated that, on average, 12% of fatally injured motorcyclists were not wearing helmets in states with universal helmet laws, compared with 64% in partial helmet law states (laws that only required specific groups, usually young riders, to wear helmets) and 79% in states without a helmet law. Additionally, in 2010, economic costs saved from helmet use by society in states with a universal helmet law were, on average, $725 per registered motorcycle, nearly four times greater than in states without such a law ($198).     

Injury Control Recommendations for Bicycle Helmets

ABSTRACT: These guidelines were developed by the Centers for Disease Control and Prevention for state and local agencies and organizations planning programs to prevent head injuries among bicyclists through use of bicycle helmets. The guidelines contain information on the magnitude and extent of the problem of bicycle-related head injuries and potential impact of increased helmet use; characteristics of helmets, including biomechanical characteristics, helmet standards, and performance in actual crash conditions; barriers that impede increased helmet use; and approaches to increasing use of bicycle helmets within the community. In addition, bicycle helmet legislation and community educational campaigns are evaluated. (J Sch Health. 1995;65(4):133–139)     

Compliance with the 1992 California motorcycle helmet use law.

To evaluate helmet use in California before and after the introduction of an unrestricted helmet use law on January 1, 1992, observations of motorcycles and their riders were made at 60 locations in seven California counties, twice before and four times after the law was introduced. Helmet use increased from about 50% in 1991 to more than 99% throughout 1992. Compliance was achieved despite variations in helmet use by motorcycle design and road type. Seven percent of riders used nonstandard helmets after the law. With adequate enforcement, unrestricted helmet use laws can achieve almost 100% compliance and reduce the number of people riding motorcycles.     

Bicyclists, helmets and head injuries: a rider-based study of helmet use and effectiveness.

We interviewed 516 bicyclists over age 10 regarding helmet use and head injuries. Although 19 per cent owned helmets, only 8 per cent were wearing them when interviewed. Riders wearing helmets were more highly educated and reported higher car seat belt use. Nearly 4 per cent of the bicyclists reported striking their heads in a cycling mishap during the previous 18 months; those wearing helmets at the time of the mishap were less likely to have sustained head injuries.     

Rates of bicycle helmet use in an affluent Michigan County.

Bicycle helmet use in the United States has remained low despite clear demonstration of its beneficial effect on reducing the incidence of serious head injury. Several interventions have been reported, with variable results and costs. Much of the recent literature has focused on child cyclists and on demographic factors associated with helmet use. This paper reports on helmet use by children and adults in a sample of 652 riders in an affluent southeast Michigan region, chosen to minimize the effect of previously recognized socioeconomic negative predictors that are not readily changed by intervention. Subjects were classified by age, sex, location, riding surface, type of bicycle, child bicycle seat use, child bicycle trailer use, and helmet use by companions. Overall helmet use was 24 percent; infants and toddlers had the highest rate of helmet use at 61 percent, followed by adults at 26 percent and school-aged children at 17 percent. The strongest predictor of helmet use in all age categories was the presence of a helmeted companion. Adult helmet use was also positively predicted by riding in the street and by riding a racing-type bicycle. The use of a city-type bicycle negatively predicted helmet use. For non-adults, female sex and the use of a child seat or trailer were positive predictors. Fostering peer pressure to increase helmet use may be an effective yet relatively inexpensive way to achieve the goal of widespread use of bicycle helmets.     

Barriers to bicycle helmet use among Dutch paediatricians

Background In the Netherlands, bicycle helmet wearing rates are very low and perceived social barriers to helmet use are important. We aimed to determine why Dutch paediatricians do or do not wear helmets while bicycling and whether their personal behaviour is influencing their position about the promotion of helmet use. Methods Attendants to the annual meeting of the Dutch Paediatric Society (7–9 November 2006) were surveyed about bicycle riding frequency, helmet use, reasons for not wearing a helmet, helmet use among their own children and personal position about the promotion and legislation of bicycle helmet use. Results Of the 1110 paediatricians who are active in the Netherlands, 258 answered the survey. Ninety‐six per cent of the respondents ride a bicycle (68% more than once a week). Bicycle was used as a mean of transport (32%), as a recreation/sport (11%) or with both purposes (57%). When cycling for transportation, 94% never wear a helmet and 2% always wear it. When cycling for recreation, 70% never wear a helmet and 18% always wear it. The most common reasons given for not wearing a helmet were: ‘I never thought about that’ (43%), ‘Poor appearance’ (31%), ‘Nobody uses it in the Netherlands’ (27%) and ‘Uncomfortable’ (25%). A majority (91%) of the respondents agreed that bicycle helmets are effective in reducing the rate of head injury to bicyclists and that they should be advised to children (82%) and adolescents (54%). Conclusions Our results indicate that among Dutch paediatricians, cycling rate is high and helmet wearing rate is very low and that they experience numerous personal barriers to bicycle helmet use. This might explain why bicycle helmet promotion campaigns are scarcely supported by Dutch paediatricians.     

