Helmet Safety for Bicyclists and In-Line Skaters
Developed by Prudential HealthCare

A "White Paper" prepared for the launching of the National Helmet Safety Campaign in 1997. The campaign was sponsored by the Brain Injury Association and Prudential HealthCare. This paper was developed by Prudential HealthCare. It is out of date now, but still has a useful overview.

Overview

One study reveals that, from 1984 to 1988, statistics show that bicycling accounted for 2,985 head injury deaths and 905,752 head injuries. Forty-one percent of head injury deaths and 76 percent of these head injuries occurred among children younger than 15 years of age. Research shows that as many as 2,500 deaths and 757,000 head injuries resulted during this period, which translates into one death every day and one head injury every four minutes that could have been prevented if helmets were worn.

Senturia et al report that bicycle injuries are the single most important cause of head injury in childhood and account for more than 900 deaths per year. Bicycle-related injuries are a leading cause of pediatric head injuries requiring hospitalization. Bicycle injury rates are highest for children aged five through 15 years. A separate study found that bicycling is the fourth leading cause of traumatic brain injury-associated death among children and adolescents younger than 15 years of age.

According to the Center for Disease Control, accidents are the number one cause of death in children. The National Pediatric Trauma Registry has recorded more than 30,000 cases of children who sustained permanent disabilities as a result of brain injuries. And, Sacks et al report that head injury is the most common cause of death, disability and serious injury in child bicyclists involved in accidents.

Despite the higher incidence of head injury among children and adolescents, only 15 percent reportedly wear a helmet all or most of the time when riding their bicycles.

A case-control study involving 3,390 injured bicyclists demonstrated that helmets are effective for bicyclists of all ages. Helmet use reportedly reduces the chance of head injury by more than 80 percent. Helmets have been found to be effective in preventing head injury in all types of crashes, even those involving motor vehicles. Every year, thousands of children unnecessarily die of fatal head injuries because they fail to wear a helmet.

While study after study has shown that helmets can reduce the chances of head injury by 85 percent and brain injury by 88 percent, only about 18 percent of the general population reportedly are wearing helmets all or most of the time while riding their bicycles and only about one in five in-line skaters.

The Brain Injury Association estimates the cost of traumatic brain injuries in the United States to be $48.3 billion annually. Hospitalization accounts for $31.7 billion, whereas fatal brain injuries cost the nation $16.6 billion. The U.S. Consumer Product Safety Commission (CPSC) estimates the societal costs of medically-attended bicycle-related injuries and fatalities to be about $8 billion annually. Nationwide, it is estimated that each dollar spent on bicycle helmets saves $2 in medical care costs.

Many of those in the medical field strongly recommend that children, as well as adults, wear helmets to prevent head injury when bicycle riding, in-line skating or skateboarding.

Parents' Attitudes Towards Helmets and Their Use

Several researchers have found that a major barrier to helmet use by children and adolescents is lack of parental awareness. When parents were asked why their children do not own bicycle helmets, the most common responses were: "never thought about purchasing a helmet" (35 percent ), "never got around to purchasing a helmet" (29 percent), "child wouldn't wear it anyway" (26 percent), and the bicycle helmet was "too expensive" (16 percent). Other reasons for not purchasing bicycle helmets for their children include: "child doesn't ride enough" (19 percent) and "only rides in safe areas" (12 percent).

In the Miller et al study, parents identified magazines, television, family and friends, and pediatricians as key sources of bicycle helmet information. The only source significantly associated with increased helmet ownership was friends and family (p<.01).

Also, in Miller's study, only 48 of the 169 children interviewed owned bicycle helmets. Of these children, only 16 (33 percent) follow strict helmet-wearing rules; 10 follow partial rules and 22 had no parental rules on helmets. As might be expected, children with strict helmet rules were more likely to wear them always or most of the time. Interestingly, the incidence of helmet wearing was no greater for children who had partial rules than those with no rules.

Since lack of parental awareness was the most frequent reason for not purchasing helmets, Miller et al suggested that parental education, particularly through pediatricians, could help to increase bicycle helmet use. A number of researchers have suggested targeting education programs at pediatricians, as well as at parents.

Children's Attitudes Towards Helmets and Their Use

According to CPSC, each year about 400,000 children under the age of 15 are treated in hospital emergency rooms for bicycle-related injuries. An additional 300 die as a result of their injuries. And, about one-third of the injuries and two-thirds of the deaths of bicyclists aged five to 14 are head-related.

