Bicycle Injuries and Safety Helmets in Children Review of Research Sherrilyn Coffman Bicycle injuries are the most common cause of serious head injury in children, and most of these injuries are preventable, The protective effect of bicycle helmets is well documented, but many child bicyclists do not wear them. This article summarizes the current state of research on bicycle injuries and helmet use and examines the effective- ness of legislation and injury-prevention strategies, Current studies indicate that children who wear helmets experience fewer head injuries and decreased severity of injury. Community-wide helmet-pro- motion campaigns combined with legislation are most successful in increasing helmet use and decreasing injury. Nurses can participate both at the institutional level and in community advocacy groups to promote bicycle safety for children. tional, are the leading cause of death among children between the ages of 1 and 19 years. Although unin- tentional injury deaths have declined by more than 40% during the past ‘two decades, rates of childhood injury deaths in the United States are still much higher than comparable rates in other developed countries (Deal, Gomby, Zippiroli, & Behrman, 2000). ay both violent and uninten- ‘Shervilyn Coffinan, DNS, RN, CPN, Asso- ciate Professor, Nevada State University, Henderson, NV. Nations and regions achieving the greatest success in childhood injury prevention have developed long-term ‘comprehensive approaches that focus ‘on widespread community change. Bicycle Injuries in Children Unintentional injuries related to bicy- dle collisions have received a great deal of attention because of the pro- tective effect of safety helmets. Bicycle injuries account for 10% of all pedi- atric traumatic deaths. In the United States in 1998, 203 children ages 14 years and under died in_bicycle- related crashes (National Safe Kids Campaign, 2002). Although boys in Orthopaedic Nursing - January/February 2008 - Volume 22 » Number 1 the 5- to 14-year-old age group have the highest incidence of bicycle- related injuries, young children are also commonly injured (Powell & Tanz, 2000). USS. statistics on bicycle injuries have shown that 76% of head injuries and 41% of deaths from head injury occurred among children younger than 15 years of age (Sacks, Holmgren, Smith, & Sosin, 1991). Bicycle crashes are the most common ‘cause of serious head injury in chil dren (Weiss, 1994). Head injury has long been recog- nized as the most important cause of bicycle-related mortality and perma- nent disability. Child cyclists are at greater risk than adults for head injuries, and younger children. are especially vulnerable. Approximately half of all bicycle-related injuries among children under age 10 years ‘occur to the head or face, compared with one fifth among older children (National Safe Kids Campaign, 2002), Other types of injuries are less com- mon but can result in significant morbidity. A study at one level Il pediatric trauma center revealed that among 211 trauma alert patients suf- fering bicycle injuries, 47% had doc- umented head injuries, 86% major or minor wounds, 29% fractures, and 9% damage to internal organs (Puranik, Long & Coffman, 1998), Injured children continue to show low use of bicycle helmets, 9despite the evidence that helmets pre- vent serious injury and even death. In a review of controlled studies, researchers determined that helmets provide 2 68% to 88% reduction in the risk of head, brain, and severe brain injury for all ages of bicyclists (Thompson, Rivara & Thompson, 2000). Kopjar (2000) estimated that 133 out of 210 bicycle head injuries in Norway could have been avoided if all children ages 14 years and younger had worn helmets. Even when chil- dren wear helmets, the helmets may not fit properly, Comparing head and helmet measurements, Rivara and col- leagues (1999) found that individuals whose helmets fit poorly had a 1.96- fold increased risk of head injury. Current Rates of Helmet Use Although the rate of bicycle helmet use is increasing among children, most areas of the United States have not achieved the goal of Healthy People 2000, that 50% of bicyclists will wear safety helmets. A national parent sur- vey conducted in 1995 estimated that children’s rates of always wearing a helmet ranged from 9.3% in. Miss sippi to 62.8% in Oregon (median state level = 23.1%) (Bolen, Sacks, & Bland, 1999). A national survey among U.S. high school students showed a small but statistically signifi- cant increase from 1.1% in 1991 to 3.8% in 1997 (Everett, Shults, Barrios, Sacks, Lowry, & Oeltmann, 2001). ‘These studies included self-report sur- vey data, which may have been inflated. In general, researchers have found that parents overestimate hel- met use in their children (Ehrlich, Longhi, Vaughan, & Rockwell, 2001). No observational study of helmet use thas been conducted at a national