Long-Term Effects of Education and Legislation Enforcement on All-Age Bicycle Helmet Use: A Longitudinal Study

Bicycle-related injuries are a leading cause of child and youth hospitalizations in Canada. The use of helmets while bicycling reduces the risk of brain injuries. This study investigated the long-term effect of legislation coupled with enforcement to improve helmet use rates. We conducted a longitudinal observational study of helmet use at 9, 11, and 14 years after bicycle helmet legislation was enacted. Data were compared to baseline observations collected after legislation was passed in 1997. A comprehensive enforcement and educational diversion program, Operation Headway–Noggin Knowledge (OP–NK), was developed and implemented in partnership with regional police during the study period. Helmet use was sustained throughout the post-legislation period, from 75.3 % in the year legislation was enacted to 94.2 % 14 years post-legislation. The increase in helmet use was seen among all age groups and genders. Helmet legislation was not associated with changes in bicycle ridership over the study years. OP–NK was associated with improved enforcement efforts as evidenced by the number of tickets issued to noncompliant bicycle riders. This observational study spans a 16-year study period extending from pre-legislation to 14 years post all-age bicycle helmet legislation. Our study results demonstrate that a comprehensive approach that couples education and awareness with ongoing enforcement of helmet legislation is associated with long-term sustained helmet use rates. The diversion program described herein is listed among best practices by the Public Health Agency of Canada.     

The cost effectiveness of three programs to increase use of bicycle helmets among children.

Each year in the United States, 280 children die from bicycle crashes and 144,000 are treated for head injuries from bicycling. Although bicycle helmets reduce the risk of head injury by 85 percent, few children wear them. To help guide the choice of strategy to promote helmet use among children ages 5 to 16 years, the cost effectiveness of legislative, communitywide, and school-based approaches was assessed. A societal perspective was used, only direct costs were included, and a 4-year period after program startup was examined. National age-specific injury rates and an attributable risk model were used to estimate the expected number of bicycle-related head injuries and deaths in localities with and without a program. The percentage of children who wore helmets increased from 4 to 47 in the legislative program, from 5 to 33 in the community program, and from 2 to 8 in the school program. Two programs had similar cost effectiveness ratios per head injury avoided. The legislative program had a $36,643 cost and the community-based one, $37,732, while the school-based program had a cost of $144,498 per head injury avoided. The community program obtained its 33 percent usage gradually over the 4 years, while the legislative program resulted in an immediate increase in usage, thus, considering program characteristics and overall results, the legislative program appears to be the most cost-effective. The cost of helmets was the most influential factor on the cost-effectiveness ratio. The year 2000 health objectives call for use of helmets by 50 percent of bicyclists.(ABSTRACT TRUNCATED AT 250 WORDS)     

Promotion of bicycle helmet use among schoolchildren: a randomized clinical trial

Although bicycle helmets have been shown to reduce the rates of head injuries and brain injuries from bicycle mishaps, use of helmets is very uncommon. We compared a comprehensive awareness program to increase bicycle helmet use among schoolchildren to the impact of that same awareness program plus a bicycle helmet subsidy. Results showed no impact of the educational program (no children observed riding to school wore helmets before or after the program). The proportion of helmet wearers at the school that obtained the subsidy increased from 0% to 22% (p = 0.036). An educational program in conjunction with a subsidy may have a significant impact on bicycle helmet use.     

A case-control study of the effectiveness of bicycle safety helmets in preventing facial injury.

In a case-control study we sought to assess the potential effectiveness of helmets in preventing facial injuries. Our study included 212 bicyclists with facial injuries and 319 controls with injuries to other body areas, who were treated in emergency rooms of five Seattle area hospitals over a one-year period. Using regression analyses to control for age, sex, education and income, accident severity, and cycling experience we found no definite effect of helmets on the risk of serious facial injury (odds ratio 0.81; 95 percent confidence interval = 0.45, 1.5), but protection against serious injuries to the upper face (odds ratio 0.27; 95% CI = 0.1, 0.8). No protection was found against serious injuries to the lower face. The independent effect of helmet use on facial injury was difficult to isolate due to the association of head and facial injuries. Our results suggest that bicycle helmets as presently designed may have some protective effect against serious upper facial injuries.     

Bicycle helmet laws and educational campaigns: an evaluation of strategies to increase children's helmet use.