National statistics show that only 15 percent of children wear bicycle helmets, even though many youngsters seemed to understand that helmets could protect their head from injury. One child said "you could be paralyzed, killed, or you could suffer brain damage." CPSC found that, of those children who own helmets, 43 percent reportedly wear them always or most of the time, 11 percent wear them occasionally, and 44 percent seldom or never wear their helmets. According to the CPSC, helmet use was highest for younger children (age six or less) and lowest for older children (12 to 14 year olds).

A survey of 282 children conducted by the American Automobile Association (AAA) and the CPSC determined that children most disliked the fit of bicycle helmets (46 percent). Many reportedly complained that the helmets felt uncomfortable on the head or that the chinstraps pinch. Interestingly, when these children were asked what one thing they would change about the helmets, the majority (52 percent) said "how they look," and only 23 percent said "how they fit."

In a bicycle injury study conducted in Ohio, many of the children who do not own a bicycle helmet seemed to lack an awareness or understanding of the importance of helmets. Twenty-nine percent of the children in this study said they "never thought of wearing a helmet" and 19 percent said that wearing a helmet is "not necessary." Only 15 percent expressed negative feelings about bicycle helmets, including they did not like helmets in general or did not like the way they look (e.g., ugly or embarrassing).

In yet a third study, child helmet owners who do not wear their helmet said they do not feel it is necessary or that they forgot or lost it. On the other hand, those who do not own helmets reportedly avoid this type of head gear because of the way they look or because they are uncomfortable. Style and comfort appear to be more important barriers to helmet use for adolescents and young adults who are reluctant to wear a helmet if their peers do not.

In a 1994 survey conducted by the Centers for Disease Control and Prevention, children most frequently pointed to low perceived risk of injury or simply "never considered the issue" as the main reasons for not owning a helmet or wearing one more often

Children in the CPSC/AAA survey suggested that helmet manufacturers use "cooler" colors and more interesting and varied designs. They also indicated that a role model, such as a celebrity or professional athlete, who would talk about the importance and benefits of helmets, might encourage some children to wear bicycle helmets. Other children indicated that discussing the consequences of riding a bicycle without a helmet would be effective in promoting helmet use. Still others suggested that retailers and local communities run promotions (e.g. wear a bike helmet and get a free pizza) to increase helmet use among children.

A number of researchers have found that the incidence of helmet use was higher among those who ride with peers wearing helmets than those who ride alone or with peers who do not wear helmets. Children were also more likely to wear helmets if their parents wear them.

No conclusive evidence has been uncovered to show that children who wear helmets as youngsters continue to wear them as they grow older. However, in a study conducted in Oregon where mandatory helmet laws exist, researchers predicted that because younger children were more likely to comply with helmet laws, helmet use by Oregon children may continue to increase as younger children grow up with the law.

Number of Head Injuries, Causes and Ways to Prevent Them

Bicycle injury rates are reportedly highest for five to 15 year-olds, with these children accounting for three-fourths of all bicycle head injuries. Within this group, females five to nine years of age and males 10 to 14 years old have the highest injury rates per 100,000 population, according to Thompson et al. For all age categories, males are injured more often than females. This may be attributed, in part, to the fact that males ride more frequently and spend more time on bicycles than females.

According to one study, children are reportedly six times less likely than adults to wear helmets even though they are over twice as likely to sustain a severe head injury.

Studies show that the most common cause of death and serious disability from bicycle crashes is head injury. Head and brain injuries are the primary or contributing cause of death in 62 percent to 90 percent of all bicycling fatalities. Riding at speeds greater than 15 miles per hour - which is not unusual -- increased the risk of severe injury by 40 percent.

Grimand, Nolan and Carlin carried out one study that demonstrates the effectiveness of bicycle helmets. This study reveals that the majority of injuries sustained by helmeted bicyclists were mild. However, helmeted children were as likely as unhelmeted children to suffer facial injuries. Helmeted bicyclists who suffered head injury, in many instances, did not properly wear the helmet.

Overall, helmets have been found to decrease the risk of head and brain injury by 70 percent to 88 percent and facial injury to the upper and mid-face by 65 percent. Acton et al recommend that manufacturers make helmets so they cover a larger area of the head, with chinstraps and visors to provide maximum protection for the head and face.

Thompson et al recommend that steps be taken to reduce the number of bicycle crashes among adults and children. Also, Thompson et al discuss the need for bicycle-friendly riding environments to encourage cycling and reduce crashes. These would include improvements in road design, bicycle design, and bicyclist behavior, all of which contribute to better safety.

