Millions of youth across the United States regularly bike, participate in roller sports (such as rollerblading), and/or skateboard (The Aspen Institute, 2019). Sports and recreational activities such as these yield multiple positive benefits for youth, especially their physical and mental health (Marquez et al., 2020). However, in part due to the potential for high velocity falls and collisions with motor vehicles, participation in bicycling, rollerblading, and skateboarding also increases the risk for injuries (National Transportation Safety Board, 2019; Thompson, Rivara, & Thompson, 2000; Zalavras, Nikolopoulou, Essin, Manjra, & Zionts, 2005). Most severe and fatal injuries to bicyclists, rollerbladers, and skateboarders result from injuries to the upper extremities, head, and brain, including traumatic brain injuries (TBIs) (Thompson et al., 2000; Tominaga, Schaffer, Dandan, Coufal, & Kraus, 2015; Zalavras et al., 2005).

A TBI is caused by a penetrating injury or a bump, blow, or jolt to the head, face, neck, or body that transmits significant force to the brain, causing it to shift or twist inside the skull. This injury may lead to short- or long-term emotional, physiologic, behavioral, and cognitive sequelae in children (Lumba-Brown et al., 2018). Late elementary and middle school age youth (ages 10 to 14 years) have the highest number of emergency department visits for sports- and recreation-related TBIs (Sarmiento et al., 2019). A prior report found that bicycling, roller sports, and skateboarding were associated with an average of approximately 35,000 emergency department visits each year for TBIs among youth over a 7-year period (Sarmiento et al., 2019). In this same report, bicycling alone had the second highest number of emergency department visits for sports- and recreation-related TBIs among males ages 0 to 17 years, exceeded only by American football (Sarmiento et al., 2019).

Although most skate parks and recreational centers across the country require rollerbladers and skateboarders to wear a helmet outside of designated skateparks or centers (e.g., streets, public parks, or other public spaces), only approximately a quarter of states have such requirements. When helmets are worn consistently and correctly during bicycling, rollerblading, and skateboarding, they substantially decrease the likelihood of admission to the hospital (Ganti et al., 2013; Ong, Soundappan, Adams, & Adams, 2018), as well as serious and fatal head injuries (Hoye, 2018a), injuries to the mid and upper face (Thompson et al., 2000), skull fractures (Olivier & Creighton, 2017), and for TBIs more generally (Hoye, 2018a; Williams, Weston, Feinglass, & Crandall, 2018). Specifically, one study (Hoye, 2018a) found that use of bicycle helmets decreased head injury by 48%, serious head injury by 60%, traumatic brain injury by 53%, face injury by 23%, and death or serious injury by 34%. Beginning in the late 1980s (Centers for Disease Control and Prevention [CDC], 2015), several states and cities have promoted helmet safety for bicyclists, including passaging helmet laws for children. Currently, only 21 states and the District of Columbia have laws on bicycle helmet use, but these laws solely focus on bicycle helmet use among children (Governors Highway Safety Association, 2022). The other 29 states have no helmet law for bicyclists of any age (Governors Highway Safety Association, 2022).

To better understand helmet usage among middle school students and help inform strategies to address helmet usage, this study used data from the Middle School Youth Risk Behavior Surveys (YRBS) conducted in select states to estimate the prevalence of self-reported helmet use while bicycling, rollerblading, or skateboarding. Differences in self-reported helmet use by activity type and by sex, grade, and race/ethnicity were also examined. While prior studies (Finnoff, Laskowski, Altman, & Diehl, 2001; Gulack et al., 2015; Jewett, Beck, Taylor, & Baldwin, 2016) have assessed helmet use and barriers to usage among youth, this article contributes new information focused specifically on middle school students.

Respondents were asked their sex (female or male), grade (6th, 7th, or 8th) and their race and ethnicity. Students were classified into seven racial/ethnic categories: American Indian or Alaska Native, non-Hispanic (“AIAN”); Asian, non-Hispanic (“Asian”); Black, non-Hispanic (“Black”); Hispanic or Latino of any race (“Hispanic”); Native Hawaiian or Other Pacific Islander, non-Hispanic (NHOPI); White, non-Hispanic (“White”) and multiple races, non-Hispanic (“Multiple”).

