Road traffic accidents are one if not the top cause of death and injuries worldwide, nearly 1.2 million people die and millions more are injured or disabled as a result of road crashes [1] . If that was not enough, these accidents are also causing an enormous social cost on individuals, families, and communities, affecting health services and countries’ economies costing them 1% - 2% of their gross national product, for applying an active road safety infrastructure can help tremendously in decreasing the amount of road traffic-related injuries and deaths [2] . In many low-income and middle-income countries, users of two-wheelers like Motorcycles and bicycle riders are at an increased risk of being involved in a crash and that is because they often share traffic spaces with fast-moving cars, buses, trucks and are less visible in addition to their lack of physical protection makes them particularly vulnerable to being injured if they are involved in a collision. In most high-income countries, motorcycle fatalities typically comprise around 5% to 18% of overall traffic fatalities [3] [4] . For instance, in China, motorcycle ownership between 1987 and 2001 grew rapidly from 23% to 63%, with a corresponding increase in the proportion of traffic fatalities sustained by motorcyclists rising from 7.5% to 19% over the same period [5] .

This is a cross-sectional study, aiming to evaluate the Knowledge, attitude, and practice of helmet use among Male and Female Parents living in Riyadh aged 21 - 60 Years old and above.

The survey was developed in English first and then translated into Arabic Sample size according to the Saudi General Authority of Statistics. The Number of married Saudi adults who lived in Riyadh in 2017 was 1,925,179. Based on an acceptable margin of error equal to 5%, an expected frequency of 50%, and a design effect of 1 with 95% confidence, a sample size of at least 385 is required for our study. The sample size was calculated using Epi Info version 7.2.3.1.

Exclusion criteria:

● Living outside Riyadh.

● Age < 21.

● No Children.

This study was approved by the Institutional Review Board (IRB) of Prince Sultan Military Medical City.

Using Google Forms as our base for online surveys with the use of snowball sampling technique, with initial written consent at the start of the online survey which was open from 12/7/2021-3/5/2022, the Number of responses collected was around 1100 with the use of our exclusion criteria we were able to reach our required sample size with 386 Male and Female Parents living in Riyadh aged 21 - 60 Years old and above.

The demographic variables used in the study were Age, Gender, Education level (High school or less, Diploma, Bachelor, Master, PhD or Higher), Number of children, Age of children, Living in Riyadh, or Outside Riyadh.

The participants (Parents) were asked if they owned a Motorcycle, Quad Bike, or Bicycle, and if they used of Motorcycle, Quad Bike, or Bicycle did they wear a Helmet, or No.

Then participants (Parents) were asked about their children where they rode the Bicycle or Motorcycle Quadbike and in certain areas (At home, on the road, in the desert, on the farm, in a public space for riding, or if they did not ride). Then participants (Parents) were asked if their children wore a Helmet during the Use of a Bicycle or Motorcycle Quad Bike if they did not own a helmet or if they did not know. Then participants (Parents) were asked if their children had sustained any injuries while riding these vehicles and if they were wearing a Helmet when the incident happened. Then participants (Parents) were asked about what they thought about the importance of Helmet use by their children while riding these vehicles. Then participants (Parents) were asked to give their opinion on the optimal way to increase the use of helmet wear.

The data were collected, reviewed and then fed to Statistical Package for Social Sciences version 27 (IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). All statistical methods used were two tailed with alpha level of 0.05 considering significance if P value less than or equal to 0.05. Descriptive analysis was done by prescribing frequency distribution and percentage for study variables including parents’ demographic data, children age, while properties at home were graphed. Also, parents and children bicycle, motor cycle riding a using helmet practices with injury history and their knowledge and attitude about using helmets in children to prevent head injuries were tabulated. Cross tabulation to assess factors associated with parent’s knowledge and attitude about using helmets in children to prevent head injuries was carried out with Pearson chi-square test for significance and exact probability test if there were small frequency distributions.

