Getting outdoors this winter? Don’t forget your helmet.

Is your family hitting the slopes, sledding hill, pond or snowmachine trails this winter? Alaska health professionals have one heartfelt request for you:

Remember your helmet, and your kids’ helmets, too.

Too many Alaskans will hit their heads while playing outdoors this winter, including children and teenagers. Most of the time, those injuries -- which can have permanent effects -- are preventable.

Why kids fall

“Alaska is unique in that it’s the highest rate of traumatic brain injury in the nation,” said Susan Romero, an ANTHC pediatric critical care nurse practitioner who specializes in neurological trauma. “We see head injuries around skiing, snowmachining, ice skating -- anything that you can fall and hit your head.”

Helmet use is common for activities like bicycling and hockey, but oftentimes parents don’t realize the injury risks common to other activities that Alaskans love.

“Obviously ice and snow is slippery and it's fun to play in, and we see an uptick in outdoor activities in the winter,” Romero said. “Snow seems like it's soft until you're a projectile. It doesn't give as much as people believe it does.”

Kids are particularly at risk because of the way their bodies grow.

“Children have a larger head compared to body weight,” Romero said. “Smaller children, their head is like a projectile because the weight of their head is disproportionate to the weight of their body. When they fall, they're going to fall forward and hit their heads.”

When a motor vehicle like a snowmachine comes into the equation, falling turns into flying.

The impact of a brain injury

Head injuries aren’t the only way kids might get hurt playing outdoors, but they’re of extra concern for one reason: The head contains the brain. And when the brain is injured, that can impact the entire body.

“If you break something in your computer, the whole thing is affected,” Romero said. “Your brain is the computer.”

Brain injuries can range from a mild concussion to a severe traumatic brain injury, or TBI, which can have lifelong impacts on physical, cognitive, and emotional health. TBI patients can end up with any of a long list of symptoms, such as headaches, dizziness, vertigo, sleeplessness, apathy, memory loss, difficulty with decision making and problem-solving, decreased concentration, speech and language problems, changes to social behavior, impaired vision, and more.

“Social is a big thing that people don’t think of right out of the box,” Romero said. “It changes your behavior. You have injured the neurons in the brain. Your personality is affected by those neurons as well. They lose their ability to judge things.” Someone who has experienced a TBI may be apathetic, she said, or they may have mood swings or make socially inappropriate comments. TBI patients may also be at increased risk for depression, anxiety, eating disorders, substance abuse and borderline personality disorder.

Even a mild brain injury heightens the risk of experiencing another one the next time you hit your head, and the symptoms may not be immediately apparent, according to ANTHC Injury Prevention Program Manager Ingrid Stevens.

“Your executive functioning, your verbal functioning -- oftentimes TBIs will go undiagnosed or not screened for,” Stevens said. Sometimes those symptoms won’t be spotted until they show up years later in a behavioral health screening.

Helmet culture in Alaska

From 2013 through 2017, the state trauma registry ranked snowmachines as among the top 10 causes of hospitalization due to injury in every age group except for children younger than 10 and adults older than 74. Sledding ranked in ninth place for kids 5 to 9 years old, and a general “sports” was a leading cause of injury among ages 10 to 19.

While many winter sports would be safer with helmets, snowmachining is of particular concern simply because crashes or falls at higher speeds often result in more severe injuries. Romero said helmet use on snowmachines tends to be more common among recreational riders than for transportation users in rural communities where a snow-go may take the place of the family car.

“In a subsistence lifestyle, you're utilizing that ATV to feed your family,” Romero said. “When it's a recreational activity, people tend to be more aware of the hazards. Their paradigm's a bit different.”

Helmets are expensive, and not everyone can access or afford them. But even helmet distribution programs aren’t enough to fix the problem. Just as seat belt use in cars has increased over time as it has become a cultural norm to buckle up, health professionals say it will take a cultural shift to get more Alaska kids wearing helmets.

“We can hand out helmets until we run out of program dollars, but really it's about education,” Stevens said.

City officials, Tribal transportation programs, parents and students all need to be taught about the importance of wearing helmets and enforcing helmet laws, she said.

“The State of Alaska actually has a helmet use law that covers the entire state,” Stevens said. “It’s just really poorly enforced.” Stevens said communities like Unalakleet, where there has been a concerted enforcement effort, are taking meaningful steps toward change.

Romero concurred, adding that the example needs to come from every member of the community.

“You have to talk about changing the entire culture, from adults to small children,” Romero said. “If we got the adults wearing helmets, I think you would see a greater change.”

Community involvement is key

Romero says a community-based plan can be an effective way to change helmet culture.

“Pilot Point, out in the Bristol Bay region, made city ordinances where the children are required” to wear helmets, she said. “If they’re caught not wearing a helmet, anyone in the village can call the VPSO. That individual has to do community service time and serve the Elders in the community.” That’s for a first offense, she added. If a child is then caught a second time, their parents have to participate in the service with them.

Since that program started the local injury prevention specialist reports that while there have been ATV accidents, those accidents had no brain injuries because the riders were wearing helmets.

“If you just give it to them, they aren't going to wear it,” Romero said. “It needs to be mentored into their way of life.”

It’s a big shift in communities that haven’t had a strong helmet culture.

“It’s not that they don’t care about safety, it’s just that no one’s ever done it,” Romero said. “They don’t even think of it, I think, until someone gets injured.”

New Stuyahok’s silver lining

That’s exactly what happened last year in New Stuyahok, where ANTHC recently staged a helmet education initiative. Community leadership invited the Tribal health organization after a local youth suffered a TBI while riding an ATV without a helmet.

“The family had gone through months of follow-up appointments -- what we call ‘postvention,’” Stevens said. “They had asked the ANTHC Trauma Center, ANTHC Injury Prevention, and also the Bristol Bay Area Health Corp. Injury Prevention to visit and essentially do more education.”

WATCH: New Stuyahok learns from a near-fatal ATV crash. Part I Part II

Using an adaptation of the ATV Safety Toolkit developed by Arkansas Children’s Hospital, ANTHC and BBAHC professionals worked with multiple age groups on helmet safety.

“A lot of what we did was education,” Stevens said. “We went into the schools and we taught this ATV toolkit education to 120 students.”

Students were ready to hear the message, she said.

“One of the things that we think about in public health is timing,” Stevens said. “I think because they knew about the crash, they knew the student, they knew the family -- it's such a small community, it was well known what happened afterwards. It seemed to resonate really well with the younger students.”

For New Stuyahok, the gradual shift in residents’ habits is a silver lining -- but it’s unclear whether the message will resonate as strongly in communities that haven’t been directly impacted.

Romero and Stevens say they don’t want other communities to wait until they’ve been affected by injury to insist on a change for themselves.

“No matter what, fast movement on slippery surfaces -- ATV, snowmachine, skiing, roller blading, bikes, skateboarding -- when you fall, you're likely going to hit your head,” Romero said. “The body heals, but the brain -- when you bruise the brain, it leaves a lasting bruise.”

This story was sponsored by Alaska Native Tribal Health Consortium, a statewide nonprofit Tribal health organization designed to meet the unique health needs of more than 175,000 Alaska Native and American Indian people living in Alaska

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Alaska Native Tribal Health Consortium. The ADN newsroom was not involved in its production.