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

Factors associated with mortality of hospitalized road traffic injury patients in 4 low- and middle-income countries

OBJECTIVES

Road traffic injuries (RTIs) are an important public health problem, especially in low- and middle-income countries (LMICs), and are highly preventable with evidence-based interventions. This study aimed to describe the sociodemographic characteristics, risk factors, and patterns of injury that are associated with in-hospital mortality among patients with RTIs.

METHODS

A prospective observational study was conducted at 8 hospitals in Cambodia, Ethiopia, Mexico, and Zambia with adult patients who sustained moderate to severe RTIs and were admitted to participating hospitals for at least 24 h. Bivariate and multivariable logistic regression models were used to examine the association between relevant variables and death in-hospital.

RESULTS

The majority of RTI deaths occurred among males aged 18 to 44 who were pedestrians or riders of 2- or 3-wheeled vehicles. The following variables were associated with in-hospital mortality: Riding a 2- or 3-wheeler (adjusted odds ratio [AOR] 3.30, 95% confidence interval [CI] 1.06-10.23), moderate-severe Glasgow Coma Scale (GCS; AOR 10.27, 95% CI 4.72-22.33), and low systolic blood pressure (AOR 5.97, 95% CI 1.97-18.04).

CONCLUSIONS

The findings reinforce the important role of traumatic brain injury (TBI) in RTI deaths and highlight the need for capacity building to develop local neurosurgery expertise to manage and treat TBI in LMICs. Evidence-based prevention strategies such as lowering speed limits in urban areas, protecting users via dedicated footpaths and cycle paths, and increasing helmet use are recommended to mitigate the impact of RTIs and reduce mortality among vulnerable road users. In addition, triage systems should be in place to identify patients with moderate-severe GCS and low systolic blood pressure for immediate and intensive care.

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Injury as a Result of Children and Adolescent Labor-An Association with Ethnicity and Peripherality: A Retrospective Cohort Study Based on the Israeli Trauma Registry

BACKGROUND

Working children and adolescents face a heightened risk of work-related injuries. This research aimed to assess the rate of hospitalizations resulting from work-related injuries among children and adolescents in Israel, with a specific focus on disadvantaged populations.

METHODS

This nationwide retrospective cohort study utilized The Israeli National Trauma Registry (INTR). It included 642 children and adolescents aged 13-17 hospitalized due to work-related injuries from 2015-2022.

RESULTS

Arab children had over five times the risk of hospitalization due to work-related injuries compared to Jewish (RR = 5.5, 95% CI: 4.7-7.4). Despite the 2018 law prohibiting young people from entering this type of work, the most common type of work leading to hospitalization was construction, accounting for 40.2% of Arab and 11.9% of Jewish injuries (p < 0.001). After adjustment, road traffic accidents and falls presented the highest odds of at least severe injury. Arabs had three times significantly higher odds of at least moderate injury compared to Jews.

CONCLUSIONS

Prioritizing the creation of safe job opportunities for Arab teenagers is imperative. Strict enforcement measures, particularly within the construction industry, especially among Arab youth and during night shifts, are essential. These initiatives should focus on establishing secure and sustainable employment opportunities for children and young individuals, effectively reducing the risks associated with hazardous labor practices. In addition, the implementation of educational programs in the school curriculum covering essential aspects of youth employment is vital.

Estimated prevalence of helmet use while bicycling, rollerblading, and skateboarding among middle school students in selected U.S. States- Youth Behavior Risk Survey, 2013-2019

BACKGROUND

Helmet use helps prevent severe and fatal head and brain injuries from bicycle, rollerblade, and skateboard crashes. This study explores the prevalence of self-reported helmet use among middle school students while bicycling, skateboarding, and rollerblading.

METHODS

Data from the Middle School Youth Risk Behavior Survey (YRBS) for selected states were analyzed. Self-reported prevalence (frequency) of helmet use while bicycling, rollerblading, or skateboarding and other variables (sex, grade level, and race/ethnicity) are reported.

RESULTS

The overall prevalence of rarely or never wearing a helmet while bicycling among middle school students in selected states was 68.6%; decreasing from 71.7% in 2013 to 67.1% in 2019. The overall prevalence of rarely or never wearing a helmet while rollerblading or skateboarding in middle school students in selected states was 74.6%; decreasing from 76.4% in 2013 to 73.5% in 2019. Students in 7th and 8th grade and students of non-Hispanic race/ethnicity had significantly higher odds of rarely or never wearing a helmet while bicycling or while rollerblading and skateboarding than students in 6th grade and non-Hispanic White students.