OBJECTIVES. The passage of a mandatory bicycle helmet law for children in Howard County, Maryland, provided an opportunity to compare legislation and education as strategies to increase helmet use. METHODS. In 1991, a survey was mailed to fourth-, seventh-, and ninth-grade students attending a stratified sample of public schools in Howard County and in two similar suburban/rural counties without helmet laws. RESULTS. Of 7217 students surveyed, 3494 responded (48.4%). Self-reported helmet use in Howard County rose from 11% to 37% after the law and accompanying educational campaign went into effect. Helmet use changed from 8% to 13% in Montgomery County, where educational efforts were undertaken, and from 7% to 11% in Baltimore County, where helmet promotion activities were minimal. Predictors of helmet use included having friends who wore helmets, believing helmet laws are good, being in fourth grade, living in Howard County, and using seatbelts regularly. CONCLUSIONS. Legislation combined with education appears to increase bicycle helmet use substantially more than does education alone. The Howard County law may be considered a successful model of a strategy to increase children's helmet use.     

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

This paper describes how the use of bicycle helmets in Swedenhas changed for different categories of cyclists from 1988 to2002, and it also estimates future trends in voluntary wearingof bicycle helmets up to the year 2010. Observational studiesof the use of bicycle helmets were conducted once a year from1988 to 2002 at 157 sites in 21 cities. The subjects observedwere children cycling to school (average n = 5471/year) andin their free time (average n = 2191/year), and adults cyclingto workplaces and on public bike paths (average n = 29 368/year).The general trend in helmet use from 1988 to 2002 was determinedby linear regression analysis, and the results were also employedto estimate future helmet wearing for the period 2003–2010.Differences in helmet use according to gender and size of citywere analysed by chi-square tests. From 1988 to 2002, all categoriesof cyclists showed an upward trend in helmet use (p < 0.01,p < 0.001). Helmet wearing increased from about 20 to 35%among children (10 years) cycling during free time, from approximately5 to 33% among school children, and from around 2 to 14% inadults. 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 upwardtrend in helmet wearing. It is estimated that 30% of cyclistswill wear helmets voluntarily by the year 2010, if helmet promotionactivities are continued at the same level as previously. Theresults suggest that Sweden will probably not reach its officialgoal of 80% helmet use unless a national bicycle helmet lawis passed.     

Age gradient in the cost-effectiveness of bicycle helmets

OBJECTIVES: This study analyzed the reduction in risk of head injuries associated with use of bicycle helmets among persons ages 3 to 70 and the cost-effectiveness of helmet use based on this estimated risk reduction. METHODS: To derive our cost-effectiveness estimates, we combined injury incidence data gathered through a detailed and comprehensive injury registration system in Norway, acute medical treatment cost information for the Norwegian health service, and information reported in the scientific literature regarding the health protective effects of helmet use. The analysis included all cases of head injuries reported through the registration system from 1990 through 1996. We performed an age-stratified analysis to determine the incidence of bicycle-related head injuries, the 5-year reduction in absolute risk of injury, the number needed to treat, and the cost-effectiveness of helmet use. To test the robustness of the findings to parameter assumptions, we performed sensitivity analysis. RESULTS: The risk of head injury was highest among children aged 5 to 16. The greatest reduction in absolute risk of head injury, 1.0 to 1.4% over 5 years estimated helmet lifetime, occurred among children who started using a helmet between the ages of 3 and 13. Estimates indicate that it would cost approximately U.S. $2,200 in bicycle helmet expenses to prevent any one upper head injury in children ages 3-13. In contrast, it would cost U.S. $10,000-25,000 to avoid a single injury among adults. CONCLUSIONS: Bicycle safety helmets appear to be several times more cost-effective for children than adults, primarily because of the higher risk of head injury among children. Programs aiming to increase helmet use should consider the differences in injury risk and cost-effectiveness among different age groups and target their efforts accordingly.     

Evaluation of a community bicycle helmet promotion campaign: what works and why

PURPOSE. This study identifies effective components of a bicycle helmet promotion campaign, and mechanisms by which these components affect child helmet ownership. DESIGN. A random telephone survey identified parents whose children did not own helmets prior to an educational campaign. A follow-up survey was conducted six months later. Regression analysis estimated the effects of four campaign components on child helmet ownership and tested for mediation by cognitive variables. SETTING. Study participants were residents of a suburban community which undertook a citywide educational campaign to increase child helmet ownership. SUBJECTS. Subjects were 210 parents with at least one school-aged child, none of whom owned helmets. INTERVENTION. A multicomponent campaign was implemented by a community coalition. In addition, random subsamples of the study participants received direct mail or direct telephone communications. RESULTS. Of the eligible respondents identified in the baseline sample, 39% completed the follow-up survey. Regression analysis showed that children whose parents received either helmet advice from a physician or direct telephone communications were 2.6 and 2.2 times more likely, respectively, to own helmets as children whose parents did not experience similar communication. Parental worry mediated the association, but parental beliefs about the effectiveness of helmets did not. CONCLUSION. Future helmet campaigns should use interpersonal strategies to increase parental worry about their children being involved in a bicycle accident. Generalization of these findings is limited by the high socioeconomic status of the study participants, and by the outcome measure, which is helmet ownership, not helmet use.     