Students were asked two questions regarding helmet use: “When you ride a bicycle, how often do you wear a helmet?” and “When you rollerblade or ride a skateboard, how often do you wear a helmet?” Responses included “did not ride a bicycle” or “I do not rollerblade or ride a skateboard” and “never,” “rarely,” “sometimes,” “most of the time,” and “always.” For each question (among students who had ridden a bicycle or rollerbladed/skateboarded), this study combined those responses into two categories; rarely or never compared to sometimes, most of the time, or always. Nine states included the bicycle helmet question (Florida, Kentucky, Maine, Maryland, North Carolina, New Mexico, Vermont, Virginia, and West Virginia) and seven states included the rollerblade or skateboard helmet question (Florida, Kentucky, Maryland, North Carolina, Vermont, Virginia, and West Virginia).

During the study period, the overall prevalence of rarely or never wearing a helmet while bicycling among middle school students in nine states was 68.6% (Table 2). Among the individual states examined, the overall prevalence ranged from 30.4% in Vermont to 78.5% in Kentucky of middle school students self-reporting rarely or never wearing a helmet while bicycling. The overall prevalence of rarely or never wearing a helmet while rollerblading or skateboarding in middle school students in seven states was 74.6% during the study period (Table 2). Among the states examined, the prevalence ranged from 37.6% in Vermont to 81.8% in Kentucky of middle school students self-reporting rarely or never wearing a helmet while rollerblading or skateboarding.

The percentage of respondents who reported rarely or never wearing a helmet while bicycling for 7th and 8th graders, for both females and males, and for White, Black, Asian, and Hispanic students declined from 2013 to 2019 (Table 3). The percentage of respondents who reported rarely or never wearing a helmet while rollerblading or skateboarding for 7th graders, for males, and for White and AIAN students declined from 2013 to 2019 (Table 4). Overall, there was a significant decrease in rarely or never wearing a helmet while bicycling during 2013 to 2019 (from 71.7% to 67.0%; Table 2), adjusted odds ratio [AOR] = 0.9, 95% confidence interval [CI] = 0.9–0.9 (Table 3). Male students, students in higher grade levels (7th or 8th), and racial and ethnic minority students (except Asian students) had significantly higher odds of rarely or never wearing a helmet while bicycling as compared with female students, students in 6th grade, and White students, respectively; Asian students had lower odds of rarely or never wearing a helmet while bicycling when compared to White students (Table 5). Similarly, there was also a significant decrease in rarely or never wearing a helmet while rollerblading or skateboarding during 2013 to 2019 (from 76.4% to 73.5%; Table 2), AOR = 0.9, 95% CI = 0.9–1.0 (Table 5). Students in higher grade levels (7th or 8th) and racial and ethnic minority students (except Asian and NHOPI students) had significantly higher odds than students in 6th grade and White students of self-reporting rarely or never wearing a helmet while rollerblading or skateboarding, respectively. However, Asian students had significantly lower odds of self-reporting rarely or never wearing a helmet while rollerblading or skateboarding compared to White students (Table 5).

Despite their safety benefits, findings from this study suggest that more than two-thirds of middle school students self-reported rarely or never wearing a helmet while bicycling and approximately three-fourths of middle school students self-reported rarely or never wearing a helmet while rollerblading or skateboarding in the states examined. While this analysis found that helmet use among middle school students improved over time, overall helmet usage during bicycling, rollerblading, and skateboarding remained low in some states. Moreover, helmet use varied by state. For example, self-reported bicycle helmet use among middle school students differed by 55% between Kentucky and Vermont; and in self-reported rollerblade and skateboard helmet use among middle school students differed by 53% in these same states. Interestingly, neither of these states have a bicycle helmet law, yet they have very different prevalence levels of middle school student helmet use. There is evidence that helmet laws increase helmet use (Jewett et al., 2016; Kraemer, 2016; Macpherson & Spinks, 2007; Venkatraman, Richard, Magee, & Johnson, 2021), though the literature is mixed on whether this might be due to a decrease in bicycle use (Carpenter & Stehr, 2011; Dennis, Potter, Ramsay, & Zarychanski, 2010; Jewett et al., 2016; Kraemer, 2016). These findings, as well as differences in helmet use by race/ethnicity and age, are consistent with prior studies and may suggest the need for a greater focus on community-based interventions for groups at higher risk of injury (Finnoff et al., 2001; Gulack et al., 2015; Jewett et al., 2016; National Transportation Safety Board, 2019; Sullins, Yaghoubian, Nguyen, Kaji, & Lee, 2014).

