Helmet Safety Overview
Prudential Paper on Helmet Safety
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 It is out of date now, but still has a useful overview.
According to the U.S. Consumer Product Safety Commission (CPSC),
67 million Americans bicycle and 22.5 million in-line skate.
Each year, hundreds of thousands of people visit the hospital
emergency room for injuries sustained during these activities.
Emergency room visits for in-line skating injuries annually numbered
about 100,000 in 1995 and for bicycle-related injuries more than
500,000. Experts agree that these figures may be underestimates
of the true number of injuries, since many are believed to go
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
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.
A study conducted with parents and with children aged five to
14 who own bicycles showed that helmet ownership by children was
significantly (p<.05) related to parental characteristics:
educational level, race, perceived effectiveness of bicycle helmets,
seat belt use and parental helmet ownership. Specifically, the
incidence of helmet ownership was significantly higher in families
in which the parent had a college or postgraduate degree (p<.001),
was Caucasian (p<.05), reported always using seat belts (p<.01),
owned a bicycle helmet (p<.001), and perceived helmets as effective
for preventing head injury (p<.05).
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
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
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
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
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
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
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
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
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
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
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
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
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.
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.
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.
Note: At the time this paper was published, Prudential HealthCare had a program in cooperation with Troxel to sell low cost helmets.
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