level. Several factors are positively asso- ciated with bicycle helmet use in chi dren: (a) legislation mandating hel- met use (Bolen et al., 1999), (b) strict enforcement of legislation (Gilchrist, Schieber, Leadbetter, & Davidson, 2000), (c) urban environment (Harlos, Wards, Buchan, Klassen, Koopp, & Moffatt, 1999), (@) higher income (Harlos et al,, 1999), (e) younger age (Finoff, Laskowski, Altman, & Diehl, 2001), (f strict parent rules about hel- met use (Miller, Binns, & Christoffel, 1996), (g) having friends and siblings who wear helmets (Finoffet al, 2001), 10 (h) support from teachers (McLellan, Rissel, Donnelly, & Bauman, 1999), and () injury prevention counseling (Quinlan, Sacks, & Kresnow, 1998). Research-documented barriers to helmet use have remained relatively consistent over time: (a) lack of peer support (Liller, Morissette, Noland, & McDermott, 1998), (b) discomfort caused by helmets (Loubeau, 2000), (© poor role modeling by parents and other adults (Twomey, Bevis, & McGibbon, 2001), (d) negative parent pressure (Hendrickson, Becker, & ‘Compton, 1997), and (e) helmet cost (Harlos et al,, 1999) Approaches to Prevention of Bicycle Injuries Injury-prevention approaches have been described in terms of the three E's: engineering, education, and enforcement. Engineering Engineering attempts to control the conditions and reduce the hazards to which bicyclists are exposed. Bicycle design (including wheel size, type of handlebars, and positioning of gear levers), as well as road design (lane widths, roadway surfaces, and traffic signs), has a significant effect on bicy- cle safety (Widner-Kolberg, 1991). The National Strategies for Advancing Bicy- le Safety is a set of goals and action plans that address several issues related to engineering. Key goals include: (a) ‘motorists will share the road with bicy- clists, (b) bicyclists will ride safely, (©) bicyclists will wear helmets, (@) the legal system will support safe bicycling, and (@) roads and paths will safely accommodate bicyclists. These strate- ages are listed in the Bicycle Helmet Safety Institute Web site (see Table 1), In 1999, the U.S. Consumer Prod- uct Safety Commission developed a comprehensive standard for bicycle helmets. The bicycle helmet standard requires that all helmet designs be tested for peripheral vision, positional stability, and impact quality. Helmets for children 1 to 4 years old must be specially designed with additional head coverage. With each new helmet must come fitting instructions, care instructions, and what to do if a hel met is damaged. This standard is dis- played on the National Safe Kids Cam- paign Web site (sce Table 1) Education Educational programs attempt to influence behavior through increased knowledge, skill, and awareness, Community helmet-incentive cam- paigns, bicycle rodeos, and school or community safety courses are exam- ples of educational offerings. Research shows that for children age 12. years and younger, most_bicycle-automo- bile collisions are the result of rider error, due to lack of skills and experi- ence rather than bicycle defects or ‘motorist error (Spence, Dykes, Bohn, & Wesson, 1993). Therefore, bicycle safety workshops or “rodeos” are important to teach children bicycling guidelines and safety measures and to vita) Cre a2a.org bhsi.org, bikefed org bikeleague.org cede.govincipe National Center for Injury Prevention & Cor COROT, Organization ‘American Academy of Pediatrics ‘American Automobile Association Bicycle Helmet Safety Insitute National Center for Bicycling & Walking League of American Bieyclists (Centers for Disease Control and Prevention) safekids.org National Safe Kids Campaign Orthopaedic Nursing ~ January/February 2003 ~ Volume 22 + Number 1promote use of helmets (Hart & Daughtridge, 1998). Many programs include helmet incentives by offering helmets at significant discounts, Individual-level_ injury-prevention strategies occur in the clinical setting where pediatric providers counsel chil dren and parents on bicycle safety. Interventions include information, persuasion, accessibility to. resources, and reinforcement of positive behav- iors, Research that evaluates the effect of individual counseling has failed to show that counseling alone increases bicycle helmet ownership. However, studies in which individual counseling is one component of a broader com- munity-based. educational. interven- tion have demonstrated successful out comes (DiGuiseppi & Roberts, 2000). Although education is necessary, it is not sufficient to promote safety and prevent injury. Enforcement Enforcement is implemented in the form of helmet legislation. Most laws mandate helmet use for child bicy- lists only. By 2001, 17 states, the Dis- trict of Columbia, and numerous localities in the United States had passed bicycle helmet legislation for children (see Table 2). Internationally, several countries, including