Every year, about 100,000 people visit hospital emergency rooms to treat injuries sustained from in-line skating accidents. An estimated 65,000 children under the age of 15 sustain in-line skating injuries, of which 29,000 will fracture a bone and 7,000 will injure their faces or heads. The number of injuries related to in-line skating increased 184 percent from 1993 to 1995. According to the CPSC, as many as two-thirds of injured in-line skaters were not wearing safety gear (i.e., helmets, elbow and knee pads, wrist guards and gloves). The rise in the number of in-line skating injuries underscores the need to encourage skaters to wear safety gear.

When in-line skating, females are generally more likely than males to wear some protective gear. However, females reportedly wear helmets as infrequently as males. Advanced and beginner skaters are much more likely to wear helmets than are average skaters. Teenagers are the least likely to wear any protective equipment (including helmets) compared with children and adults. Helmets are reportedly worn by 10.3 percent of older skaters, 8.1 percent of children, 2.0 percent of adults, 0.0 percent of teenagers.

As with many bicyclists, in-line skaters' lack of knowledge of the importance of protective equipment (including helmets), discomfort from the equipment, perceived unattractive appearance while wearing protective gear, and cost all contribute to low rates of safety equipment usage.

Types of Helmets, How to Use Them, and Types That Work

A study sponsored by the Snell Memorial Foundation discussed the importance of bicycle helmets meeting at least one of three helmet standards established by the Snell Memorial Foundation (Snell), American National Standards Institute (ANSI), and American Society for Testing and Materials (ASTM). Snell reportedly has the most stringent certification standards, so those meeting Snell requirements would also meet ANSI and ASTM standards.

Experts say that helmet ownership does not necessarily guarantee protection against head injuries. A helmet that is not properly worn provides little protection against head and brain injury. In the majority of instances where helmeted bicyclists have head injuries, it is because their helmets were not properly worn. In many cases, helmets are worn too far back on the head or are not tightly secured with the chinstrap.

Studies have shown that helmets are primarily damaged in the front and at the edge of the helmet which suggests that manufacturers should consider building extra energy-absorbing capacity in the front and improve the retention system to prevent the helmet from falling to the back of the head. One study of head injuries in helmeted children indicates that the fit and placement of straps may be significant factors in the improper fit of helmets and suggests the need for a better passive mechanism to secure the helmet.

A study conducted during Cycle Oregon, a multi-day, 500-mile bicycle tour for adults, tested helmet fit at the end of a day's 80-mile ride. The study found that 70 percent of riders failed to pass one of three tests recommended by helmet manufacturers that check for proper helmet fitting. While the researchers conducting this particular survey criticized helmet manufacturers for focusing too much attention on style, weight, ventilation and passing the impact resistance test rather than the ease of fitting, other experts point to the importance of these other factors in encouraging bicyclists to wear helmets in the first place.

Helmet manufacturers have developed a five-step, helmet fit test to ensure that helmets are positioned and secured properly. When fitting the helmet, experts say: 1) the helmet should rest on the head so that it sits evenly between the ears and rests low on the forehead - it should only be one-two finger widths above your eyebrow; 2) foam pads should be put inside the helmet so that it feels comfortable but really snug, and 3) the chin strap should be tightened as snugly as possible by adjusting the junction of the front and back straps just under the ears, and securing the back strap without putting pressure on the front strap.

[BHSI Note: The last two steps were not included in the paper.]

At this time, there is no conclusive evidence that proves that hard-shell bicycle helmets are more effective in preventing head and brain injury than thin-shell or no-shell helmets. All three helmet types have been found to reduce the chances of head injury in a bicycle crash.

Many of those in the medical profession urge parents to put helmets on their children who ride bicycles, skates, tricycles, etc. Some researchers have found that helmets are generally not designed to fit children younger than six years of age. Unfortunately, this age group experienced the highest proportion of bicycle-related head and facial injuries. To increase the effectiveness of helmets in young children, experts say that it will be necessary to design a helmet that is safe and comfortable, lightweight and has a lower face guard to protect the mouth and chin. In addition, parents and physicians need to be educated about the risk of head injury for small children on wheeled toys.

Even infants should wear helmets when riding with their parents. The American Academy of Pediatricians (AAP) recommends that only children who are old enough - about nine months of age - to sit well unsupported and whose necks are strong enough to support a lightweight helmet should be carried in rear-mounted seats of adult bicycles.

To encourage those children who indicate they do not wear helmets for various superficial reasons (e.g., the looks), researchers have suggested that manufacturers of helmets and other protective equipment should consider style, cost and safety (e.g., meeting ANSI, ASTM, or Snell standards) in equipment design and should use well-respected role models who are particularly appealing to children and adolescents, as spokespersons in helmet safety campaigns.

