Prevention of bicycle-related injuries in children and youth: a systematic review of bicycle skills training interventions Sarah A Richmond, 1 Yu Janice Zhang, 1 Andi Stover, 1 Andrew Howard, 1,2,3,4 Colin Macarthur 1,5 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ injuryprev-2013-040933). 1 Department of Child Health Evaluative Sciences, Research Institute, Hospital For Sick Children, Toronto, Canada 2 Division of Orthopaedic Surgery, Hospital for Sick Children, Toronto, Ontario, Canada 3 Department of Surgery, University of Toronto, Toronto, Ontario, Canada 4 Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 5 Department of Paediatrics, University of Toronto, Toronto, Canada Correspondence to Dr Sarah A Richmond, Department of Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8; sarah. richmond@sickkids.ca Received 18 June 2013 Revised 8 October 2013 Accepted 24 October 2013 To cite: Richmond SA, Zhang YJ, Stover A, et al. Inj Prev Published Online First: [ please include Day Month Year] doi:10.1136/ injuryprev-2013-040933 ABSTRACT Background Bicycling is a popular means of recreation and transportation for children; however, it is a leading cause of recreational injury. Bicycle skill development and safety education are important methods of bicycle injury prevention. Objective To determine the effectiveness of bicycle skills training programmes in reducing bicycle-related injuries in children and youth. Methods Sixteen databases were systematically searched to include studies involving children less than 19 years of age who participated in interventions that targeted bicycle skills and safety education. Outcome measures included injury, behaviour, knowledge and attitudes. Data extraction included study characteristics, intervention and outcomes. Quality of evidence was assessed using the Downs and Black criteria. Results Twenty-five studies, including both observational (ie, case–control) and experimental (ie, randomised controlled trials) designs met the inclusion criteria. Overall, there was no statistically significant intervention effect on measures of injury. Eight of 16 studies measuring knowledge reported significant knowledge gains as a result of the intervention. Of 13 studies evaluating behavioural and attitude changes, five reported significant improvement. There was no significant difference in quality index scores between studies that showed an improvement in knowledge or behaviour (61%, 95% CI 49% to 74%) and studies that did not (57%, 95% CI 48% to 66%). Conclusions There is a paucity of high-quality research in the area of bicycle skills training programmes. Educational and skills training bicycling programmes may increase knowledge of cycling safety, but this does not seem to translate into a decrease in injury rate, or improved bicycle handling ability and attitudes. INTRODUCTION Bicycling is a popular means of recreation, exercise and transportation for children and youth world- wide. There are more than 800 million bicycles in the world, twice the number of motor vehicles. 1 In Canada, it is estimated that 80% of children under 12 years of age ride a bicycle. 2 Only 20% of bicycle-related injuries requiring hospitalisation involve motor vehicle collisions; however, such col- lisions represent over 90% of all fatal cycling-related injuries. 2 A primary strategy to prevent bicycle-related injuries is the promotion of bicycle helmet use. A Cochrane systematic review showed that helmet use reduces the risk of head injury by up to 88% and facial injuries by up to 65% for cyclists of all ages. 3 In addition, reviews examining legislative and non- legislative helmet interventions demonstrate that both approaches are effective in increasing helmet use. 3–5 Other strategies to prevent bicycle-related injuries include environmental modification, education and skills training. Environmental modifications may include the installation of marked bicycle lanes, on-road bike routes or off-road bicycle paths. A recent systematic review reported that purpose-built bicycle- specific lanes reduce crashes and injuries among cyclists. 6 Educational and skills intervention strategies often focus on helmet use, but may also extend to bicycle skills training courses of varied duration, from 1-day bicycle rodeos (ie, a clinic that aims to educate children about rules and behaviours associated with safe cycling) to long-term courses integrated with school curricula. 78 It has been hypothesised that these training programmes may reduce the frequency of bicycle-related injuries through increased knowledge and compliance with traffic regulations, along with enhanced bicycle handling skills. 9 Skills training may be an important approach for vulnerable road users including cyclists and pedestrians who account for approximately 46% of global road traffic deaths. 10 To our knowledge, there has not been systematic evalu- ation of the effectiveness of bicycle skills training pro- grammes. Therefore, the primary objective of this systematic review was to determine the effectiveness of bicycle skills training programmes in preventing bicycle-related injuries in children and youth aged 0– 18 years. METHODS Data sources Data capture and manuscript preparation have fol- lowed PRISMA guidelines (see supplementary appendix A, available online only; figure 1). In col- laboration with a research librarian, comprehensive search strategies including combinations of medical subject headings and keywords were developed (table 1). The following electronic databases were systematically searched: BIOSIS, Canadian Research Index, CENTRAL, CINAHL, Dissertations & Theses, EBM Reviews, EMBASE, ERIC, ISI Web of Science, LILACS, MEDLINE, PsycINFO, SCOPUS, SafetyLit and TRANSPORT. All databases were searched from inception and the search is up to date as of February 2013. The journals Injury Prevention, Accident Analysis and Prevention and Pediatrics were hand-searched for relevant articles published from July 2007 to July 2012. Reference Richmond SA, et al. Inj Prev 2013;0:1–5. doi:10.1136/injuryprev-2013-040933 1 Systematic review IP Online First, published on November 21, 2013 as 10.1136/injuryprev-2013-040933 Copyright Article author (or their employer) 2013. Produced by BMJ Publishing Group Ltd under licence. group.bmj.com on June 16, 2017 - Published by http://injuryprevention.bmj.com/ Downloaded from