May 16, 2020

Using A Bicycle Helmet Is Using Your Head: The Evidence for Helmet Use Across Canada

Article by: Alan Morris, Ph.D, (Eng.).

It’s spring and cycling is now in full swing, and due to the global pandemic it appears more popular than usual. Most adults insist that their children wear a helmet when they ride a bicycle, but often only able to enforce use to a certain age. Ironically, you may also see these adults cycling without helmets while accompanying their helmeted children.

Most adults who are serious about recreational cycling will wear helmets, but we also see many adults commuting to and from work on city streets without wearing a helmet. Bicycle sharing programs do not include helmets nor insist that users wear one. Bicycle accidents can happen with and without motor vehicles, and regardless of experience, gender, education, etc. In this article, we make the case for wearing a helmet. Head injuries impose a significant economic burden on society due to hospital-related costs, rehabilitation costs, and support services required for brain-damaged individuals. It is estimated that each dollar invested in a helmet saves about $30 to societal costs, and that a head injury will impose $400,000 in medical costs in the first year following injury.(1)

A 2017 publication by Statistics Canada (2) of 2013/14 data studied cyclists by age (12+), gender, education level, household income level, urban or rural location, and by province. On average, only 42% of those surveyed always wore helmets when cycling. On average, across all categories, females wore helmets 2-10% more often than their male counterparts. Children aged 12-14 showed the greatest use of helmets (47.1%), with use dropping amongst youth 15-17 (27.9%) and amongst adults 18-24 (25.3%). Those with only a high-school education wore helmets significantly less than those with post-secondary education (26.7% vs. 45.2%). By income, lower income households tended to wear helmets less than those with middle and upper-middle incomes or greater (28.4% vs. 45.5%). In population centres (cities) there was a greater usage compared with rural areas (44.1% vs. 32.4%). By province and territory, there was great variation in reported helmet use: Prince Edward Island (67.4%), British Columbia (65.3%), Nova Scotia (64.3%), New Brunswick (52.5%), Yukon (50.5%), Alberta (48.2%), Newfoundland/Labrador (45.9%), Ontario (38.2%), Quebec (34.5%), Northwest Territories (31.8%), Manitoba (31.5%), and Saskatchewan (22.0%). 

Table 1 summarizes mandatory bicycle helmet legislation by province, average helmet use and annual age-adjusted rate of cycling injuries. There appears to be no correlation between the existence of mandatory bicycle helmet legislation, helmet usage rates, and annual age-adjusted rates of cycling injury. Differences in injury rates may be due to differences between the numbers of rural and urban cyclists as well as the frequency of cycling activity of those surveyed.

A recent study by (Tescke et al., 2015)(3) looked at Canadian hospitalization rates between 2006 and 2011. The authors found that:

  1. Females had consistently lower hospitalization rates than males.
  2. A greater proportion of road use by cyclists (mode sharing) was associated with lower hospitalization rates.
  3. Helmet legislation was not associated with rates of brain, head, scalp, skull, face or neck injuries.

The results of the Teschke group’s study might, incorrectly, lead some to conclude that hospitalizations for head and neck injuries are independent of helmet use. Since the 1980’s, numerous western studies have been undertaken since the 1980s to evaluate the efficacy of bicycle helmets in preventing head injuries: Dorsch et al. (1987)(4), Wasserman et al. (1988)(5), Thompson et al. (1989)(6), Wasserman and Buccini, (1990)(7), Spaite et al. (1991)(8), McDermott et al. (1993)(9), Maimaris et al. (1994)(10), Thomas et al. (1994)(11), Finvers et al. (1996)(12), Thompson et al. (1996)(13), Rivara et al. (1997)(14), Jacobson et al. (1998)(15), Linn et al. (1998)(16), Shafiet et al. (1998)(17), Hausotter, W. (2000)(18), Hansen et al. (2003)(19), Heng et al. (2006)(20), Amoros et al. (2009)(21), Amoros et al. (2012)(22), and Persaud et al. (2012)(23).

Typically, such studies review Emergency Department records of attending children, youth, and adults that have sustained an injury while cycling, examined the nature of the accident and established whether the individual had been wearing a helmet and what type of helmet it was. The hospital records typically record the location, type and level of an injury.

