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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Moving Targets: Bicycle-Related Injuries and Helmet Use among University Students a
Lynne Fullerton BS & Thomas Becker Md, PhD a
b
Department of Anthropology , University of New Mexico , Albuquerque, USA
b
University of New Mexico School of Medicine , USA Published online: 09 Jul 2010.
To cite this article: Lynne Fullerton BS & Thomas Becker Md, PhD (1991) Moving Targets: Bicycle-Related Injuries and Helmet Use among University Students, Journal of American College Health, 39:5, 213-217, DOI: 10.1080/07448481.1991.9936237 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936237
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Moving Targets: BicycleRelatd Injuries and Helmet Use Among Univers'ity Students
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LYNNE FULLERTON, BS, and THOMAS BECKER, MD, PhD
We conducted a cross-sectional study to evaluate bicycling habits and helmet use in a sample of universii students in a southwestern state university. Thirty-one of 100 students in our sample owned bicycle helmds; of these, 17 (54.8%) wore helmets during most (more than three fourths) of their bicycle trips. Almost half of the students reported that more than 25% of their bicycling was done in heavy traffic but they rarely used bicycle trails. Sixty-fiw students in the sample had sustained at least one minor injury during the previous 5 years, and 18 had been hospitalized as a result of bicyck-dated injuries. We found no substantial differences between male and female subjects in bicycle-dated hospitalizations, although male subjects were more likely to sustain minor injuries than were females. Helmet ownership was most strongly associated with previous injury experience, especially hospitalization resulting from bicycling injuries (OR = 3.6 95% CI = 1.3,lO.l). We also observed an association between helmet ownership and possession of insurance cowage for b i d i n g injuries (OR = 3.0; 95% CI I 1.2, 7.6). Ethnicii was a factor in helmet ownershiphelmets were owned by 26 of 69 (37.7%)of non-Hispanic whites, in contrast to 1 of 24 (4.2%) of all other enthic groups combined. Our survey data s u m that perceived risk is an important factor in bicyclists' use of safety helmets.
Every year, bicyclists in the United States are involved in incidents that lead to both fatal and nonfatal injuries. Fifteen hundred to 1,600 bicyclists die annually in bicycle crashes,' approximately 400,OOO are treated in emergency rooms, and about 1 million require medical treatment of some sort.' The National Electronic Injury Surveillance System lists bicycles and bicycle equip ment first in its Rank of Injuries Related to Sports and Recreational Equipment.' The magnitude of bicycle-re-
lated morbidity is probably more serious than is reflected by medical records because such incidents are underreported.' Among student bicyclists at the University of Wisconsin, more than one fourth had experienced a mishap in the preceding 3 years; of this group, 67% has sustained at least one injury, 33% received medical attention, and 12% were evaluted as seriously injured.' Only 1% of these students were admitted to a hospital as a result of a bicycle-related injury. Bicyclists are at greater risk for head injury than participants in almost any other sport.5 Mortality data suggest that, if head injuries could be averted, many otherwise fatally injured bicyclists would survive.6 Recent studies suggest that helmets for bicyclists reduce the risk of head trauma to individuals who strike their In a sample of bicyclists interheads while viewed along a bicycle trail in Burlington, Vermont, however, less than 20% owned helmets, and less than half of that 20% wore helmets at the time of the interview.' Only 10% of bicyclists at the university of Arizona use helmets, whereas adult recreational cyclists wear helmets 85% of the time.6 Data from a study conducted in North Carolina in 1987 showed that less than 5% of those presenting in the emergency room with bicycle-related injuries reported wearing helmets.' Published studies have not addressed reasons why students have a low rate of helmet use. Our study was designed to collect information from University of New Mexico (UNM) students concerning their weekly bicycling mileage in Albuquerque, reasons for bicycling, number of bicycling injuries, the frequency of helmet use, and reasons why helmets were not worn on some or all occasions.
METHOD Lynne Fullerton is a graduate student in the Department of Anthropology at the University of New Mexico, Albuquerque. Thomas Becker is an assistant professor of medicine at the University of New Mexico School of Medicine, also in Albu-
querque.
V 0 1 3 9 , MARCH 1997
Subjects were chosen from UNM students in Albuquerque. Students were approached at or near the student union building on several days during the 1988 fall term. Individuals in the convenience sample were first asked whether they were UNM students, then whether
2 13
COLLEGE HEALTH they rode a bicycle in Albuquerque. Those students who fit both categories were asked to complete the bicycle helmet use questionnaire (available from Dr BeckeO. O f those students who rode bicycles, all agreed to complete the questionnaire. Odds ratios (ORS) were calculated to determine which variables were associated with helmet ownership.
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RESULTS Questionnaires were completed by 100 UNM students; demographic characteristics of the sample population are shown in Table 1. The data in Tables 2 and 3 give details of the student sample members' bicycling behaviors. Subjects reported bicycling from 1 to 300 miles per week, primarily for commuting (36x1 or exercise (45Oh). Approximately one third (31%) of student cyclists owned helmets, and 17 (54.8% of that group) who owned helmets reported wearing them during more than 75% of their bicycling trips. About half of the students in the sample reported bicycling no more than 25% in heavy traffic, but most indicated bicycling in darkness (80%) and during rainstorms (74%). Most of our subjects used bicycle trails less than one quarter of the time.
