Bicycle helmet use four years after the introduction of helmet legislation in Alberta, Canada

Background

Bicycle helmets reduce fatal and non-fatal head and face injuries. This study evaluated the effect of mandatory bicycle helmet legislation targeted at those less than 18 years old on helmet use for all ages in Alberta.

Methods

Two comparable studies were conducted two years before and four years after the introduction of helmet legislation in Alberta in 2002. Bicyclists were observed in randomly selected sites in Calgary and Edmonton and eight smaller communities from June to October. Helmet wearing and rider characteristics were recorded by trained observers. Poisson regression adjusting for clustering by site was used to obtain helmet prevalence (HP) and prevalence ratio (PR) (2006 vs. 2000) estimates.

Results

There were 4002 bicyclists observed in 2000 and 5365 in 2006. Overall, HP changed from 75% to 92% among children, 30% to 63% among adolescents and 52% to 55% among adults. Controlling for city, location, companionship, neighborhood age proportion <18, socioeconomic status, and weather conditions, helmet use increased 29% among children (PR = 1.29; 95% CI: 1.20–1.39), over 2-fold among adolescents (PR 2.12; 95% CI: 1.75–2.56), and 14% among adults: (PR = 1.14; CI: 1.02–1.27).

Conclusions

Bicycle helmet legislation was associated with a greater increase in helmet use among the target age group (<18). Though HP increased over 2-fold among adolescents to an estimated 63% in 2006, this percentage was approximately 30% lower than among children <13.     

Improper motorcycle helmet use in provincial areas of a developing country

Motorcycle helmet wearing rates remain low in smaller cities in developing countries. We therefore examined the knowledge, attitudes, and behavior of motorcyclists towards helmet use in two mid-sized cities in China. The methods included roadside observation and interview. Observational sites were randomly selected from main roads and secondary streets; all motorcycles passing by were observed. Riders near the sites were opportunistically approached and asked about knowledge of and perceptions about helmet use. Altogether, 75,949 drivers and 17,230 passengers were observed. A large proportion of both drivers and passengers (34% and 71%, respectively) did not wear a helmet, or did not have their helmet fastened (34% and 14%). Proper helmet usage rates were lower among male drivers, younger people, on secondary streets, and during the evenings and weekends. The majority of the 2325 drivers interviewed (90%) acknowledged the benefits of helmet wearing, but 72% reported that helmets are not always comfortable, and only 20% said they would wear a helmet for preventive purposes. Furthermore, many felt that police enforcement was not strict (62%). These results suggest that educational programs about helmet use in provincial China should emphasize the risks of improper use. Strict enforcement, especially on secondary roads and during non-peak hours, could also improve helmet usage.     

Correlates of motorcycle helmet use among recent graduates of a motorcycle training course

Helmets significantly decrease morbidity and mortality from motorcycle crashes, but many areas of the world lack universal helmet laws. To educate motorcyclists in areas without helmet laws, more knowledge of motorcyclists’ helmet beliefs is needed.A web-based survey was therefore designed to assess motorcyclists’ attitudes, norms and behaviors towards helmets in a U.S. state with a limited helmet law. Of 445 survey respondents, 68.4% of respondents reported always wearing a helmet. The not-always-helmeted riders were more likely than the always-helmeted to be male; to bave less education; and to have a history of previous motorcycle crashes and injuries. Although both groups had taken rider training classes, fewer of the not-always-helmeted had learned how to ride in a class. The strongest correlates of being not-always-helmeted (vs. always-helmeted) were attitudes that helmets were not protective and impaired sight/hearing; and the normative belief that they would only wear helmets if forced by law. Because attitudes are often more easily changed than normative beliefs, education may increase helmet use. However, less than half of riders in this state with a mandatory education program learned how to ride from a rider education course, and 44% of non-helmeted said they would only wear a helmet if forced by law. Legislation may therefore be a more efficient and effective strategy than education to increase helmet use.     

Motorcycle protective clothing: protection from injury or just the weather?

Background

Apart from helmets, little is known about the effectiveness of motorcycle protective clothing in reducing injuries in crashes. The study aimed to quantify the association between usage of motorcycle clothing and injury in crashes.

