Socioeconomic Factors Associated with Helmet Use in Pediatric ATV and Dirt Bike Trauma

Background: Recreational ATV and dirt bike crashes yield severe injury and death in children, often from head trauma sustained while riding without a helmet. Although helmets are required for competition, recreational riders commonly forego helmets. This study aimed to identify socioeconomic factors associated with lower helmet use among children riding ATVs and dirt bikes recreationally, thus informing injury prevention efforts.

Methods: Retrospective review of an institutional trauma registry identified patients <18 years presenting after ATV or dirt bike crash to an ACS-verified Level 1 pediatric trauma center (2010-2019). Riders injured in competition were excluded. Demographic, injury, and outcome data were collected. U.S. Census data regarding median income, poverty prevalence, and high school graduation rate were recorded for each patient’s home county. Relationships between helmet use, demographics, and socioeconomic variables were examined using univariable and multivariable statistical analyses.

Results: The cohort comprised 680 recreational ATV (n=510; 75%) and dirt bike (170; 25%) riders. Unhelmeted riders (n=450; 66.2%) were significantly older (median age 13 vs. 11) and more often rode ATVs (n=399; 88.7%). Significantly greater percentages of females (77.9%) and passengers (89.5%) rode without helmets. Residents of counties with lower median income, higher poverty prevalence, and lower high school graduation rate were significantly less likely to wear a helmet. In multivariable analysis, unhelmeted riding was predicted by older age (OR=1.219, p<0.0001), ATV use (OR=6.757, p<0.0001), and riding as a passenger (OR=6.457, p<0.0001). Lower median income of home county predicted unhelmeted riding (p=0.0085), with a decrease in median income from the 75th to 25th percentile making unhelmeted riding 1.4 times more likely.

Conclusion: Older age, female gender, passenger status, and ATV use were associated with unhelmeted recreational vehicle use among children. Additionally, residence in a county with greater poverty, lower median income, and lower high school graduation rate was associated with reduced helmet use. Lower median income of home county significantly predicted unhelmeted riding. This study characterized the demographics of children who are least likely to wear a helmet and delineated the specific regional communities with greatest need for injury prevention initiatives.