TABLE 1 Demographic Characteristics of University Students Responding to Bicycle Helmet Use Questionnaire, Albuquerque, NM, 1989 (N = 100) ~~
~~
~
Characteristic
~
Number
Percentage
~
~
Sex
Male Female
Total Ethnicity Black Hispanic Native American White, non-Hispanic Other Total Age group (years)
18-20 21-24 25-29 30-34 35 + Total Year in school Freshman Sophomore Junior Senior Graduate Total ~~
~
61 .O 39.0 100.0
61 39 100 2 19 3 69 6 99t
2.0 19.2 3.0 69.7 6.1 100.0
28 30 14 12 5 89
31.5 33.7 15.7 13.5 5.6 100.0
14 20 22 21 20 97
14.4 20.6 22.7 21.6 20.7 100.0 ~
~
tTotal number of respondents differs for some questions because some subjects did not answer all questions.
2 14
TABLE 2 Bicycling-Related Behaviors of University Students, Albuquerque, NM, 1989 (N = 100)
Behavior Weekly mileage 0-10 1 1-20 21-30 31-40 41 -50 51-100 > 100 Total
Major purpose* Cornmuting Exercise Other
Total Helmet ownership Own Do not own Total
Number
Percentage
36 19 5 12 11 8 8 99t
36.4 19.2 5.0 12.1 11.1 8.1 8.1 100.0
27 34 15 76
35.5 44.7 19.7 99.9
31 69 100
31 .O 69.0 100.0
tTotal number of respondents differs for some questions because some subjects did not answer all questions. *For the question on the major purpose of bicycling, 19 answers were discarded because respondents chose both exercise and commuting despite instructions indicating that only one answer was to be selected for each question; percentage does not total 100 because of rounding.
A substantial proportion of students (18%) had been hospitalized as a result of bicycling injuries (Table 4). One or more minor injuries were sustained by 65% of the subjects at some time during the previous 5 years and one or more by 44% of the subjects during the preceding year. Head injuries accounted for 11.1% of the hospitalizations reported and for 13.8% of the minor injuries sustained by the student bicyclists in the past 5 years. O f those individuals who were injured while wearing a helmet, only one reported sustaining a minor head injury. None of the students who wore helmets was hospitalized with a bicycle-related head injury. Less than half of the student sample (39%) had insurance coverage that covered injuries sustained while bicycling. The percentage of male respondents who reported injuries exceeded that of female respondents in most injury categories. Although the percentage of female cyclists who had been hospitalized was higher than that of males, more men than women reported multiple hospitalizations. Men were more likely to sustain minor injuries than women and were particularly more likely to report multiple minor injuries in a year-long period. The average rate of minor injuries reported for the previous year for men was .97 injuries per personyear, 1.6 times greater than the rate for women, which was .62 injuries per person-year. Multiple injuries in the
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BICYCLE-RELATED lNJURlES for injury exposure, the rate of multiple injuries was .0073 per mile for male cyclists, 1.6 times the rate among females, .0046 per mile. We calculated odds ratios to evaluate possible correlations between helmet ownership and several variables. No association was evident between helmet ownership and students' marriage status, whether students had children, major purpose of bicycling, or gender of the respondents. Bicyclists who had insurance coverage for bicycling injuries more often owned helmets than those who did not (OR 3.0; 95X CI 1.2, 7.6). An association was found between helmet ownership and individuals who had suffered at
previous year were reported by 29.5% of male subjects and by only 12.8% of female subjects. To examine sex differences in injury frequency more critically, we standardized injury exposure, using the average mileage for men and for women. Male cyclists had higher weekly mileage (average 40 miles per week) than females (average 28 miles per week). The rate of minor injuries per person-year-mile for male subjects was .024, only slightly higher than the women's rate of .022 injuries per person-year-mile. The frequency of students who sustained multiple injuries in the previous year remained substantially higher among men than among women. After standardization
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TABLE 3 Bicycling-Related Risk and Risk-Avoidance Behaviors of University Students, Albuquerque, NM, 1989 (N = 100)
Behavior
Rare (0%-25% of the time)
Occasional (26%-50% of the time)
Often (51%-75% of the time)
Usual (76%-700% of the time)
51 20 26
29 28 44
14 37 24
6 15 6
60
14 3
13 4
13 17
I
- --
Risk Bicycling in heavy traffic (n 100)t Bicycling in darkness (n 100)t Bicycling during rainstorms (n 100)t Risk avoidance 100)t Bicycling on trails (n Bicycle trips during which helmet was worn (n 31)$
-
-
7
I
I
tNurnber of students responding. *Number of students who own helmets.