It is unclear from the findings in this study why helmet use among middle school students varied among the states examined. One limitation is due to the data measured by YRBS. Questions on the YRBS are intended to get prevalence estimates and cannot provide further insights that more in-depths questions might yield. Further, the data do not allow for analysis of why some students (those in 7th and 8th grade, as well as racial and ethnic minority students [with the exception of Asian students]) were less likely to self-report regular helmet use while bicycling, rollerblading, or skateboarding as compared to others (students in 6th grade and White students). However, prior studies may provide insight into potential barriers to helmet use among youth (Finnoff et al., 2001; Ong et al., 2018; Piotrowski et al., 2020). Ong and colleagues interviewed youth who were seen at an emergency department for a bicycle or other non-motorized wheeled recreational vehicle-related injury and found that one-third (31.9%) of patients did not wear a helmet as they believed helmets only needed to be worn when skating in specific locations, such as a skate park or on a road (Ong et al., 2018). Similarly, the authors noted that another one-third (31.9%) of patients did not wear a helmet due to the perceived low levels of risk (e.g., have enough skill/experience to limit injury risk) (Ong et al., 2018). Examples of other identified potential barriers from previously published studies include poor helmet fit and discomfort, not owning a helmet, limited helmet use among peers and/or parents, and lack of parental rules on helmet use (Finnoff et al., 2001; Ong et al., 2018; Piotrowski et al., 2020).

Importantly, barriers to helmet use may vary between groups. For example, Robertson and colleagues found that parents in rural areas reported unique barriers related to helmet use among their children, including difficulty in finding proper helmets and the belief that activities in rural areas are safer than those in urban areas (Robertson, Lang, & Schaefer, 2014). Other factors that may contribute to the likelihood of helmet use among some groups included insurance status, as well as socioeconomic and certain demographic characteristics (Gulack et al., 2015; Robertson et al., 2014; Sullins et al., 2014). For example, studies examining the association between income and helmet use have been limited. After implementing bicycling helmet legislation in Ontario, Canada, one study found that helmet use increased in lower and middle income areas, but only slightly increased in higher income areas (Parkin, Khambalia, Kmet, & Macarthur, 2003). However, the slight increase in the higher income areas might be due to a ceiling effect or other confounding variables (Karkhaneh, Kalenga, Hagel, & Rowe, 2006), as communities with higher income tend to have a higher proportion of helmet use than communities with mid and low income populations (Harlos et al., 1999; Parkin et al., 1993). Additionally, another study (Jewett et al., 2016) found that White, non-Hispanic children (5–17 years old) were more likely to wear bicycle helmets than other racial and ethnic minority children (i.e., non-Hispanic Black, Hispanic, and non-Hispanic other race), similar to our study. Altogether, this may point to the importance of customizing helmet use interventions at the community level to address potential barriers and actions specifically designed to promote helmet use among middle school students (Owen, Kendrick, Mulvaney, Coleman, & Royal, 2011).