New Zealand and Australia, have passed leg- islation. Several advocacy groups have supported helmet legislation, includ- ing the Safe Kids Coalition, League of Ametican Bicyclists, and Bicycle Hel- ‘met Safety Institute (see Table 1). ‘The research data clearly indicate that legislation is the most cost-effec- tive method to increase bicycle hel- met use. Despite an increase in the umber of states passing helmet laws, 44 of the 50 states in the United States had not met the Healthy People 2000 goal of 50% helmet use in 1995 (Bolen et al, 1995). More recent data have demonstrated a decrease in the sever- ity and incidence of head injuries after the passage of helmet legislation. Effectiveness of Approaches Community-based injury-prevention interventions that include strategies from all three areas, engineering, edu- cation, and enforcement, have demonstrated both increased helmet use and decreased bicycle injuries, Controlled research studies have repeatedly proved the effectiveness of ‘multifaceted approaches to injury pre- uray See ee enn rc ‘State Date Passed ‘labama 1995 California 1993 Connecticut 1995 Disrict of Columbia 200 Delaware 1996 Florida 1996 Georgia 1993, Havall 2001 louisiana 2001 Massachusetts 1994 Maryland 1995 Maine 1999 Nor Carotina 2001 New Jersey 192 New York 1994 Oregon 1994) Pennsylvania 1994) Rhode Island 1996 Source: National SAFE KIDS Campaign (1/19/2002), Available at hupuwww-safekids.onp/CSL_ list, vention (Klassen, MacKay, Moher, Walker, & Jones, 2000). Such wide- spread. efforts change community norms and behaviors and alter the physical environment of communities to reduce the risk of injury. These approaches have particular relevance to children, because efforts target the safety awareness, attitudes, and behav- iors of both children and parents. As families set rules and standards for hel- ‘met use, children are more likely to wear helmets when riding. Among older children, compliance with hel- met legislation helps to alter peer pres- sure and promote acceptance of new behaviors. As studies in diverse com- munities show, different interventions Orthopaedic Nursing ~ January/February 2008 — Volume 22 » Number 1 may be required for different popula- tions (Klassen et al, 2000). Summary of Research ‘The author conducted a literature search of bicycle injury-prevention studies published between 1995 and 2001, The search was built upon an earlier integrative review article (Coff- ‘man, 1996). MEDLINE and CINAHL databases were searched for research measuring the outcomes of bicycle safety interventions. A total of 18 stud- ies were found. Most of the earlier stud- jes measured helmet wearing rates as outcomes. As more states passed hel- ‘met legislation, recent studies have also ‘measured injuries as outcomes of inter- ventions. Therefore, studies are orga- nized according to these two different outcomes. Table 3 includes studies measuring helmet use as an outcome of interventions. Table 4 summarizes studies measuring injuries rate and severity of inj ‘Studies Measuring Helmet Use Current research has documented ‘modest gains in the rate of bieycle hel- ‘met use, with the greatest gains found in younger children, as compared to adolescents (Mosiman, Thimmesch, Martin, & Greitigan, 1995), Both sur- vey and observational studies docu- mented increased helmet use after widespread community campaigns (Lee, Mann, & Taktiti, 1997; Mock, Maier, Boyle, Pilcher, & Rivara, 1995), Single isolated interventions had lim- ited or no effect (Kim, Rivara & Koepsell, 1997; Tenn & Dewis, 1996). Furthermore, the effectiveness of limited interventions tended to decrease over time (Seijts, Kok, Bouter, & Klip, 1995). Legislative programs were found to be most cost effective (Fatziandreu et al, 1995; Shafi et al., 1998). Laws that were more compre- hensive or more strictly enforced resulted in increased helmetwearing rates (Puder, Visintainer, Spitzer, & Casal, 1999). ‘Studies Measuring Bicycle- Related Injuries The first highly publicized community campaign to decrease injury rates was in Victoria, Australia (Cameron, Vul- can, Finch, & Newstead, 1994). One year after legislation became effective, the number of cyclists killed or hospi- talized with head injuries decreased by "1Poa] ‘Study Author/Date Intervention ‘Outcomes Related to Helmet Use Borgland, Hayes, & Eckes, 1999 Community helmet-promotion program Helmet use of injured children increased from and passage of Florida legislation 5.6% to 20.8% after legislation passed Brit, Silver, & Rivera, 1998 ‘Community helmet-promotion program in Helmet use increased in intervention group from ‘Washington State 43% to 89% and in control group ftom 42% to 60%. Caplow & Runyan 1995 Community bicycle helmet ordinance Increase in wearing rates: a) 70% of children who in Chapel Hill, NC “never” wore helmets increased to “sometime,” {b) 44% who “Sometime” wore helmet increased to “al of time” FloerchingerFranks et al, 2000 School-based helmet-promotion programs Increase in helmet use in 35 schools from 1997 to with financial incentives 1998 Gilchrist eta, 2000 Georgia legislation with active police Helmet use increased from 0% to 45% at 5 months eniorcement, education, and free helmets afer legislation and to 54% at 2 years after legislation Hatziandreu etal, 1995 ‘Comparison of legislation, community Helmet use increased as follows: legislative program ‘education, and school-based program from 4 to 47%, community program from 5% to 33%, and school program from 2% to 8%. Based on program costs, the legislative program is most cost lective. kim, Rivara, & Koepsell, 1997 Helmet education and subsidy n six public 82% of intervention group and 76% of control group health clinics. Intervention group paid small reported consistent helmet use in the 2 to 3 weeks co-pay for helmet; control group received ater the intervention. free helmet. Lee, Mann, & Takrta, 2000 Hospital led bicycle helmet-promotion Helmet use among 11 to 15 year olds increased from campaign 11% to 31% after 5 years, with no change in control ‘group. Lilleret at, 1995 School subsidy and educational campaign Helmet use increased ftom 8.5% to 21% in the 2 to 3 weeks after program. This was three times greater than in the control schools Mock et al, 195 Seattle, Washington, bicycle helmet campaign Helmet use rose from 5% in 1987 t0 62% in 1998. Mosiman etal, 1995 Helmet subsidy program: 1,500 helmets CCilden less than 10 years old reported a significant were sold for $13 each increase in helmet use. Parkin et a, 1995 School subsidy and educational program Helmet use increased from 4% to 18% in intervention group and from 3% to 19% in control ‘group 2 yeas aftr intervention (nonsignificant difference) Puder eta, 1999 ‘Comparison of three different bicycle helmet Helmet use ranged from 14% to 35% with higher laws in three New York City suburbs use in the county with the most comprehensive la. Sets etal, 1995 Helmet incentive campaign with free 21% reported always wearing a helmet 6 weeks after helmet distribution intervention; 3% reported consistent helmet use 3:months after intervention, Shafi et al, 198 ‘New York slate legislation, community Helmet use increased from 2% with education alone eduction, and helmet distribution 10 26% after legislation Tenn et al, 1996 School-based safety education by peers No significant change in self-report of risk-taking and health professionals ‘behavior. 12 Orthopaedic Nursing - January/February 2003 - Volume 22 + Number 1e082 Pvitey) Bee Raced Author/Date Intervention | ‘Outcomes Related to Injury Borgland, Hayes, & Fikes, 1999 Ekman, 197 Community helmet-promotion program and passage of Florida legislation ‘School-based education, publiciparent education, economic incentives Helmeted children had lower injury severity scores than nonhelmeted children, 3.1% decrease in injuries that led to inpatient care in intervention group; 1.1% to 3.4% decrease in these in control groups Lee, Mann, & Takrita, 2000 Hospital led bicycle helmet-promotion ‘campaign Head injuries decreased from 21 bicycle injuries. 1% to 11.7% of all Mock et al., 1995 Seaitle, Washington, bicycle helmet ‘campaign Severe head injuries decreased from 29% of all bicycle crash admissions in 1986 10 11% in 1993. Scuftham etal, 2000 Shafi etal, 1998, Helmet-wearing law in New Zealand New York state legislation, community 19% reduction in head injury to bicyclists of all ages during first 3 years after law passed Proportion of head injuries was similar but severity of eduction, and helmet distribution 51%, Since the passage of legislation in several U.S. states between 1992. and 1996, researchers have focused more on. rates and severity of injury in the United States as study outcomes. Many of these studies draw from trauma cen- ter data and make comparisons before and. after passage of legislation, Researchers have documented reduc- tions in head injuries (Lee et al., 2000; Scuffham, Alsop, Cryer, & Langley, 2000), decreased inpatient admissions (Ekman, Schelp, Welander, & Svan- strom, 1997; Shafi et al., 1998), and lower injury-severity scores in helmeted children. (Borghind, Hayes, & Eckes, 1999) after legislation took effect. Implications for Nursing Nurses are in key positions to imple- ment strategies for injury prevention among children and families. Nurses encounter children and parents in a variety of settings, including inpatient units, outpatient clinics, emergency departments, schools, managed care organizations, and community organi- zations. In each setting, nurses can find opportunities to share informa- tion about helmets and bicycle safety. Fach setting provides unique opportu nities for educational and motiva- tional strategies. Clinical implications Nurses who work in hospitals, emer- gency departments, and urgent care facilities