Methods and findings

Cross-sectional analytic study. Crashed motorcyclists (n = 212, 71% of identified eligible cases) were recruited through hospitals and motorcycle repair services. Data was obtained through structured face-to-face interviews. The main outcome was hospitalization and motorcycle crash-related injury. Poisson regression was used to estimate relative risk (RR) and 95% confidence intervals for injury adjusting for potential confounders.

Results

Motorcyclists were significantly less likely to be admitted to hospital if they crashed wearing motorcycle jackets (RR = 0.79, 95% CI: 0.69–0.91), pants (RR = 0.49, 95% CI: 0.25–0.94), or gloves (RR = 0.41, 95% CI: 0.26–0.66). When garments included fitted body armour there was a significantly reduced risk of injury to the upper body (RR = 0.77, 95% CI: 0.66–0.89), hands and wrists (RR = 0.55, 95% CI: 0.38–0.81), legs (RR = 0.60, 95% CI: 0.40–0.90), feet and ankles (RR = 0.54, 95% CI: 0.35–0.83). Non-motorcycle boots were also associated with a reduced risk of injury compared to shoes or joggers (RR = 0.46, 95% CI: 0.28–0.75). No association between use of body armour and risk of fracture injuries was detected. A substantial proportion of motorcycle designed gloves (25.7%), jackets (29.7%) and pants (28.1%) were assessed to have failed due to material damage in the crash.

Conclusions

Motorcycle protective clothing is associated with reduced risk and severity of crash related injury and hospitalization, particularly when fitted with body armour. The proportion of clothing items that failed under crash conditions indicates a need for improved quality control. While mandating usage of protective clothing is not recommended, consideration could be given to providing incentives for usage of protective clothing, such as tax exemptions for safety gear, health insurance premium reductions and rebates.     

Barriers to, and factors associated, with observed motorcycle helmet use in Vietnam

This study investigated barriers to, and factors associated with, observed motorcycle helmet use among motorcyclists in Hai Duong Province, Vietnam. The findings highlighted an array of factors associated with observed helmet use namely, support for universal helmet legislation and a positive attitude towards what might be perceived as negative attributes of helmet use such as inconvenience and discomfort in hot weather. As well, older age (greater than 25 years in age), riding on a compulsory road, being a driver, trips of greater than 10 km, higher levels of education (having a university degree and higher) were found to be key determinants of helmet use. Despite over 95% of motorcyclists disagreeing with the statement that wearing a helmet does not reduce the severity of head injury in a crash, most motorcyclists believed that helmets did not need to be worn for a short trip. Overall, only 23% of motorcyclists were observed wearing a helmet. The authors conclude that efforts to increase helmet use need to focus on the necessity for universal helmet legislation in association with identifying solutions to reduce the negative attitudes towards helmet use.     

The prevalence of non-standard helmet use and head injuries among motorcycle riders

OBJECTIVES: This study examined the prevalence of non-standard helmet use among motorcycle riders following introduction of a mandatory helmet use law and the prevalence of head injuries among a sample of non-standard helmet users involved in motorcycle crashes. METHODS: Motorcycle rider observations were conducted at 29 statewide locations in the 2 years following the introduction of the mandatory helmet use law in January, 1992. Medical records of motorcyclists who were injured in 1992 for whom a crash report was available and for whom medical care was administered in one of 28 hospitals were reviewed. Chi-squares and analysis of variance were used to describe differences between groups. RESULTS: Prevalence of non-standard helmet use averaged 10.2%, with a range across observation sites from 0 to 48.0%. Non-standard helmet use varied by type of roadway, day of week, and time of day. Injuries to the head were more frequent and of greater severity among those wearing non-standard helmets than both those wearing no helmet and those wearing standard helmets. CONCLUSIONS: Non-standard helmets appear to offer little head protection during a crash. Future study is needed to understand the dynamics leading to head injury when different types of helmets are worn.     

Increased patterns of risky behaviours among helmet wearers in skiing and snowboarding

Background

There has been an ongoing debate as to whether wearing helmets in skiing and snowboarding increases the risk tolerance of participants.

Objective

To investigate the roles of demographic and personality variables, and helmet usage in predicting risk taking behaviours in a cross-sectional sample of intermediate and proficient skiers and snowboarders.

Methods

Risk taking in skiing was measured using a validated 10-item self-report measure which was designated as the outcome variable in a three step hierarchical regression. Independent predictors included age, sex, education, sport, ability, helmet usage, and personality traits that have been associated with risk taking: impulsivity and sensation seeking.