CONCLUSIONS

While helmet use among middle school students improved over time, overall helmet use during bicycling, rollerblading, and skateboarding remained low. These estimates illustrate the continued call for universal implementation of helmet use efforts among kids using established strategies.

PRACTICAL APPLICATIONS

Future research on helmet use among youth who rollerblade and skateboard, as well as multi-pronged efforts to promote helmet use among middle schoolers who bicycle, skateboard, and rollerblade (inclusive of education, helmet distribution, and social marketing techniques, as well as the provision of helmets at no-cost) may be beneficial for addressing perceived risks for injury and other barriers.

Perceptions, barriers, and strategies regarding helmet use by female pillion riders in Pakistan: A qualitative study

INTRODUCTION

Despite the existence of a national motorcycle helmet law that applies to both riders and pillion riders, the use of helmets among female pillion riders is low in Pakistan. This study aimed to explore perceptions, barriers, and strategies related to helmet use by female pillion riders.

METHODS

Data was collected from nine focus group discussions held with female pillion riders and male riders working at the Aga Khan University. Focus group discussions were transcribed verbatim and checked for accuracy before being imported into NVivo2. Transcriptions were analyzed using a thematic analysis approach.

RESULTS

Four overarching themes emerged, including: (1) motorcycle as mode of transportation, (2) law on helmet use and its enforcement, (3) barriers to helmet use among female pillion riders, and (4) strategies to improve helmet use among female pillion riders. Female participants never wore a helmet or considered wearing it even though "safety" was the most important benefit of helmet usage expressed. The motorcycle is an economical mode of transportation for families, particularly those in the middle and lower socioeconomic groups. Helmet laws are not strictly enforced for pillion riders, including females. Possible barriers to helmet use among female pillion riders included discomfort in wearing a helmet, uninvited attention from others, concerns about physical appearance, and substandard quality and design of helmets. Suggested strategies for implementing helmet use among female pillion riders encompassed awareness generation through media, complementary distribution of helmets, strict law enforcement in the form of fines, and the influence of religious leaders regarding social norms and cultural barriers.

CONCLUSION

Motorcycles are a risky mode of transport, and there are several social and cultural barriers regarding helmet use by female pillion riders. Enforcing helmet laws for female pillion riders, raising awareness about helmet laws, and making helmet use among pillion riders a norm are some essential steps to take to promote helmet use among female pillion riders in Pakistan.

Bicycle Injury Prevention Education Using 360° Virtual Reality Experiences of Accidents and Computer-Based Activity

Injury prevention programs for children and adolescents need to be immersive and interactive. This study assessed a bicycle injury prevention program using technology-based education based on the Activated Health Education model and evaluated its effect on environmental factor awareness and attitude toward helmet-wearing. Using virtual reality technology, elementary and middle school students could experience simulated bicycle accidents. It was followed by an awareness phase that included a 30-min lecture where students self-learned and discussed risk-preventive factors. Students then developed user-created content and customized helmets they were given. We assessed students before the program, immediately afterward, and one month after the program. The number of respondents who said they were aware of surrounding bicycle lanes increased from 75.3% (pre-program) to 92.5% (one month after). Those who said they wore helmets often or always rose from 14.3% (pre-program) to 32.5% (one month later). The number needed to treat helmet-wearing behavior was approximately four, meaning that four people were required to participate in the program to have an impact on one person’s helmet-wearing. We found that virtual reality and computer-based activities can help children and adolescents experience bicycle accidents, be aware of risk factors, and change their behaviors responsibly.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports

Bicycling, snow sports, and other recreational activities and sports are important activities to keep children and youth active as part of a healthy lifestyle. These activities can be associated with serious and fatal head and facial injuries. Helmets, when worn correctly, are effective in decreasing head injuries and fatalities related to these activities. Legislation for helmet use is effective in increasing helmet use in children and, ultimately, in decreasing deaths and head and facial injuries. A multipronged strategy employing legislation, enforcement of laws, and medical clinicians and community programs is important for increasing helmet use to decrease deaths and injuries from recreational sports.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports

Recreational activities and sports are a common and popular way for youth to enjoy physical activity; however, there are risks related to physical injury. Injuries can potentially result in death and long-term disability, especially from traumatic brain injury. Helmet use can significantly decrease the risk of fatal and nonfatal head injury, including severe traumatic brain injury and facial injuries when participating in recreational sports. The most robust evidence of helmet effectiveness has been demonstrated with bicycling and snow sports (eg, skiing, snowboarding). Despite this evidence, helmets are not worn consistently with all recreational sports. A multipronged approach is necessary to increase helmet use by children and youth participating in recreational sports. This approach includes legislation and enforcement, public educational campaigns, child education programs, and anticipatory guidance from clinicians. This policy statement guides clinicians, public health advocates, and policymakers on best practices for increasing helmet use in recreational sports, including bicycling and snow sports.