often encounter children who have experienced bicycle injuries. This is a time when parents and children ‘may be especially sensitive to informa- tion about safety helmets and injury- prevention behaviors. Individual counseling can be enhanced within the framework of a total injury-pre- vention program. An example is the Safety Helmet Discharge Plan devel- oped by one community hospital (Puranik et al, 1998). Children and parents were given a video to view, a packet of educational materials to take home, and a complimentary safety helmet ifa child did not have one. Fol- low-up telephone calls helped to rein- force information after discharge Nurses in ambulatory care cli outpatient case management settings, and other community-based agencies have opportunities to do well-child counseling and education. Many guidelines for teaching are available (See organizations listed in Table 1) including the American Academy of Pediatric guidelines (1995): 1. All bicyclists should wear properly fitted bicycle helmets each time they ri 2. Young children who ride as passen- gets must wear an appropriately sized helmet and be placed securely in a bicycle-mounted child seat or bicycle-towed child trailer. 3. Helmets involved in a crash or damaged in any way should be dis- carded and replaced. ‘Orthopaedic Nursing - January/February 2003 ~ Volume 22 » Number 1 injury decreased afer legislation 4, Parents and children should learn all aspects of bicycle safety. As much as. possible, nurses should address all aspects of safety promotion, including risks of injury, protective value of helmets, local hel- ‘met legislation, cost and resource information on purchasing a helmet, and the need for parent rules. They should encourage parents to establish firm rules to require children to wear bicycle helmets when they begin rid- ing tricycles and then bicycles. Par- ents should be encouraged to wear helmets when bicycling to model safe behavior for their children, School nurses can ensure that school districts promote use of safety helmets by students who ride bicycles to and from school. They should examine the curriculum on injury pre- vention and participate in teaching children when appropriate. Interactive hands-on programs are most effective, such as bicycle rodeos, and are often jointly sponsored by schools and park and recreation departments (Hart & Daughtridge, 1998). The entire peer culture needs to be addressed, espe- ally at the middle school and high school level, to change the image of helmet-wearing. Educational _pro- ‘grams can emphasize physical fitness and sportsmanship and promote pro- fessional cyclists as role models. To be effective, nurses’ efforts must extend beyond single institutions to involvement in community-wide 13campaigns. Nurses can serve as com- munity advocates to encourage pas- sage of legislation and enforcement of helmet laws. Several advocacy groups have developed model legislation, which is available on the Internet for reference (see Table 1). Nurses can join with parents, other health profession- als, and community leaders to develop and support community-based cam- paigns, such as the Safe Kids Coalition (Coffman & Kuniansky, 1997) Research Needed Nurse researchers can be part of research teams that conduct rigorous trials of widespread community inter vention strategies. These research find: ings must be translated into effective injury-prevention programs. Within the context of community-wide efforts, smaller studies can also be helpful, especially at the local level. Epidemio- logic studies that describe bicycle injuries and helmet use in a specific location can provide baseline data for local intervention projects and research, (Puranik et al., 1998). Qualitative stud- ies can explore parents’ strategies to enforce bicycle helmet use in their chil dren, such as the study by Hendrickson, Becker, and Compton (1997). Nurse researchers who have access to trauma center data can conduct prospective or retrospective research to better describe the pattems of injury and needs of chil- dren in their community 14 Conclusion Promotion of bicycle safety for chil- dren is a responsibility of every com- munity member. Nurses are key indi- viduals because of their exposure to injured children and their work in wwell-child settings. Nurses have access to the total picture of injury, including injury severity and the potential for prevention Research has shown that wide- spread community-promotion cam- paigns combined with legislation have the greatest effect on increasing bicycle helmet use and decreasing injuries. As educators, clinicians, and researchers, nurses can examine these research findings and apply them in their prac- tice. Each individual effort contributes to the larger goal of bicycle safety and injury prevention References American Academy of Pediatrics. (199). 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