A few meta-analysis studies have been performed to analyse the results of a group of various previous individual studies and draw conclusions of helmet efficacy:

Attewell et al. (2001)(24), Elvik (2011)(25) and Elvik (2013)(26). Attewell found that helmets reduced the risk of head injury by 60%, reduced the risk of brain injury by 58%, reduce the risk of facial injury by 47% and reduce the risk of fatality by 73%. Elvik similarly concluded that helmets reduced the risk of head injury by 57-62%, reduce the risk of brain injury by 58-60%, reduce the risk of a facial injury by 23-44%, reduce the risk of a neck injury by 36-40%, and reduce the risk of a fatality by 63-77%. These meta-analyses indicate that bicycle helmets offer a significant reduction in the risk of head injury and fatality. In fact, these estimates of helmet effectiveness may be conservatively low as it would be realistic to suspect that there would be more unreported non-injured head impacts while wearing a helmet than unreported non-injured non-helmeted head impacts.

This is a lot of information to unpack for stakeholders, but the take-home messages regarding cycling collisions, helmet use and usefulness are:

  • Helmet use will reduce a cyclist’s risk of serious head injury by at least 57% and risk of fatality by at least 63%.
  • Provincial helmet legislation was not associated with rates for brain, head, scalp, skull, face or neck injuries.
  • As provincial helmet legislation does not appear to affect injury rates, it is imperative that public health units continually promote helmet usage in order to reduce rates of potentially life-changing head injury.
  • Helmet use is generally affected by gender, education, economic circumstance and residing province.
  • There are lower hospitalization rates for cyclists in areas where there is a greater occurrence of road-sharing between motorists and cyclists.
  • Urban roadway design strategies to better address cohabitation of the roadways between bicycles and motor will reduce motor vehicle-bicycle collision rates.
  • The relative risk of serious head injury between non-helmeted and helmeted cyclists is independent of the absolute risk of a motor vehicle-bicycle collision, so helmet use is always warranted.

References:

1 Safe Kids Canada Position Statement on Bicycle Helmet Legislation 

2 Canadian Community Health Survey (2013/14)

3 Teschke, K. et al. (2015) BMJ Open 5 (11): 1-12.

4 Dorsch, M.M. et al. (1987) Accident Analysis and Prevention 19: 183-190.

5 Wasserman, R.C. et al. (1988) American Journal of Public Health 78: 1220-1221.

6 Thompson, R.S. et al. (1989) New England Journal of Medicine 320: 1361-1367.

7 Wasserman, R.C. and Bucini, R.V. (1990) American Journal of Sports Medicine 18: 96-97.

8 Spaite, D.W. et al. (1991) Journal of Trauma 31: 1510-1516. 

McDermott, F.T. et al. (1993) Journal of Trauma 34: 834-845. 

10 Maimaris, C. et al. (1994) British Medical Journal 308: 1537-1540.

11 Thomas, S. et al. (1994) British Medical Journal 308: 173-176.

12 Finvers, K.A. et al. (1996) Clinical Journal of Sport Medicine 6: 102-107.

13 Thompson, D.C. et al. (1996) Journal of the American Medical Association 276: 1968-1973.

14 Rivara, F.P. et al. (1997) Injury and Prevention 3: 110-114.

15 Jacobson, G.A. et al. (1998) Australian New Zealand Journal of Public Health 22: 451-455.

16 Linn, S. et al. (1998) Injury and Prevention 4: 122-125.

17 Shafi, S. et al. (1998) Journal of Pediatric Surgery 33: 317-321.

18 Hausotter, W. (2000) Versicherungsmedizin 52: 28-32.

19 Hansen, K.S. et al. (2003) Traffic Injury and Prevention 2: 285-290.

20 Heng, K.W.J. et al. (2006) Singapore Medical Journal 47: 367-372.

21 Amoros, E. et al. (2009) Convention InVS J06-24,. INRETS, Lyon.

22 Amoros, E. et al. (2012) Injury and Prevention 18: 27-32.

23 Persaud, N. et al. (2012) Canadian Medical Association Journal 184(17): E921-E923.

24 Attewell, R.G. et al. (2001) Accident Analysis and Prevention 33: 345-352.

25 Elvik, R. (2011) Accident Analysis and Prevention 43: 1245-1251.

26 Elvik, R. (2013) Accident Analysis and Prevention 60: 245-253.

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