Bike Helmet Usage in the Most Disadvantaged Neighborhoods: A Focused Area for Trauma Prevention

INTRODUCTION

There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries.

METHODS

Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage.

RESULTS

Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P < 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage.

CONCLUSIONS

Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Road accidents in children involving light electric vehicles cause more severe injuries than other similar vehicles

Road accidents in Israel were responsible for 23% of injuries in pediatric population between 2013 and 2017. In recent years, the massive entrance of e-bike and other light electric vehicles (called collectively LEV) into the roads is significantly changing the epidemiology of road accidents among children. The study aims to describe the causes, injury types, and other epidemiological characteristics of children injured in road accident and compare injuries of LEV to regular bicycles and other light non-electric vehicles (called collectively LNEV). This retrospective study included all referrals to pediatric emergency department due to road accidents, from April 2015 through March 2017. The details of the accidents and injuries were retrieved, and the subjects' characteristics were compared based on vehicle type. A total of 1531 children met the inclusion criteria. The study found that LEV road accidents among children cause more severe injuries than other LNEV in terms of injury severity score (ISS) (mean ISS 5.8 ± 4.9 vs. 4.7 ± 3.6, P = 0.001), head and neck injuries (18.7% vs. 12.9%, respectively, P < 0.05), lower extremities (36.5% vs. 23.9%, P = 0.001), and multisystem injuries (58.6% vs. 31.8%, P < 0.001). The findings of the current study suggest that the use of LEVs is changing the epidemiology of road accidents, which requires adjustments in accident and injury prevention strategies.Conclusion: The study results should encourage authorities to provide appropriate community-based programs to promote helmet use, introduce mandatory training and licensing program for LEV riders, and enhance enforcement. What is Known: • Road accidents are the leading cause of death among children and young adults (5 to 29 years). • In recent years, there is a massive entrance of e-bikes and other light electric vehicles on the roads. What is New: • LEV (light electric vehicle) accidents among children impose more severe injuries than other LNEVs (light non-electric vehicles) in terms of ISS, hospitalizations, and multisystem injuries. • The use of LEV is changing the epidemiology of road accidents. This change requires enhancing accident and injury prevention strategies.

The Association of Payer Status and Injury Patterns in Pediatric Bicycle Injuries

BACKGROUND

Bicycle injuries continue to cause significant morbidity in the United States. How insurance status affects outcomes in children with bicycle injuries has not been defined. We hypothesized that payer status would not impact injury patterns or outcomes in pediatric bicycle-related accidents.

METHODS

The National Trauma Data Bank was used to identify pediatric (≤18 y) patients involved in bicycle-related crashes admitted in year 2016. Patients with private insurance were compared with all others (uninsured, Medicaid, and Medicare).

RESULTS

There were 5619 patients that met study criteria. Of these, 2500 (44%) had private insurance. Privately insured were older (12 y versus 11, P < 0.001), more likely to be white (77% versus 56%, P < 0.001), and more likely to wear a helmet (26% versus 9%, P < 0.001). On multivariate analysis, factors associated with traumatic brain injury included age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.06-1.08; P < 0.001) and helmet use (OR, 0.64; 95% CI, 0.55-0.74; P < 0.001). Patients without private insurance were significantly less likely to wear a helmet (OR, 0.52; 95% CI, 0.44-0.63; P < 0.001). Uninsured patients had significantly higher odds of a fatal injury (OR, 4.43; 95% CI, 1.52-12.92; P = 0.006).

CONCLUSIONS

Uninsured children that present to a trauma center after a bicycle accident are more likely to die. Although helmet use reduced the odds of traumatic brain injury, minorities and children without private insurance were less likely to be helmeted. Public health interventions should increase helmet access to children without private insurance, especially uninsured children.