TABLE 4 Bicycling-Rdated Injuries Among University Students, Albuqueque, NM, 1989 (N
Injury
Number
Ever hospitaIized Head injury Injury sustained while wearing helmet Head injury while wearing helmet Minor injury in past 5 yearst Head injury
18 2 4 0 65 9
Injury sustained while wearing helmet
14
Head injury while wearing helmet Minor injury in past yeart Head injury Injury sustained while wearing helmet Head injury while wearing helmet
1 44 4 10
-
100)
Percentage
(11.1 % of those hospitalized) (22.2% of those hospitalized)
(13.8% of those sustaining minor injuries in the past 5 years) (21.5% of those sustaining minor injuries in the past 5 years) (7.1 % of those sustaining minor injuries in the past 5 years) (9.1 % of those sustaining minor injuries in the past year) (22.7% of those sustaining minor injuries in the past year)
0
tlnjured but not hospitalized.
VOL 39, MARCH 1991
215
COLLEGE HEALTH least one minor injury in the past 5 years (OR = 3.0; = 1.1, 8.11,as well as for individuals who had been hospitalized as a result of a bicycling injury (OR = 3.6;9594, CI = 1.3, 10.1).Other parameters examined for an association with helmet ownership included age, year in school, ethnicity, weekly mileage, percentage of time bicycling in heavy traffic and on bicycle trails, and frequency of bicycling during rainstorms or in darkness. Of these variables, only ethnicity showed a consistent pattern: non-Hispanic whites were highly overrepresented among the group of helmet owners. The percentages of helmet owners among the ethnic groups studied were: black = 0% (0 of 21, Hispanic 5.8% (1 of 19),native American 0% (0 of 31, and nonHispanic white 37.7% (26of 69).(Four respondents who reported helmet ownership did not indicate their et hnicity.) Among subjects who owned helmets, students most often indicated (34.5%) that the length of the bicycle trip was the primary factor in deciding whether or not to wear the helmet. Cost (32.9%)and lack of comfort (32.9%)were most frequently reported as the major drawbacks to helmet use.
95% CI
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-
-
-
DISCUSSION In our study, most of the students we interviewed who owned helmets used them most of the time. Helmet ownership was most strongly associated with having been previously injured, presumably because students personally became more aware of the possibility of bicyclists' sustaining serious injuries. The association between t nsurance coverage and helmet ownership suggested that perceived risk is an important factor in bicyclists' use of safety helmets. If an awareness of personal risk is a factor in helmet use, increased education concerning the hazards of bicycling and the potential life-saving qualities of safety helmets may increase helmet use among college students. The students surveyed reported that cost was one of the two greatest drawbacks to helmet use. An informal survey of four Albuquerque bicycle shops showed that adult bicycle helmet prices ranged from $25 to $89, with an average cost of almost $50.Because we did not measure socioeconomic status of students in this study, we can only speculate that the high cost of bicycle helmets prohibits their use among the less economically advantaged students. The amount of time a bicyclist spends in heavy traffic is a factor in the number of bicycle-related injuries and fatalities. Approximately 90% of bicyclist deaths result from collisions with motor vehicle^.^,^,^ Almost half of the students in our sample reported bicycling in heavy traffic (Table 3). A Swedish study on bicycle mortality suggested that providing such alternative routes for bicyclists as bike trails would reduce the number of fatal injuries sustained by bicyclists.2 Although Albuquerque has several bicycle trails, more than half of the students (60%) reported using these trails for < 25% of their
216
bicycling. We need further information to determine what modifications and additions to the available Albuquerque bicycle trails would increase their usefulness to UNM cyclists. To contrast male and female injury statistics accurately, it would be necessary to know the proportion of each sex represented in the bicycling population, as well as the exposure to injury, ie, the average mileage for each group over a defined time period. Unfortunately, these data are not available in any published studies we encountered. Most bicycle studies contrast numbers instead of proportions, and almost invariably the studies report that males are considerably more likely than females to suffer injury or death while bicycling. In a study of bicycle injuries in Calgary, males suffered 1.5 times as many injuries as females." Males were also overrepresented (4:l)in a study of bicycle fatalities in Dade County, Florida." UNM Hospital Trauma Registry records for 1987/88show that males outnumber females at least 3:l in bicycle-related injuries (Leticia Rutledge, personal communication) and 4:l in bicycle-related deaths." Nationwide statistics show that male:female bicycle-related mortality is 4:l over all age group^.^ The US Consumer Product Safety Commission, using its National Electronic Injury Surveillance System, reported in 1986 that males and females had approximately equal proportions of bicyclerelated injuries compared with total trauma visits to h0spita1s.l~Although our results initially concurred with the observed trend in which males outnumbered females in bicycle-injury statistics, gender differences are markedly decreased after consideration of injury exposure and the proportion of each gender in the sample. The results of this study should be interpreted cautiously, and consideration should be given to potential sources of bias. Information derived from interviews may be subject to recall bias. Data pertainingto weekly bicycling mileage may also be inaccurately reportedmany cyclists reported being unaccustomed to gauging mileage, and most indicated seasonal fluctuations in their mileage. Thirteen students reported that they were uncertain whether their insurance covered injuries sustained while they were bicycling, so statistics related to insurance are based on a reduced sample (n 87). Students who only attend evening classes may have been underrepresented in our sample because the data were collected at the university during the daytime class hours, and evening students may include a relatively large number of individuals who ride after dark. No emergency room or hospital records were examined to verify reports of injuries. The small number of subjects in the various injury categories limits our analysis. Finally, the association between helmet ownership and health insurance may be confounded by income because we would anticipate that income would have an impact on both variables.
