A National Study of Rural Adolescent Bicycle Helmet Attitudes and Use

AnnaMarie Fjeld, BS
Brianna Iverson, MD
Kareem Shoukih, BS
Parker Sternhagen, BS
Sarah Nichols, BS
Taeuk Kang, MBiotech, MSc
Kristel Wetjen, RN, BSN
Brenda Vergara
Pam Hoogerwerf, BA
Charles Jennissen, MD

Bicycling is a common activity among children and adolescents but remains an important source of preventable injury. Head injuries account for the majority of bicycle-related fatalities, and prior research demonstrates that bicycle helmets substantially reduce the risk of head injury and fatal head injury. Despite this evidence, helmet use remains low among youth, particularly adolescents, who may be influenced by peer norms, reduced parental supervision, and low perceived injury risk. Most studies of youth bicycle helmet use have focused on urban or general pediatric populations, with limited data addressing rural adolescents. This study evaluated bicycle helmet use, attitudes toward helmet use and helmet laws, and factors associated with helmet use among rural adolescents.

A convenience sample of attendees at the 2025 National FFA Convention & Expo completed an anonymous survey at the University of Iowa Stead Family Children’s Hospital injury prevention booth. Responses were collected in Qualtrics and analyzed using SAS 9.4. Descriptive statistics were calculated. Bivariate analyses were performed using chi-square, Fisher’s exact, Kruskal-Wallis, and Wilcoxon rank sum tests. Multivariable logistic regression was used to assess factors associated with helmet use and support for helmet laws.

2,516 respondents aged 13–18 years participated. Most respondents were female (56%), ages 16–18 years (56%), and non-Hispanic White (91%). Thirty-eight percent lived on a farm, 38% lived in the country but not on a farm, and 14% lived in towns. Most participants (86%) reported having at least one bicycle in their household. Two-thirds (67%) had ridden a bicycle in the past year with those from farms and the South having lower ridership, both p<0.008. Overall helmet use was low: 15% always, 12% mostly, 12% sometimes, 18% rarely, and 43% never wore a helmet while riding. The mean helmet-use importance rating was 5.5 out of 10, and only 26% supported bicycle helmet laws. Compared with adolescents from other regions, Midwest respondents had lower proportions supporting helmet laws (23% vs 30%) and always/mostly wearing a helmet (23% vs 32%), both p?0.001. Farm respondents had approximately half the odds of supporting helmet laws compared with town dwellers, and reported lower helmet importance ratings and lower helmet use than those living elsewhere, both p<0.008. Respondents from states with youth bicycle helmet laws had higher helmet importance ratings (6 vs 5) and higher percentages always/mostly wearing helmets (33% vs 24%) than those from states without such laws, both p<0.001. Adolescents with a strict parental “no helmet, no riding” rule had 22 times greater odds of supporting helmet laws and nearly 5 times greater odds of always/mostly wearing helmets.

Rural adolescents, particularly those living on farms and in the Midwest, reported infrequent bicycle helmet use and limited support for helmet laws. State helmet laws and strict parental helmet rules were associated with more favorable helmet attitudes and greater helmet use. Injury prevention efforts should target both rural adolescents and parents by addressing social norms, parental rule-setting, and policy-level strategies to increase helmet use and reduce bicycle-related head injuries.

Attendees will be able to:
1. State the frequency of rural adolescent’s use of bicycles and bicycle helmets, and which youth might be at greater risk for not wearing a helmet while riding bicycles.
2. Identify at least three rural adolescent demographic groups who ascribe lower importance to helmet use.
3. Discuss how a strict parental “no helmet, no bike riding rule” might influence bike helmet use and attitudes.