Despite evidence of effective strategies (Venkatraman et al., 2021), improving bicycle helmet use among youth is an ongoing challenge. For example, Sullins and colleagues found that approximately 90% of children involved in bicycle-related crashes and received medical care in Los Angeles County between 2006 and 2011 were not wearing a helmet, and helmet use was lower among older children, racial and ethnic minorities, and those from a low socioeconomic status (Sullins et al., 2014). Bicycle helmet laws are associated with long-term sustained helmet use rates and a 20%−55% reduction in bicycle-related head injuries, including TBIs (Hoye, 2018b; Huybers et al., 2017; Macpherson & Spinks, 2007). However, the effect of policy interventions is limited to only about 15% of the U.S. population (Governors Highway Safety Association, 2022; Jewett et al., 2016), as fewer than half of U.S. states and only some cities and communities have any kind of helmet law in place for bicycling. As such, a multipronged approach to promoting helmet use, inclusive of programmatic, educational, behavioral, and policy interventions, is considered most beneficial. Effective nonpolicy-related interventions may include community-based programs that consist of education and the provision of helmets at no cost (Owen et al., 2011; Royal, Kendrick, & Coleman, 2007). Further, as helmets are only designed to prevent injuries to the head, face, and neck, the National Transportation Safety Board recommends promoting overall bicyclist safety through actions such as infrastructure changes (e.g., adding bicycle lanes and adding signage and pavement markings at interactions); separation on roadways between cars and bicycles (e.g., adding physically protected bicycle lanes and intersections); decreased presence of road hazards (e.g., potholes); addressing drivers’ and bicyclists’ behaviors (e.g., reducing or eliminating impaired or distracted driving or cycling, improving awareness and compliance to traffic laws); and increasing awareness of high-risk activities (e.g., bicycling in dark conditions, undesignated street crossing; Helak et al., 2017; Hoye, 2018b; Richard, Magee, Bacon-Abdelmoteleb, & Brown, 2018). Further information can be found at https://www.cdc.gov/transportationsafety/bicycle/index.html.

While there are systematic reviews and reports dedicated to bicycle safety, little to no such detailed scientific reports are dedicated to the effect of policies and programs on rollerblading and skateboarding, nor to the effectiveness of helmet laws for these activities. Still, multiple studies call for helmet use among youth who participate in recreational and competitive skateboarding and rollerblading due to the risk for severe head and brain injuries (McIntosh, Patton, & McIntosh, 2021; Mitchao, Lewis, Jakob, Benjamin, & Demetriades, 2021; Ong et al., 2018; Partiali, Oska, Barbat, Sneij, & Folbe, 2020; Sadeghian et al., 2017). Mitchao and colleagues analyzed skateboard-related injuries over a 10 year period and found that helmet use was significantly associated with a reduced odds of severe TBI (OR 0.534, 95% CI 0.455–0.627, p < 0.001; Mitchao et al., 2021). The American Academy of Pediatrics (2021), Consumer Products Safety Commission (2012), American Academy of Orthopaedic Surgeons (2015), SafeKids Worldwide (2022), and others have educational materials that include strategies to reduce the risk for injuries while rollerblading and skateboarding. Injury prevention strategies in these materials not only emphasize wearing helmets and other protective gear, but also inspecting equipment prior to use, not rollerblading or skateboarding alone and when it is dark outside, limiting speeds, and avoiding motor vehicles. The effectiveness of available educational materials on rollerblade and skateboard helmet use and overall safety is not currently available in the published literature. Future efforts to evaluate and identify effective strategies to promote helmet use among youth who rollerblade and skateboard may prove to be effective.

While findings from this study indicate that helmet use among middle school students improved over time, overall helmet usage during bicycling, rollerblading, and skateboarding remained low in some states. Among the states examined, more than two-thirds of middle school students and approximately three-fourths of middle school students self-reported rarely or never wearing while bicycling and rollerblading and skateboarding, respectively. Students in 7th and 8th grade, as well as select racial and ethnic minority students were less likely to report wearing a helmet during while bicycling, rollerblading, or skateboarding as compared to 6th grade students and White students. Several systematic reviews and detailed reports are dedicated to exploring bicycle helmet use and safety; however, there is little to no available research on strategies to promote helmet use among youth who rollerblade and skateboard. 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, rollerblade, and skateboard (inclusive of education, helmet distribution, and social marketing techniques) that address perceived risks for injury and other barriers may be beneficial.