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BICYCLE-RELATED 1N)URIES The number of bicycles nationwide has increased fourteenfold since 1940; the death rate decreased markedly from 1940 to 1981 but has remained approximately steady since that time.' Mortality rates among different age groups are changing, however, with the risk to college-aged bicyclists increasing4 Because head trauma is responsible for approximately 85% of bicycle death^,^ efforts should be directed toward decreasing head injuries among bicyclists. Safety helmets appear to be the most effective technique currently available to protect the head from injury. Education programs initiated in elementary schools may be the best strategy to encourage helmet use among bicyclists of all ages.",'4 Recently, a community campaign promoting helmet use in Seattle, Washington, was shown to increase helmet use among school-aged children." In the Same way, college health programs could stress increased use of bicycle helmets among student cyclists. Legislation has been proposed as a way of forcing bicyclists to wear helmets." Distribution of discount bicycle-helmet coupons and free helmets have been used to increase helmet use among low-income cyclist~.'~ Finally, our results indicate that further studies should be conducted to evaluate the utility of the available bicycle trails in Albuquerque. Increased use of these trails would be likely to reduce the number of bicycle-motor-vehicle collisions and thus the morbidity and mortality associated with bicycle use in Albuquerque. INDEX TERMS bicycle safety, helmets, injuries, risk, university students
NOTE Please address all reprint requests to Dr Thomas Becker, University Hospital Cancer Center, 900 Camino de Salud NE, Albuquerque, NM 87131.
ACKNOWLEDGMENTS We wish to thank Leticia Rutledge of the New Mexico Trauma Registry; Lenora Olson, Infection Control Practitioner at the University Department of Epidemiology; Patricia
I I
McFeeley, Chief Medical Investigator for the State of New Mexico; Marsha Starr of the New Mexico Office of the Medical Examiner; Raylene McCalmon and George McCue for assistance in the preparation of this manuscript.
REFERENCES 1. National Safety Council. Accident Facts. Chicago: National Safety Council; 1988:55,63,86. 2. Lind M, Wollin S. Bicycle accidents. In: Schneider R, Kennedy J, Plant M, Fowler P, Hoff I, Matthews L, eds. Sports Injuries: Mechanisms, Prevention, and Treatment. Baltimore: Williams and Wilkins; 1985:532-552. 3. Damron F, Hoerner E, Shaw J.Injury surveillance systems for sports. In: Vinger P, Hoerner E, eds. Sports Injuries: The Unthwarted Epidemic. Littleton, MA: PSG Publishing Co, Inc, 1986:ll-14. 4. Baker S, 0"eill 6, Karpf R. The Injury Fact Book. Toronto: Lexington Books; 1984. 5. Dempsey R, Schneider R. The management of head injuries in sports. In: Schneider R, Kennedy J,Plant M, Fowler P, Hoff J, Matthews L, eds. Sports Injuries: Mechanisms, Prevention, and Treatment. Baltimore: Williams and Wilkins; 1985: 660. 6. Weiss 6. Bicycle helmet use by children. Pediatrics.
1986;77(5):677-679. 7. Wasserman R, Waller J, Monty M, Emery A, Robinson D. Bicyclists, helmets and head injuries: A rider-based study of helmet use and effectiveness. Am Public Health. September
1988;78(9):1220-1221. 8. Thompson R, Rivara F, Thompson D. A case-control study of the effectiveness of bicycle safety helmets. New Engl /
Med. 1989;320(21):1 361-1 367. 9. Balderston T. Bicycle helmets: Which one? Bicycling. 1983;March: 1 24-145. 10. Guichon D, Myles T. Bicycle injwies: One-year sample in Calgary. I Trauma. 1975;15(6):504-506. 11. Fife D, Davis I, Tate L, Wells J,Mohan D, Williams A. Fatal injuries to bicyclists: The experience of Dade County, Florida. I Trauma. 1983;23(8):745-755. 12. Office of the Medical Investigator, State of New Mexico. Annual Report 7987. Albuquerque, New Mexico: 15. 13. Centers for Disease Control. Bicycle-related injuries: Data from the National Electronic Injury Surveillance System. MMWR. 1987;36(17):269-271. 14. Howland J,Sargent J,Weltzman M, et al. Barriers to bicycle helmet use among children. Am I Dis Child. 1983143:
741-744. 15. DiGuiseppi C, Rivara F, Koepsell T, Polissar L. Bicycle helmet use by children: Evaluation of a community-wide helmet campaign. IAMA. Oaober 1989;262(16):2256-2261.