Educational Efforts

Many of those researching the effects of helmets in preventing head, brain and facial injuries strongly recommend community-wide education programs targeted at parents, children and physicians. School-based educational programs and community-based interventions are seen as necessary to improve the rate of helmet usage among children, as well as adults.

A successful helmet education safety campaign - the Washington Children's Bicycle Helmet Campaign - was launched in 1986. The Harborview Injury Prevention and Research Center (HIPRC) of Seattle designed the campaign around four key objectives: increasing public awareness of the importance of helmets, educating parents about helmet use and overcoming peer pressure among children against wearing helmets and lowering helmet prices. HIPRC, along with various health, bicycling, helmet industry and community organizations, sponsored a number of promotions and donated free helmets to underprivileged children.

As a result of the HIPRC campaign, parents and children heard about helmets on television, on the radio, in newspapers, in their doctor's office, at school and at youth groups. By September 1993, helmet use had jumped from one percent to 37 percent among children in the greater Seattle area. Adult use of helmets increased to 70 percent, as parents learned the benefits of helmets.

In a separate bicycle safety education program -- the MORE HEALTH campaign -- children in kindergarten, first and second grade in nine schools in Hillsborough County, Florida, were targeted. This program consisted of interactive education sessions and reduced-cost bicycle helmet sales. In the course of the program, more than 1,000 helmets were distributed and approximately 3,500 children participated in the education sessions. The pre-program helmet use rate among all schools was 8.5 percent. Post-program results showed that helmet use rates in the participating schools significantly greater than among control schools.

As part of many community programs, including the Harborview and MORE HEALTH promotional campaigns, free helmets are distributed and subsidies for discounts on helmets are provided to increase the incidence of helmet ownership, particularly in low income areas. Parkin et al carried out a study to test the impact of helmet subsidies on helmet-wearing rates in low-income areas. The study found that despite encouraging helmet sales and helmet ownership, the incidence of helmet use did not differ significantly from those areas that received the subsidies and those areas that did not. Researchers found that ignorance was a more important barrier to helmet use than were economic factors. Hence, Parkin et al recommend implementing long-term community and school-based campaigns (which may or may not include helmet subsidies), in addition to passing legislation, to raise the rate of helmet use.

To demonstrate the impact of helmet safety education campaigns and legislation on the rate of helmet use in a multiracial population of New York, children aged one to 14 were observed before and after legislation passed and promotions took place in two boroughs of New York.

A total of 276 observations were made in Queens where a helmet safety program had taken place and 342 observations in Brooklyn where helmet legislation had passed. The data show that, in Queens, the rate of helmet use increased for all children in all racial groups: White (6.5 percent to 23.5 percent), Black (1.1 percent to 8.6 percent), Hispanic (2.1 percent to 7.7 percent), and Asian (13.3 percent to 15.2 percent). In Brooklyn, helmet use actually decreased from 5.6 percent to 4.2 percent, thus demonstrating that legislation alone is inadequate for ensuring increased bicycle helmet use.

Sacks et al suggest that educational efforts be targeted at mainly parents and healthcare providers, as they tend to have the greatest influence in changing children's behavior. Also, programs targeted at these groups are thought to be especially effective since most younger children are under more "parental control" than older children.

In a related study that measured the impact of educational programs in injury prevention, Ytterstad and Wasmuth found that local relevance, the involvement of the mass media, and some legislation contributed to fewer injuries in the community under study.

In May 1997, Maryland launched its first state-wide helmet use awareness campaign. Maryland passed a mandatory helmet law in 1996, requiring all bicyclists under 16 to wear a helmet. The "Wear A Helmet" campaign will be seen on 55 billboards, 80,000 milk cartons, the backs of buses, on thousands of bumper stickers, on street signs, and in public service TV announcements. This is one of the largest coalitions aimed at promoting helmet use. Evaluation of the success of this program is forthcoming, according to the World Health Organization Helmet Initiative, based at the Center for Injury Control of the Rollins School of Public Health, Emory University, Atlanta, Georgia.

Legal Efforts

Most researchers agree that a combination of community-wide helmet education campaigns and mandatory legislation is needed to increase the rate of helmet use. Studies have shown that educational campaigns cannot do the job alone, nor can legislation. Similar to the mandate requiring motorists to wear seat belts, legislation requiring children to wear helmets is considered necessary to push helmet use rates higher. Even in Seattle where the HIPRC education campaign was so successful, helmet usage has leveled off. HIPRC officials have publicized the fact that communities with helmet laws achieve higher usage rates than Seattle in less time.