A total of 386 eligible parents were included in the study. Parents ages ranged from 21 to more than 60 years with a mean age of 41.2 ± 11.9 years old. A total of 202 (52.3%) respondents were mothers, 174 (45.1%) had a bachelor degree and 76 (19.7%) had a post-graduate degree. Exact of 124 (32.1%) respondents had 1 to 2 children, 144 (37.3%) had 3 to 4 children and 118 (30.6%) had 5 or more children. As for age of the child, 108 (28%) had a child aged more than 15 years, 105 (27.2%) had a child aged 6 to 10 years, and 77 (19.9%) had a child aged less than 5 years (Table 1).

Figure 1, prosperities parents have in their own, Riyadh city, Saudi Arabia. A total of 157 (40.7%) of the parents had bicycle, 28 (7.3%) had motorcycle, 27 (7%) had quadbike, while most of the study parents did not have any of those.

Table 2, parents and children bicycle, motor cycle riding practices and injury history. Exact of 89 (23.1%) of stud fathers ride a Bicycle or Motorcycle or Quad bike and 16 (4.1%) parents (fathers and mothers) do. Also, 56 (50.5%) of fathers

who wear a helmet when using a Bicycle or Motorcycle or Quad bike and 11 (9.9%) of both parents do (9.9%). A total of 145 (37.6%) of children ride the Bicycle at home, 87 (22.5%) ride in public parks, and 51 (13.2%) on the road. Also, 78 (20.2%) of the study parents’ children usually ride the Motorcycle or Quadbike in the desert, 42 (10.9%) at home, and 34 (8.8%) in public parks. As for wearing helmet, 182 (47.2%) of the parents reported that their children don’t own helmet, 57 (14.8%) wear helmet while riding both (Bicycle and Motorcycle/Quadbike), 33 (8.5%) wear helmet while riding a Bicycle only and 26 (6.7%) wear helmet While riding a Motorcycle or Quadbike. A total of 128 (39.3%) of the study parents told that their children had injuries while riding a Bicycle or Motorcycle or Quad bike and only 26 (16.8%) of them were wearing a helmet while riding a Bicycle or Motorcycle or Quad bike when they sustained their injury.

Table 3, parents knowledge and attitude about using helmets in children to prevent head injuries. The vast majority of the study parents (76.7%; 296) agreed that its important for the children to wear a helmet when riding Bicycle and Motorcycle/Quadbike, 58 (15%) agreed to wear while riding a Motorcycle or Quadbike, and 8 (2.1%) agreed to wear while riding a Bicycle. The most reported optimal way to increase the use of helmet wear suggested by the study parents included improving public awareness of the importance of helmet wear (18.7%), Setting a clear law and enforcing it when not using the helmet (18.7%), Forcing rental shops to give out helmets when renting a bicycle or Motorcycle or Quadbike

(8.5%), Forcing sellers to recommending the use of helmet when purchasing a bicycle, Motorcycle or Quadbike (5.7%) while 48.4% reported for all of these.

Table 4, factors associated with parent’s knowledge and attitude about using helmets in children to prevent head injuries. All parents who wear helmet when using a Bicycle or Motorcycle or Quad bike totally agreed for its impotence to prevent injuries compared to 63.2% of those who did not (P = 0.046). Also, 89.5% of parents whose children wear helmet during riding both (Bicycle and Motorcycle/Quadbike) totally agreed for its importance compared to 84.8% of parents whose children wear during bicycling but 69.8% of those whose children didn’t own helmet (P = 0.029). Likewise, 96.1% of parents whose children were injured while riding a Bicycle or Motorcycle or Quad bike agreed for wearing helmet importance versus 93% of others who had non-injured child (P = 0.049).

The current study aimed to assess knowledge, attitude, and practice of using helmets in children amongst parents to prevent head injuries. As riding bicycles and all-terrain vehicles (ATVs) is a popular pastime among kids, despite the American Academy of Pediatrics’ (American Academy of Pediatrics Committee on Injury and Poison Prevention) recommendation that minors under 16 not ride ATVs [1] [2] .