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VOL 39, MARCH 1991
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217
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Moving Targets: Bicycle-Related Injuries and Helmet Use among University Students a
Lynne Fullerton BS & Thomas Becker Md, PhD a
b
Department of Anthropology , University of New Mexico , Albuquerque, USA
b
University of New Mexico School of Medicine , USA Published online: 09 Jul 2010.
To cite this article: Lynne Fullerton BS & Thomas Becker Md, PhD (1991) Moving Targets: Bicycle-Related Injuries and Helmet Use among University Students, Journal of American College Health, 39:5, 213-217, DOI: 10.1080/07448481.1991.9936237 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936237
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Moving Targets: BicycleRelatd Injuries and Helmet Use Among Univers'ity Students
Downloaded by [ECU Libraries] at 16:59 22 April 2015
LYNNE FULLERTON, BS, and THOMAS BECKER, MD, PhD
We conducted a cross-sectional study to evaluate bicycling habits and helmet use in a sample of universii students in a southwestern state university. Thirty-one of 100 students in our sample owned bicycle helmds; of these, 17 (54.8%) wore helmets during most (more than three fourths) of their bicycle trips. Almost half of the students reported that more than 25% of their bicycling was done in heavy traffic but they rarely used bicycle trails. Sixty-fiw students in the sample had sustained at least one minor injury during the previous 5 years, and 18 had been hospitalized as a result of bicyck-dated injuries. We found no substantial differences between male and female subjects in bicycle-dated hospitalizations, although male subjects were more likely to sustain minor injuries than were females. Helmet ownership was most strongly associated with previous injury experience, especially hospitalization resulting from bicycling injuries (OR = 3.6 95% CI = 1.3,lO.l). We also observed an association between helmet ownership and possession of insurance cowage for b i d i n g injuries (OR = 3.0; 95% CI I 1.2, 7.6). Ethnicii was a factor in helmet ownershiphelmets were owned by 26 of 69 (37.7%)of non-Hispanic whites, in contrast to 1 of 24 (4.2%) of all other enthic groups combined. Our survey data s u m that perceived risk is an important factor in bicyclists' use of safety helmets.
Every year, bicyclists in the United States are involved in incidents that lead to both fatal and nonfatal injuries. Fifteen hundred to 1,600 bicyclists die annually in bicycle crashes,' approximately 400,OOO are treated in emergency rooms, and about 1 million require medical treatment of some sort.' The National Electronic Injury Surveillance System lists bicycles and bicycle equip ment first in its Rank of Injuries Related to Sports and Recreational Equipment.' The magnitude of bicycle-re-
lated morbidity is probably more serious than is reflected by medical records because such incidents are underreported.' Among student bicyclists at the University of Wisconsin, more than one fourth had experienced a mishap in the preceding 3 years; of this group, 67% has sustained at least one injury, 33% received medical attention, and 12% were evaluted as seriously injured.' Only 1% of these students were admitted to a hospital as a result of a bicycle-related injury. Bicyclists are at greater risk for head injury than participants in almost any other sport.5 Mortality data suggest that, if head injuries could be averted, many otherwise fatally injured bicyclists would survive.6 Recent studies suggest that helmets for bicyclists reduce the risk of head trauma to individuals who strike their In a sample of bicyclists interheads while viewed along a bicycle trail in Burlington, Vermont, however, less than 20% owned helmets, and less than half of that 20% wore helmets at the time of the interview.' Only 10% of bicyclists at the university of Arizona use helmets, whereas adult recreational cyclists wear helmets 85% of the time.6 Data from a study conducted in North Carolina in 1987 showed that less than 5% of those presenting in the emergency room with bicycle-related injuries reported wearing helmets.' Published studies have not addressed reasons why students have a low rate of helmet use. Our study was designed to collect information from University of New Mexico (UNM) students concerning their weekly bicycling mileage in Albuquerque, reasons for bicycling, number of bicycling injuries, the frequency of helmet use, and reasons why helmets were not worn on some or all occasions.
METHOD Lynne Fullerton is a graduate student in the Department of Anthropology at the University of New Mexico, Albuquerque. Thomas Becker is an assistant professor of medicine at the University of New Mexico School of Medicine, also in Albu-
querque.
V 0 1 3 9 , MARCH 1997
Subjects were chosen from UNM students in Albuquerque. Students were approached at or near the student union building on several days during the 1988 fall term. Individuals in the convenience sample were first asked whether they were UNM students, then whether
2 13
COLLEGE HEALTH they rode a bicycle in Albuquerque. Those students who fit both categories were asked to complete the bicycle helmet use questionnaire (available from Dr BeckeO. O f those students who rode bicycles, all agreed to complete the questionnaire. Odds ratios (ORS) were calculated to determine which variables were associated with helmet ownership.