Changes in motorcycle-related head injury deaths, hospitalizations, and hospital charges following repeal of Pennsylvania's mandatory motorcycle helmet law

To evaluate the 2003 repeal of Pennsylvania's motorcycle helmet law, we assessed changes in helmet use and compared motorcycle-related head injuries with non-head injuries from 2001-2002 to 2004-2005. Helmet use among riders in crashes decreased from 82% to 58%. Head injury deaths increased 66%; nonhead injury deaths increased 25%. Motorcycle-related head injury hospitalizations increased 78% compared with 28% for nonhead injury hospitalizations. Helmet law repeals jeopardize motorcycle riders. Until repeals are reversed, states need voluntary strategies to increase helmet use.     

Motorcycle helmet use in Texas

Helmets worn by motorcyclists decrease head injuries and the likelihood of being killed in a crash by about 30 percent. From 1968 to 1977, Texas had a comprehensive motorcycle helmet use law, which was estimated to have saved 650 lives. But the law was amended in 1977 to apply only to motorcycle operators and passengers under age 18. In September 1989, a new law was passed that required helmets for all motorcycle operators and passengers. Observations of helmet use were conducted before and after the law took effect in 18 Texas cities using a survey design providing a cross-section of urban and suburban traffic across the State. The surveys indicated that helmet use increased from less than 50 percent just before the law to 90 percent immediately after, and it increased further to more than 95 percent 2 months later. These results confirm the unique effectiveness of comprehensive helmet use laws in applying the proven public health benefits of helmets to the reduction of motorcycle injuries and deaths.     

The cost-effectiveness of compulsory bicycle helmets in New Zealand

Abstract: This paper examines the cost-effectiveness for primary school children (age 5–12 years), secondary school children (13–18 years) and adults (over 18 years) of the legislation enacted on 1 January 1994 requiring road-cyclists in New Zealand to wear helmets. The cost to cyclists not in possession of a helmet before they became compulsory of either obtaining one or quitting cycling was compared with the number of deaths and hospitalisations expected to be prevented over the average life of a helmet. Corresponding to Victorian and United States estimates of the efficacy of cycle helmets at preventing serious head injuries, the cost per life saved was $88 379 to $113 744 for primary school children, $694 013 to $817 874 for secondary school children, and $890 041 to $1 014 850 for adults (New Zealand dollars = approximately 0.95 Australian dollars). The cost per hospitalisation avoided was $3304 to $4252, $17 207 to $20 278, and $49 143 to $56 035 respectively. These estimates are extremely sensitive to the estimated efficacy of helmets at protecting cyclists. Mainly anecdotal evidence for New Zealand suggests that they are not be very effective at preventing serious head injuries; future research into the change in injury patterns as a result of the helmet regulation would be valuable. Nonetheless, the ranking of the above mentioned estimates does not contradict the policy in some parts of the world requiring helmets for children and/or teenagers, but not adults.     

Bicycle helmet-wearing variation and associated factors in Ontario teenagers and adults

BACKGROUND: The incidence of bicycle helmet use and the factors associated with helmet use in Ontario are presented in this study. The Ontario Health Survey (1996), a population-based survey of Ontario residents, was used as the data source. METHODS: As the factors associated with helmet use were found to differ between adults and teens, a separate analysis was performed for each age grouping. A logistic regression model (with Bootstrap confidence intervals--95%) was used and adjusted odds ratios (OR) are reported. RESULTS: Of the 7,693 respondents, 41.1% reported wearing their helmets on a regular basis when riding a bicycle. Helmet use was greatest among 12-14 year olds (71.7%) and lowest among those 15-18 years old (33.3%). In teenagers, drinking alcohol (OR: 2.8) and smoking (OR: 4.4) were strongly associated with helmet non-use. In the adult group, female gender (OR: 1.26), higher income (OR: 1.43), higher education (OR: 1.68), nonsmoking status (OR: 2.0) and abstinence from alcohol (1.27) were associated with helmet use. Living in a rural area was also associated with helmet use in the multi-variable analysis. CONCLUSION: This study indicates that bicycle helmet non-use is a multifaceted problem and thus any strategy for increasing helmet-wearing rates requires multi-dimensional interventions. The results of this study are discussed within the context of other studies and related to their public health implications.