Bike helmets prevent pediatric head injury in serious bicycle crashes with motor vehicles

BACKGROUND

Approximately 75% of all bicycle-related mortality is secondary to head injuries, 85% of which could have been prevented by wearing a bicycle helmet. Younger children appear to be at greater risk than adults, yet helmet use is low despite this risk and legislation and ordinances requiring helmet use among younger riders. We sought to determine whether bicycle helmets are associated with the incidence and severity of head injury among pediatric bicyclists involved in a bicycle crash involving a motor vehicle.

METHODS

We performed a retrospective review of patients age ≤ 18 years hospitalized at a level I pediatric trauma center between January 1, 2008, and December 31, 2018. Data were abstracted from the institutional trauma registry and electronic medical record. International Classification of Diseases 9th and 10th editions and external causes of injury codes were used to identify MV related bicycle crashes and determine the abbreviated injury severity (AIS) for head injury severity. Injury narratives were reviewed to determine helmet use. We calculated the incidence of head injury from bicycle vs. MV crashes utilizing descriptive statistics. We analyzed the risk and severity of injury utilizing univariate and multivariate logistic regression.

RESULTS

Overall, 226 bicyclists were treated for injuries from being struck by a MV. The median age was 11 (interquartile range (IQR): 8 to 13) years. Helmeted bicyclists (n = 26, 27%) were younger (9.4 years versus 10.8 years, p = 0.04), and were less likely (OR 0.21, 95% CI 0.09 to 0.49) to be diagnosed with a head injury compared to unhelmeted bicyclists (n = 199). Of those with a head injury, helmeted bicyclists were less likely (OR 0.57, 95% CI 0.11-2.82) to sustain severe or higher injury using AIS. When adjusting for demographics (age, sex, race) and injury severity, helmet use predicted a reduction in head injury (OR 6.02, 95% CI 2.4-15.2).

CONCLUSIONS

Bicycle helmet use was associated with reduced odds of head injury and severity of injury.. These results support the use of strategies to increase the uptake of bicycle helmets wearing as part of a comprehensive youth bicycling injury prevention program.

The Injuries and Helmet Use in Bike Share Programs: A Systematic Review

To investigate the injury effects of bike share programs and the helmet usage status in bike share programs. We conducted a systematic review of peer reviewed scientific literature. Searches were conducted in three databases (Pubmed, Scopus, and Web of Science) on March 1 2020 to identify all articles on the injury incidence related to bike share programs and the helmet usage status in bike share programs. Titles, abstracts, and full-text articles were screened to identify all articles relevant to the themes by two authors independently, and discrepancies were resolved after discussion with the third author. Standardised data extraction and quality assessment (The Newcastle-Ottawa Scale) were implemented. A sum of 491 records after removing duplicates was identified, 181 fulltext articles were screened, and 13 studies were included in the review. The primary outcome are injuries of bike share users and unhelmeted rate among bike share users as well as the unhelmeted rate among personal bike users. Two studies evaluated the injuries related to bike share users, but have inconclusive results. A total of 11 studies reported the unhelmeted rates in bike share programs ranging from 36.0 to 88.9%. There is a significant change in bike injuries with the implementation of bike share programs. Moreover, the unhelmeted rate of bike share users was generally higher than that of personal bike users, which may result from helmets' accessibility and users' safety perception.

Primary prevention of road traffic accident-related traumatic brain injuries in younger populations: a systematic review of helmet legislation

OBJECTIVE

Road traffic accidents are the most frequent cause of severe traumatic brain injury (TBI), particularly among young populations worldwide. Helmets are proven to prevent injuries; however, estimates of helmet compliance are low globally. Surgical/critical care management of TBI is often used to treat these injuries, but primary prevention should be recommended. A key component in promoting TBI prevention among pediatric and young populations is through helmet legislation. The authors investigated helmet policies for motorcycles and bicycles globally to provide recommendations for how related legislation may impact TBI and guide advocacy in pediatric neurosurgery.

METHODS

The authors conducted a systematic review of helmet laws and/or policies by using the National Library of Medicine PubMed and SCOPUS databases. Additional articles were identified using citation searches of key publications. Abstracts from articles of all sources were read and selected for full-text review. Details of relevant full articles were extracted and analyzed for the following: bibliographic data, study aim, design and duration, study participants, intervention characteristics, and intervention effect data.