The current study showed that most of the parents were highly educated with 3 or more children. Also, about half of the study families had bicycle, motorcycle,

P: Pearson X² test, ^: Exact probability test, *P < 0.05 (significant).

or quad bike which mean high liability for injuries. Also, about one-third of the parents ride a Bicycle or Motorcycle or Quad bike but two-third of them wear a helmet when using a Bicycle or Motorcycle or Quad bike. This may be negatively reflected on their children behavior making them more liable for injuries if wear bicycles or motorcycles unprotected simulating their parents. This was proved in a study conducted in USA by Jewett A. et al. [3] who found that 21% of adults reported riding a bicycle in the previous 30 days, and 29% said they always used a helmet. Of the 61% of kids who rode bicycles in the previous 30 days, 42% of respondents said they always wore helmets. When adult respondents said that they always wore helmets, children were more likely to do the same (90%) than when they reported that they did not (38%). Also, Ehrlich P.F. et al. [4] found that More than 60% of parents don’t wear helmets when riding, and their kids tend to simulate that. In the current study this was more clarified later where more than half of the parent’s children use mainly bicycles, but others also use motorcycle or quadbike with a disappointing finding was that nearly half of them don’t own helmet and very few percent use it while using any. This explains the high rate of reported injuries while riding a Bicycle or Motorcycle or Quad bike (more than one-third) and about two-thirds were not wearing helmet while riding a Bicycle or Motorcycle or Quad bike when they sustained their injury. Similar poor practice regarding wearing helmet was reported by Weiss B.D. [5] as Just only 1.85% of elementary schools’ bicyclists had on a helmet. Also, 1.9% of the senior high riders and none of the 103 junior high bikers used helmets. Helmet use was reported by 10% of university bikers, which is substantially higher than the other age groups. Also, Linn S. et al. [6] found that more than 70% of cyclists who suffered injuries said they never used a helmet. When it came to bicycle accidents, the percentage of patients who were admitted without a helmet was consistently greater than the percentage of patients who did. Similarly, Shafi S. et al. [7] documented that only 15% of Bicycle crash victims wore helmets at the time of the crash. Wymore C. et al. [8] documented that the percentage never wearing a helmet while on an ATV was 68% for subjects, 71% for spouses, and 47% for children.

Regarding parent’s knowledge an attitude about using helmet in children to avoid injury, the current study showed that most of the study parents agreed about the importance of wearing a helmet when riding Bicycle and Motorcycle/Quadbike but less than one-fifth of them partially agreed (told about importance during only bicycling or during motorcycle only). In concordance to the current study findings, Wymore C et al. [8] reported that on a scale of 1 to 10, the importance of children wearing helmets on bicycles and ATVs was assessed as high and equally important, at 9.28 and 9.58 points, respectively. Also, Jantz P.B. and Trinh T.L., [9] in their study concluded that parents showed a high significant attitude towards the adult and child motorcycle helmet-wearing practices. Many other studies revealed that parents who participated in the studies were aware that helmets can prevent brain injury and that their behavior is ultimately influenced by their modeling and promotion of helmet wear [10] [11] [12] . On the other hand, Miller P.A. et al. [13] in their study found that about 33% of the parents heard about helmets from their children’s pediatrician.

In conclusion, the current study revealed that irrespective of high parents’ awareness and attitude towards the significance of using helmet during bicycling, most parents did not use it which was negatively reflected on their children behavior. Most parents know about the helmet use importance to prevent head injury and they also agreed for the significance of raising public awareness about this issue either through health education campaigns or through legislations.

The authors declare no conflicts of interest regarding the publication of this paper.

Bukhari, T.S.A., Aldhban, A.Y., Alqasem, A.A., Al Hatlani, D.J., Aldosaimani, H., Al Madi, H.A. and Alqahtani, K. (2024) Knowledge, Attitude, and Practice of Using Helmets in Children amongst Parents to Prevent Head Injuries: A Cross-Sectional Study in Riyadh, Saudi Arabia. Open Journal of Pediatrics, 14, 255- 265. https://doi.org/10.4236/ojped.2024.142024