As of March 20, 1997, 15 states and numerous local communities have adopted mandatory helmet laws. Now, states with helmet laws include more than one-third of the U.S. population. California was the first state to pass mandatory helmet laws in January, 1987, followed by New York in October, 1989. The majority of other states and localities instituted helmet laws after 1993.

Helmet laws vary from state to state. These laws cover children ranging in age from under eight (in Rhode Island) to under 18 (in California). Penalties assessed to violators of helmet laws range from verbal warnings only (in Connecticut, Delaware, and Maryland) to fines up to $100 (in New Jersey) for multiple offenses. In addition, some state laws have a contributory negligence provision, while others do not.

Because helmet laws are a fairly recent phenomenon, not enough research has been conducted to determine which states' helmet laws have been the most effective.

According to the Bicycle Safety Institute, helmet laws educate riders and parents as much as they force compliance. One study shows that among census regions of the U.S., those with the highest proportion of states with statewide helmet use laws in 1994 also had the highest proportion of helmet use among children.

Graitcer et al discuss several effects of laws requiring bicycle helmets. They contend that these types of laws would appeal to most people's citizenship obligation by making them feel they should comply "with the law." As with laws requiring child restraints in motor vehicles, the hope is that bicycle helmet laws will change societal norms, making helmets an assumed and natural part of bicycling. Another hoped for effect is that helmet laws will discourage people from giving into negative peer pressure, which many children (and adults) are prone to do.

Despite the weak penalties for breaking bicycle helmet laws and the difficulties in enforcement, as well as the question of whether children growing up with helmet laws will continue to wear helmets into their adulthood, Graitcer et al argue that some type of legislation is necessary to encourage helmet use among children.

This conclusion is supported by a comparison of helmet use in three counties in Maryland: Howard County which passed bicycle helmet legislation, Montgomery County which held bicycle education programs, and Baltimore County which had neither legislation nor educational programs. This study found that helmet use increased most in Howard County (four percent to 47 percent), followed by Montgomery County (eight percent to 19 percent). Helmet usage actually decreased in Baltimore County (19 percent to four percent) where no helmet intervention took place.

In New York, the number of people hospitalized for bicycle-related injuries fell after the introduction of helmet laws. It is very possible, however, that increased helmet use may have resulted, in part, to promotions that took place in New York communities that educated riders and parents about helmet safety.

Oregon was among the first states to pass a law requiring bicyclists under the age of 16 to wear a helmet. A four-part, prelaw and postlaw study was conducted. The study showed that helmet-wearing rates increased after the law passed, to a compliance rate of about 50 percent. Younger children and girls were found to be more likely to use helmets, while older children were less likely to comply with the helmet law and less likely to fear the threat of a fine for breaking the law.

While most students (87.8 percent) and parents (95.4 percent) who were surveyed said they knew about the helmet law, only 42.6 percent of children thought the law was a good idea. This lends support to the argument that legislation is not enough to attain 100 percent compliance. Enhanced enforcement of the law, coupled with a promotional and educational program, is necessary to push helmet-wearing rates even higher.

One consideration in promoting helmet safety is to do so in as cost effective a manner as possible. A team of researchers compared the cost effectiveness of three programs -- legislative (in Howard County, Maryland, where the first U.S. bicycle helmet law passed), community (in Seattle, Washington, where Harborview Hospital formed a coalition to promote helmet use) and school-based (in Oakland County, Michigan involving six schools and targeting 10-14 year olds) -- aimed at increasing bicycle helmet use among children. Overall, the legislative program was deemed most cost efficient, followed by the community program and then the school-based program. This was mainly due to the fact that legislation does not require the purchase of helmets and the labor to implement the program, both of which are part of community and school-based programs. Also, legislation has the quickest effect. In the end, however, researchers emphasize the need for a combination of legislation, community and school-based programs to achieve the best results.

Closing Comments

There is no doubt that helmets can prevent a large majority of head and brain injuries from bicycle and in-line skating accidents. Study after study shows that helmets of any type that meet Snell or ANSI standards, when properly worn, can prevent head injuries from falls and crashes.

The main barrier to helmet use seems to be a lack of awareness of the potential benefits of helmets. Studies have shown that legislation appears to be the most effective when it is coupled with a well-coordinated helmet promotion campaign. So, experts strongly recommend launching educational campaigns targeted at parents, children and pediatricians to teach them about the importance of helmets, in addition to passing legislation mandating helmet use, in order to achieve the highest compliance rate as possible.

This page was last revised for links on: July 1, 2010.

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