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RESULTS Questionnaires were completed by 100 UNM students; demographic characteristics of the sample population are shown in Table 1. The data in Tables 2 and 3 give details of the student sample members' bicycling behaviors. Subjects reported bicycling from 1 to 300 miles per week, primarily for commuting (36x1 or exercise (45Oh). Approximately one third (31%) of student cyclists owned helmets, and 17 (54.8% of that group) who owned helmets reported wearing them during more than 75% of their bicycling trips. About half of the students in the sample reported bicycling no more than 25% in heavy traffic, but most indicated bicycling in darkness (80%) and during rainstorms (74%). Most of our subjects used bicycle trails less than one quarter of the time.
TABLE 1 Demographic Characteristics of University Students Responding to Bicycle Helmet Use Questionnaire, Albuquerque, NM, 1989 (N = 100) ~~
~~
~
Characteristic
~
Number
Percentage
~
~
Sex
Male Female
Total Ethnicity Black Hispanic Native American White, non-Hispanic Other Total Age group (years)
18-20 21-24 25-29 30-34 35 + Total Year in school Freshman Sophomore Junior Senior Graduate Total ~~
~
61 .O 39.0 100.0
61 39 100 2 19 3 69 6 99t
2.0 19.2 3.0 69.7 6.1 100.0
28 30 14 12 5 89
31.5 33.7 15.7 13.5 5.6 100.0
14 20 22 21 20 97
14.4 20.6 22.7 21.6 20.7 100.0 ~
~
tTotal number of respondents differs for some questions because some subjects did not answer all questions.
2 14
TABLE 2 Bicycling-Related Behaviors of University Students, Albuquerque, NM, 1989 (N = 100)
Behavior Weekly mileage 0-10 1 1-20 21-30 31-40 41 -50 51-100 > 100 Total
Major purpose* Cornmuting Exercise Other
Total Helmet ownership Own Do not own Total
Number
Percentage
36 19 5 12 11 8 8 99t
36.4 19.2 5.0 12.1 11.1 8.1 8.1 100.0
27 34 15 76
35.5 44.7 19.7 99.9
31 69 100
31 .O 69.0 100.0
tTotal number of respondents differs for some questions because some subjects did not answer all questions. *For the question on the major purpose of bicycling, 19 answers were discarded because respondents chose both exercise and commuting despite instructions indicating that only one answer was to be selected for each question; percentage does not total 100 because of rounding.
A substantial proportion of students (18%) had been hospitalized as a result of bicycling injuries (Table 4). One or more minor injuries were sustained by 65% of the subjects at some time during the previous 5 years and one or more by 44% of the subjects during the preceding year. Head injuries accounted for 11.1% of the hospitalizations reported and for 13.8% of the minor injuries sustained by the student bicyclists in the past 5 years. O f those individuals who were injured while wearing a helmet, only one reported sustaining a minor head injury. None of the students who wore helmets was hospitalized with a bicycle-related head injury. Less than half of the student sample (39%) had insurance coverage that covered injuries sustained while bicycling. The percentage of male respondents who reported injuries exceeded that of female respondents in most injury categories. Although the percentage of female cyclists who had been hospitalized was higher than that of males, more men than women reported multiple hospitalizations. Men were more likely to sustain minor injuries than women and were particularly more likely to report multiple minor injuries in a year-long period. The average rate of minor injuries reported for the previous year for men was .97 injuries per personyear, 1.6 times greater than the rate for women, which was .62 injuries per person-year. Multiple injuries in the
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BICYCLE-RELATED lNJURlES for injury exposure, the rate of multiple injuries was .0073 per mile for male cyclists, 1.6 times the rate among females, .0046 per mile. We calculated odds ratios to evaluate possible correlations between helmet ownership and several variables. No association was evident between helmet ownership and students' marriage status, whether students had children, major purpose of bicycling, or gender of the respondents. Bicyclists who had insurance coverage for bicycling injuries more often owned helmets than those who did not (OR 3.0; 95X CI 1.2, 7.6). An association was found between helmet ownership and individuals who had suffered at
previous year were reported by 29.5% of male subjects and by only 12.8% of female subjects. To examine sex differences in injury frequency more critically, we standardized injury exposure, using the average mileage for men and for women. Male cyclists had higher weekly mileage (average 40 miles per week) than females (average 28 miles per week). The rate of minor injuries per person-year-mile for male subjects was .024, only slightly higher than the women's rate of .022 injuries per person-year-mile. The frequency of students who sustained multiple injuries in the previous year remained substantially higher among men than among women. After standardization
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TABLE 3 Bicycling-Related Risk and Risk-Avoidance Behaviors of University Students, Albuquerque, NM, 1989 (N = 100)
Behavior
Rare (0%-25% of the time)
Occasional (26%-50% of the time)
Often (51%-75% of the time)
Usual (76%-700% of the time)
51 20 26
29 28 44
14 37 24
6 15 6
60
14 3
13 4
13 17
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Risk Bicycling in heavy traffic (n 100)t Bicycling in darkness (n 100)t Bicycling during rainstorms (n 100)t Risk avoidance 100)t Bicycling on trails (n Bicycle trips during which helmet was worn (n 31)$
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tNurnber of students responding. *Number of students who own helmets.
