Bicycling is a popular activity that individuals and especially children overindulge. Unfortunately, there is public concern regarding this activity due to a high number of injuries that are associated with high levels of hospitalization. 35% to 40% of pediatric head injuries are attributed to bicycling. Also, poor bicycling procedures have led to increased traumatic brain injury and death. Bicycle safety and helmet is an imperative topic to nursing practice because it helps in the development of effective strategies to promote helmet use. Past research has indicated that all bicycle users do not uniformly use the helmets. Hence, in order to prevent preventable injuries that tend to overwhelm the healthcare system, nurses can use the evidence on the effectiveness of helmet use to plan for campaigns aiming to alleviate the situation (Macpherson & Spinks, 2008). A review by Thompson (cited in Macpherson & Spinks, 2008) indicates that 88% of head injuries and 65% of facial injuries can be reduced by the use of helmets among cyclists regardless of age. Identifying effective strategies in bike safety and reduction of bicycling-associated injuries will enable nurses to integrate these strategies in their practice; thereby, offer evidence-based interventions. SRRs are the best sources of evidence like the one reviewed herein because the studies included rigorous methodologies (Garg, Hackam, & Tonelli, 2008).
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Studies for inclusion in this review were obtained from reputable databases, such as the Cochrane Central Register of Controlled Trials, MEDLINE, The Cochrane Injuries Group, EMBASE, CINAHL, and TRANSPORT. Also, government websites and references used in the selected publications were included in this review. The studies used in this review were experimental studies that aim to establish an absolute cause and effect relationship. Hence, these studies were of high rigor. In addition, their methodological approach affirms this strong rigor because studies included in this SRR had to be:
- Cluster randomized controlled trials.
- Interrupted time series analysis with concurrent comparison groups.
- Controlled before-after study.
In accordance with the recommendations by Abalos, Carroli, Mackey, and Bergel (2001), this review articulately stated its study participants, types of interventions and expected outcomes, as well as the methods used to identify the studies.
The inclusion criterion of the studies to be involved in the SRR depicts evidence of high level because there is inclusion of at least one well-designed Randomized Controlled Trial as mentioned by The Board of Regents of the University of Wisconsin System (2016). However, the levels of evidence of the different types of studies based on the inclusion criterion are varied. The cluster randomized controlled trials fall in level II. In reference to a study by Grijalva et al. (2007), a time series analysis is a type of quasi-experimental study whose rigor of evidence is at level III. Controlled pre-post/before-after study is also a quasi-experimental study with level III kind of evidence. Unfortunately, the actual review did not identify any RCT, thus only quasi-experimental designs were used in the SRR and the evidence was of level III.
The studies included in the SRR have been described in a systematic manner. Initially, a brief description of the different studies in reference to the problem, hypothesis, methodology, adequacy of the sample size on the basis of power, and determination of both internal and external validity was indicated and later results were presented based on the intervention effects. The manner in which the results were presented in the SRR was clear, but indications of statistical significance were not included in all study results, yet no justification was indicated for this omission. Imperative results of any research are those which indicate high levels of statistical difference or associations; hence, it is not wrong to assume that no significant results emerged in such instances. The authors have been cautious of the validity of their SRR, and they have explained the possible areas where bias might have emerged, including lack of blinding as a potential source of bias (Karanicolas, Farrokhyar, & Bhandari, 2010). However, the aspect of reliability was not covered.
The SRR indicated a positive correlation between helmet use and bicycling safety. Unfortunately, the study did not determine the influence of the bicycle helmet legislation on societal and health domains. On the basis of the inclusion criteria, only 6 studies were included in the SRR. One study indicated a reduction in mortality rate of children younger than 16 years by 52% in the intervention group, which is equivalent to 55% reduction in mortality per 100,000 persons. Three studies evaluated the effect of bicycle helmet legislation on head injury and it was found out that despite reduction in head injury after the introduction of bicycle helmet legislation, this reduction was not statistically significant for both children (p=0.19) and adults (p=0.40). In another study, injuries among individuals aged 17 and younger significantly reduced (p=0.001) but the same was not observed in the adult population (p=0.505). Odds ratios were used to determine the odds of occurrence of traumatic brain injury (TBI), other head and facial injuries and injuries below the neck. The results indicated reduction in TBI (OR 0.82; 99% CI 0.76 TO 0.89) while reduction was not seen in head and facial injuries (OR 1.08; 99% CI 0.90 to 1.23) and injuries below the neck (OR 1.09; 99% CI 1.05 to 1.13). ORs in the adult group for TBI, head and facial injuries and injuries below the neck were OR 1.01; 99% CI 0.93 to 1.10, OR 1.05; 99% CI 0.9 to 1.22 and OR 0.99; 99% CI 0.97 to 1.02, respectively.
In Canada, bicycle helmet legislation indicated a 45% decline in the occurrence of head injuries in the intervention provinces in comparison to 27% reduction in the control provinces. The variation between the control and intervention was significant (p<0.001) and head injuries were shown to have significant decreases in comparison to other types of injuries in both intervention and control provinces. Two studies on helmet use indicated that helmet use enforcement programs have more effect on children than teens and adults. Similar results were realized in two other studies that examined the association between helmet use enforcement programs and actual helmet use.
The SRR revealed that bicycle helmet legislation had a significant effect on head injuries. Therefore, nurses can use this information in their practice when educating and promoting bicycle safety through helmet use. The fact that helmet use enforcement programs are effective on children helps in planning for education, campaign and promotion activities among children. The SRR reveals a challenge for the nursing practice because the bicycle and helmet legislation as well as the helmet enforcement programs have no effect on injury outcomes among adults as well as on helmet use in this population. Therefore, future research should take up a qualitative approach to find out from the adult population what would stimulate their increased usage of helmets and associated reduction in bicycle related injuries.
Abalos, E., Carroli, G., Mackey, M. E., & Bergel, E. (2001). Critical appraisal of systematic reviews: The WHO Reproductive Health Library, No 4. Geneva: The World Health Organization.
Garg, A. X., Hackam, D., & Tonelli, M. (2008). Systematic review and meta-analysis: When one study is just not enough. Clinical Journal of the American Society of Nephrology, 3(1), 253-260.
Grijalva, C. G., Nuorti, J. P., Arbogast, P. G., Martin, S. W., Edwards, K. M., & Griffin, M. R. (2007). Decline in pneumonia admissions after routine childhood immunization with pneumococcal conjugate vaccine in the USA: a time-series analysis. The Lancet, 369(9568), 1179-1186.
Karanicolas, P. J., Farrokhyar, F., & Bhandari, M. (2010). Blinding: Who, what, when, why, how? Canadian Journal of Surgery, 53(5), 345–348.
Macpherson, A., & Spinks, A. (2008). Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews. Web.
The Board of Regents of the University of Wisconsin System. (2016). Nursing resources: Levels of evidence (I-VII). Web.