Racial/Socioeconomic Disparities| Volume 158, ISSUE 2, P556-561, August 2015

Inequalities in the use of helmets by race and payer status among pediatric cyclists


      Despite nationwide campaigns to increase the use of helmets among pediatric cyclists, many children continue to be injured while riding without a helmet. To determine where programs and policies intended to promote helmet use should be directed, we surveyed a large national dataset to identify variables associated with helmet use.


      The National Trauma Data Bank was queried during the years 2007, 2010, and 2011 for children younger than the age of 16 years who were involved in a bicycle accident. Children were grouped based on whether they had a helmet on during the accident. A multivariable logistic mixed-effects model was utilized to determine factors associated with helmet use.


      Of the 7,678 children included in the analysis, 1,695 (22.1%) were wearing a helmet during their accident. On unadjusted analysis, nonhelmeted riders were more likely to be older (median age 11 years vs 10 years, P < .001), black (10.1% vs 3.7%, P < .001) or insured by Medicaid (32.8% vs 14.3%, P < .001). After adjustment, black children were still less likely to have had worn a helmet compared with white children (adjusted odds ratio 0.38, 95% confidence interval 0.28–0.50). Children on Medicaid were also less likely to have been wearing a helmet compared to children with private insurance (adjusted odds ratio 0.33, 95% confidence interval 0.28–0.39).


      Children who are black or who are on Medicaid are less likely to be wearing a helmet when involved in a bicycle accident than white children or children with private insurance, respectively. Future efforts to promote helmet use should be directed towards these groups.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Egberts J.B.
        • Connaughton D.P.
        • Spengler J.O.
        Bicycle Helmet Statutes: An Analysis of State Legislation.
        Journal of Legal Aspects of Sports. 2013; 23: 36-46
        • Sosin D.M.
        • Sacks J.J.
        • Webb K.W.
        Pediatric head injuries and deaths from bicycling in the United States.
        Pediatrics. 1996; 98: 868-870
        • Rodgers G.B.
        Bicycle helmet use patterns in the United States. A description and analysis of national survey data.
        Accident Anal Prev. 1995; 27: 43-56
        • Chen W.S.
        • Dunn R.Y.
        • Chen A.J.
        • Linakis J.G.
        Epidemiology of nonfatal bicycle injuries presenting to united states emergency departments, 2001–2008.
        Acad Emerg Med. 2013; 20: 570-575
        • Thompson R.S.
        • Rivara F.P.
        • Thompson D.C.
        A case-control study of the effectiveness of bicycle safety helmets.
        N Engl J Med. 1989; 320: 1361-1367
        • Meehan 3rd, W.P.
        • Lee L.K.
        • Fischer C.M.
        • Mannix R.C.
        Bicycle helmet laws are associated with a lower fatality rate from bicycle-motor vehicle collisions.
        J Pediatr. 2013; 163: 726-729
        • Thompson D.C.
        • Rivara F.P.
        • Thompson R.
        Helmets for preventing head and facial injuries in bicyclists.
        Cochrane Database Syst Rev. 2000; : Cd001855
        • Wesson D.E.
        • Stephens D.
        • Lam K.
        • Parsons D.
        • Spence L.
        • Parkin P.C.
        Trends in pediatric and adult bicycling deaths before and after passage of a bicycle helmet law.
        Pediatrics. 2008; 122: 605-610
        • Fife D.
        • Davis J.
        • Tate L.
        • Wells J.K.
        • Mohan D.
        • Williams A.
        Fatal injuries to bicyclists: the experience of Dade County, Florida.
        J Trauma. 1983; 23: 745-755
        • Rodgers G.B.
        Bicycle helmet use patterns among children.
        Pediatrics. 1996; 97: 166-173
        • Macpherson A.
        • Spinks A.
        Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries.
        Cochrane Database Syst Rev. 2008; : Cd005401
        • Macy M.L.
        • Cunningham R.M.
        • Resnicow K.
        • Freed G.L.
        Disparities in age-appropriate child passenger restraint use among children aged 1 to 12 years.
        Pediatrics. 2014; 133: 262-271
        • Schuster M.A.
        • Elliott M.N.
        • Kanouse D.E.
        • et al.
        Racial and ethnic health disparities among fifth-graders in three cities.
        N Engl J Med. 2012; 367: 735-745
        • Sullins V.F.
        • Yaghoubian A.
        • Nguyen J.
        • Kaji A.H.
        • Lee S.L.
        Racial/ethnic and socioeconomic disparities in the use of helmets in children involved in bicycle accidents.
        J Pediatr Surg. 2014; 49 (discussion 1003): 1000-1003
      1. National Trauma Data Bank. Available from: December 20, 2014.

        • Zibung E.
        • Riddez L.
        • Nordenvall C.
        Helmet use in bicycle trauma patients: a population-based study.
        Eur J Trauma Emerg Surg. 2014; ([Epub ahead of print]): 1-5
        • Klein K.S.
        • Thompson D.
        • Scheidt P.C.
        • Overpeck M.D.
        • Gross L.A.
        Factors associated with bicycle helmet use among young adolescents in a multinational sample.
        Injury Prev. 2005; 11: 288-293
        • Karkhaneh M.
        • Rowe B.H.
        • Saunders L.D.
        • Voaklander D.C.
        • Hagel B.E.
        Trends in head injuries associated with mandatory bicycle helmet legislation targeting children and adolescents.
        Accid Anal Prev. 2013; 59: 206-212
        • DiGuiseppi C.G.
        • Rivara F.P.
        • Koepsell T.D.
        • Polissar L.
        Bicycle helmet use by children. Evaluation of a community-wide helmet campaign.
        JAMA. 1989; 262: 2256-2261
        • Bergman A.B.
        • Rivara F.P.
        • Richards D.D.
        • Rogers L.W.
        The Seattle children's bicycle helmet campaign.
        Arch Pediatr Adolesc Med. 1990; 144: 727
      2. Governors Highway Safety Association: The States' Voice on Highway Safety. Helmet Laws. Available from: December 20, 2014.

        • Parkin P.C.
        • Khambalia A.
        • Kmet L.
        • Macarthur C.
        Influence of socioeconomic status on the effectiveness of bicycle helmet legislation for children: a prospective observational study.
        Pediatrics. 2003; 112: e192-196
        • Khambalia A.
        • MacArthur C.
        • Parkin P.C.
        Peer and adult companion helmet use is associated with bicycle helmet use by children.
        Pediatrics. 2005; 116: 939-942