TABLE 4 Bicycling-Rdated Injuries Among University Students, Albuqueque, NM, 1989 (N
Injury
Number
Ever hospitaIized Head injury Injury sustained while wearing helmet Head injury while wearing helmet Minor injury in past 5 yearst Head injury
18 2 4 0 65 9
Injury sustained while wearing helmet
14
Head injury while wearing helmet Minor injury in past yeart Head injury Injury sustained while wearing helmet Head injury while wearing helmet
1 44 4 10
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100)
Percentage
(11.1 % of those hospitalized) (22.2% of those hospitalized)
(13.8% of those sustaining minor injuries in the past 5 years) (21.5% of those sustaining minor injuries in the past 5 years) (7.1 % of those sustaining minor injuries in the past 5 years) (9.1 % of those sustaining minor injuries in the past year) (22.7% of those sustaining minor injuries in the past year)
0
tlnjured but not hospitalized.
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COLLEGE HEALTH least one minor injury in the past 5 years (OR = 3.0; = 1.1, 8.11,as well as for individuals who had been hospitalized as a result of a bicycling injury (OR = 3.6;9594, CI = 1.3, 10.1).Other parameters examined for an association with helmet ownership included age, year in school, ethnicity, weekly mileage, percentage of time bicycling in heavy traffic and on bicycle trails, and frequency of bicycling during rainstorms or in darkness. Of these variables, only ethnicity showed a consistent pattern: non-Hispanic whites were highly overrepresented among the group of helmet owners. The percentages of helmet owners among the ethnic groups studied were: black = 0% (0 of 21, Hispanic 5.8% (1 of 19),native American 0% (0 of 31, and nonHispanic white 37.7% (26of 69).(Four respondents who reported helmet ownership did not indicate their et hnicity.) Among subjects who owned helmets, students most often indicated (34.5%) that the length of the bicycle trip was the primary factor in deciding whether or not to wear the helmet. Cost (32.9%)and lack of comfort (32.9%)were most frequently reported as the major drawbacks to helmet use.
95% CI
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DISCUSSION In our study, most of the students we interviewed who owned helmets used them most of the time. Helmet ownership was most strongly associated with having been previously injured, presumably because students personally became more aware of the possibility of bicyclists' sustaining serious injuries. The association between t nsurance coverage and helmet ownership suggested that perceived risk is an important factor in bicyclists' use of safety helmets. If an awareness of personal risk is a factor in helmet use, increased education concerning the hazards of bicycling and the potential life-saving qualities of safety helmets may increase helmet use among college students. The students surveyed reported that cost was one of the two greatest drawbacks to helmet use. An informal survey of four Albuquerque bicycle shops showed that adult bicycle helmet prices ranged from $25 to $89, with an average cost of almost $50.Because we did not measure socioeconomic status of students in this study, we can only speculate that the high cost of bicycle helmets prohibits their use among the less economically advantaged students. The amount of time a bicyclist spends in heavy traffic is a factor in the number of bicycle-related injuries and fatalities. Approximately 90% of bicyclist deaths result from collisions with motor vehicle^.^,^,^ Almost half of the students in our sample reported bicycling in heavy traffic (Table 3). A Swedish study on bicycle mortality suggested that providing such alternative routes for bicyclists as bike trails would reduce the number of fatal injuries sustained by bicyclists.2 Although Albuquerque has several bicycle trails, more than half of the students (60%) reported using these trails for < 25% of their
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bicycling. We need further information to determine what modifications and additions to the available Albuquerque bicycle trails would increase their usefulness to UNM cyclists. To contrast male and female injury statistics accurately, it would be necessary to know the proportion of each sex represented in the bicycling population, as well as the exposure to injury, ie, the average mileage for each group over a defined time period. Unfortunately, these data are not available in any published studies we encountered. Most bicycle studies contrast numbers instead of proportions, and almost invariably the studies report that males are considerably more likely than females to suffer injury or death while bicycling. In a study of bicycle injuries in Calgary, males suffered 1.5 times as many injuries as females." Males were also overrepresented (4:l)in a study of bicycle fatalities in Dade County, Florida." UNM Hospital Trauma Registry records for 1987/88show that males outnumber females at least 3:l in bicycle-related injuries (Leticia Rutledge, personal communication) and 4:l in bicycle-related deaths." Nationwide statistics show that male:female bicycle-related mortality is 4:l over all age group^.^ The US Consumer Product Safety Commission, using its National Electronic Injury Surveillance System, reported in 1986 that males and females had approximately equal proportions of bicyclerelated injuries compared with total trauma visits to h0spita1s.l~Although our results initially concurred with the observed trend in which males outnumbered females in bicycle-injury statistics, gender differences are markedly decreased after consideration of injury exposure and the proportion of each gender in the sample. The results of this study should be interpreted cautiously, and consideration should be given to potential sources of bias. Information derived from interviews may be subject to recall bias. Data pertainingto weekly bicycling mileage may also be inaccurately reportedmany cyclists reported being unaccustomed to gauging mileage, and most indicated seasonal fluctuations in their mileage. Thirteen students reported that they were uncertain whether their insurance covered injuries sustained while they were bicycling, so statistics related to insurance are based on a reduced sample (n 87). Students who only attend evening classes may have been underrepresented in our sample because the data were collected at the university during the daytime class hours, and evening students may include a relatively large number of individuals who ride after dark. No emergency room or hospital records were examined to verify reports of injuries. The small number of subjects in the various injury categories limits our analysis. Finally, the association between helmet ownership and health insurance may be confounded by income because we would anticipate that income would have an impact on both variables.