RESULTS

Of 618 search results, 53 full-text articles were analyzed for recommendations. Helmet legislation is associated with increased helmet use among bicyclists and decreased road traffic accident-related head injuries and fatalities among motorcyclists and bicyclists. Laws are more effective if comprehensive and inclusive of the following: both primary riders and passengers, all age groups, all modes of transportation made safer by helmets, a proper use clause, and standardized helmet quality measures. Cultural, socioeconomic, and infrastructural circumstances are important as well, and legislation must consider enforcement mechanisms with penalties significant enough to incentivize behavioral changes, but proportional to community socioeconomic status.

CONCLUSIONS

Compulsory use laws are the optimal primary intervention; however, concurrent programs to support financial access to helmets, change cultural attitudes, increase health literacy, and improve road infrastructure will augment legislative benefits. Pediatric neurosurgeons are caretakers of children suffering from TBI. Although extensive study has explored the surgical management of TBI, the authors believe that primary prevention is instrumental to improving outcomes and reducing injury. All helmet laws are not equal; based on these findings, a comprehensive, context-specific approach is the key to success, especially in resource-limited countries.

Free-Floating Bikeshare and Helmet Use in Seattle, WA

Wearing a helmet when bicycling prevents traumatic brain injury in the event of a crash. Most cyclists nationwide use helmets when riding. However, the growth of free-floating bike sharing systems, which offer short-term access to bicycles but not helmets, may erode helmet-wearing norms among cyclists. We counted cyclists over several hours at four locations in Seattle, WA. We categorized each rider according to whether he or she was wearing a helmet and to whether or not he or she was riding a bike share bike. Whereas 91% of riders of private bikes wore helmets, only 20% of bike share riders wore helmets. Moreover, in locations where a greater proportion of riders were on bikes hare bikes, fewer riders of private bicycles wore helmets (r = - 0.96, p = 0.04). The impact of bike sharing programs on helmet wearing norms among private bike riders warrants further exploration.

The impact of bicycle helmet legislation on cycling fatalities in Australia

Background

Australian bicycle helmet laws were first introduced in Victoria in July 1990 and the remaining Australian states, Australian Capital Territory and Northern Territory by July 1992. Previous research on helmet legislation has focused on changes in helmet wearing and bicycle-related head injury. Although it is generally accepted that bicycle helmets can reduce the risk of fatality due to head injury, there has been little research assessing the impact of helmet legislation on cycling fatalities.

Methods

An interrupted time series approach was used to assess the impact of bicycle helmet legislation on yearly-aggregated rates of bicycle-related fatalities per population from 1971 to 2016.

Results

Immediately following bicycle helmet legislation, the rate of bicycle fatalities per 1 000 000 population reduced by 46% relative to the pre-legislation trend [95% confidence interval (CI): 31, 58]. For the period 1990–2016, we estimate 1332 fewer cycling fatalities (95% CI: 1201, 1463) or an average of 49.4 per year (95% CI: 44.5, 54.2). Reductions were also observed for pedestrian fatalities; however, bicycle fatalities declined by 36% relative to pedestrian fatalities (95% CI: 12, 54).

Conclusions

In the absence of robust evidence showing a decline in cycling exposure following helmet legislation or other confounding factors, the reduction in Australian bicycle-related fatality appears to be primarily due to increased helmet use and not other factors.

Bicycle Helmets save More than Heads: Experience from a Pediatric Level I Trauma Hospital

We studied pediatric bicycle accident victims (age ≤ 15 years) who were treated at our pediatric Level I trauma center during a 10-year period. Demographic data, injury severity, hospital course, and hospital cost data were collected. We compared the children who were helmeted to those who were unhelmeted. Our study cohort consisted of 516 patients. Patients were mostly male (70.2%) and white (84.7%); the median age was nine years. There were 101 children in the helmet group and 415 children in the unhelmeted group. Helmeted children were more likely to have private insurance (68.3% vs 35.9%, P < 0.001). Unhelmeted children were more likely to sustain multiple injuries (40% vs 25.7%, P = 0.008), meet our trauma activation criteria (45.5% vs 16.8%, P < 0.001), and be admitted to the hospital (42.4% vs 14.9%, P < 0.001). Helmeted children were less likely to sustain brain injuries (15.8% vs 25.8%, P = 0.037), skull fractures (1% vs 10.8%, P = 0.001), and facial fractures (1% vs 6%, P = 0.040). Median hospital costs were more expensive in the unhelmeted group. Helmet usage was suboptimal. Although most children sustained relatively minor injuries, the unhelmeted children had more injuries and higher costs than those who used helmets. Injury prevention programs are warranted.