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BICYCLE-RELATED 1N)URIES The number of bicycles nationwide has increased fourteenfold since 1940; the death rate decreased markedly from 1940 to 1981 but has remained approximately steady since that time.' Mortality rates among different age groups are changing, however, with the risk to college-aged bicyclists increasing4 Because head trauma is responsible for approximately 85% of bicycle death^,^ efforts should be directed toward decreasing head injuries among bicyclists. Safety helmets appear to be the most effective technique currently available to protect the head from injury. Education programs initiated in elementary schools may be the best strategy to encourage helmet use among bicyclists of all ages.",'4 Recently, a community campaign promoting helmet use in Seattle, Washington, was shown to increase helmet use among school-aged children." In the Same way, college health programs could stress increased use of bicycle helmets among student cyclists. Legislation has been proposed as a way of forcing bicyclists to wear helmets." Distribution of discount bicycle-helmet coupons and free helmets have been used to increase helmet use among low-income cyclist~.'~ Finally, our results indicate that further studies should be conducted to evaluate the utility of the available bicycle trails in Albuquerque. Increased use of these trails would be likely to reduce the number of bicycle-motor-vehicle collisions and thus the morbidity and mortality associated with bicycle use in Albuquerque. INDEX TERMS bicycle safety, helmets, injuries, risk, university students
NOTE Please address all reprint requests to Dr Thomas Becker, University Hospital Cancer Center, 900 Camino de Salud NE, Albuquerque, NM 87131.
ACKNOWLEDGMENTS We wish to thank Leticia Rutledge of the New Mexico Trauma Registry; Lenora Olson, Infection Control Practitioner at the University Department of Epidemiology; Patricia
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McFeeley, Chief Medical Investigator for the State of New Mexico; Marsha Starr of the New Mexico Office of the Medical Examiner; Raylene McCalmon and George McCue for assistance in the preparation of this manuscript.
REFERENCES 1. National Safety Council. Accident Facts. Chicago: National Safety Council; 1988:55,63,86. 2. Lind M, Wollin S. Bicycle accidents. In: Schneider R, Kennedy J, Plant M, Fowler P, Hoff I, Matthews L, eds. Sports Injuries: Mechanisms, Prevention, and Treatment. Baltimore: Williams and Wilkins; 1985:532-552. 3. Damron F, Hoerner E, Shaw J.Injury surveillance systems for sports. In: Vinger P, Hoerner E, eds. Sports Injuries: The Unthwarted Epidemic. Littleton, MA: PSG Publishing Co, Inc, 1986:ll-14. 4. Baker S, 0"eill 6, Karpf R. The Injury Fact Book. Toronto: Lexington Books; 1984. 5. Dempsey R, Schneider R. The management of head injuries in sports. In: Schneider R, Kennedy J,Plant M, Fowler P, Hoff J, Matthews L, eds. Sports Injuries: Mechanisms, Prevention, and Treatment. Baltimore: Williams and Wilkins; 1985: 660. 6. Weiss 6. Bicycle helmet use by children. Pediatrics.
1986;77(5):677-679. 7. Wasserman R, Waller J, Monty M, Emery A, Robinson D. Bicyclists, helmets and head injuries: A rider-based study of helmet use and effectiveness. Am Public Health. September
1988;78(9):1220-1221. 8. Thompson R, Rivara F, Thompson D. A case-control study of the effectiveness of bicycle safety helmets. New Engl /
Med. 1989;320(21):1 361-1 367. 9. Balderston T. Bicycle helmets: Which one? Bicycling. 1983;March: 1 24-145. 10. Guichon D, Myles T. Bicycle injwies: One-year sample in Calgary. I Trauma. 1975;15(6):504-506. 11. Fife D, Davis I, Tate L, Wells J,Mohan D, Williams A. Fatal injuries to bicyclists: The experience of Dade County, Florida. I Trauma. 1983;23(8):745-755. 12. Office of the Medical Investigator, State of New Mexico. Annual Report 7987. Albuquerque, New Mexico: 15. 13. Centers for Disease Control. Bicycle-related injuries: Data from the National Electronic Injury Surveillance System. MMWR. 1987;36(17):269-271. 14. Howland J,Sargent J,Weltzman M, et al. Barriers to bicycle helmet use among children. Am I Dis Child. 1983143:
741-744. 15. DiGuiseppi C, Rivara F, Koepsell T, Polissar L. Bicycle helmet use by children: Evaluation of a community-wide helmet campaign. IAMA. Oaober 1989;262(16):2256-2261.
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