Results

In the final regression model, helmet use significantly predicted variance in risk taking (standardized β = .10, p = .024), and the relationship remained after accounting for variance due to demographic variables and general trait measures. The partial relationship between risk taking and sex, ability, impulsivity, and sensation seeking were also significant (p < .05).

Conclusion

High sensation seeking, high impulsivity, male sex, and proficiency were associated with increased patterns of risky behaviours in skiers and snowboarders, and after accounting for these factors, helmet use was a significant predictor of risk taking. The relationship between helmet use and risk taking was modest suggesting that the costs of increased risk taking is not likely to outweigh the protective benefits of a helmet.     

A cross-sectional observational study of helmet use among motorcyclists in Wa,Ghana

Motorcyclists’ injuries and fatalities are a major public health concern in many developing countries including Ghana. This study therefore aimed to investigate the prevalence of helmet use among motorcyclists in Wa, Ghana. The method used involved a cross-sectional roadside observation at 12 randomly selected sites within and outside the CBD of Wa. A total of 14,467 motorcyclists made up of 11,360 riders and 3107 pillion riders were observed during the study period. Most observed riders (86.5%) and pillion riders (61.7%) were males. The overall prevalence of helmet use among the observed motorcyclists was 36.9% (95% CI: 36.1–37.7). Helmet use for riders was 45.8% (95% CI: 44.8–46.7) whilst that for pillion riders was 3.7% (95 CI: 3.0–4.4). Based on logistic regression analysis, higher helmet wearing rates were found to be significantly associated with female gender, weekdays, morning periods and at locations within the CBD. Riders at locations outside the CBD were about 7 times less likely to wear a helmet than riders within the CBD (48.9% compared to 42.3%; χ²₍₁₎ = 49.526; p < 0.001). The study concluded that despite the existence of a national helmet legislation that mandates the use of helmets by both riders and pillion riders on all roads in Ghana, helmet use is generally low in Wa. This suggests that all stakeholders in road safety should jointly intensify education on helmet use and pursue rigorous enforcement on all road types especially at locations outside the CBD to improve helmet use in Wa.     

Prevalence rates of helmet use among motorcycle riders in a developed region in China

This study aimed to determine the prevalence rates of helmet use, and of correct helmet use (chinstrap firmly fastened) among motorcycle riders and their passengers in Zhongshan, Guangdong Province, China. A cross-sectional survey involving direct observation of motorcycle riders was conducted at 20 randomly selected intersections. A total of 13,410 motorcycles were observed during a 10-day period in February 2009. The overall prevalence of helmet use was 72.6% (95% CI: 71.8–73.3%) among drivers and 34.1% (95% CI: 32.7–35.5%) among pillion passengers. The prevalence of correct use was 43.2% (95% CI: 42.4–44.0%) and 20.9% (95% CI: 19.8–22.1%) for drivers and passengers respectively. The helmet wearing rate on city streets was almost 95%, however city riders were more likely than rural riders to wear non-motorcycle helmets while riding. In multivariate analyses, factors associated with increased helmet use included riding on city streets, male gender, being a driver, carrying less passengers and riding a registered motorcycle. The results indicated enforcement and education activities need to be strengthened with respect to both helmet use and helmet quality, especially in rural areas, in order to improve wearing rates.     

Distribution of transport injury and related risk behaviours in a large national cohort of Thai adults

Background

A major barrier to addressing the problem of transport injury in low to middle-income countries is the lack of information regarding the incidence of traffic crashes and the demographic, behavioural and socio-economic determinants of crash-related injury. This study aimed to determine the baseline frequency and distribution of transport injury and the prevalence of various road safety behaviours in a newly recruited cohort of Thai adults.

Methods

The Thai Health-Risk Transition Study includes an ongoing population-based cohort study of 87,134 adult students residing across Thailand. Baseline survey data from 2005 includes data on self-reported transport injury within the previous 12 months and demographic, behavioural and transportation factors that could be linked to Thailand's transport risks.

Results

Overall, 7279 (8.4% or 8354 per 100,000) of respondents reported that their most serious injury in the 12 months prior to recruitment in the cohort was transport-related, with risk being higher for males and those aged 15–19 years. Most transport injuries occurred while using motorcycles. A much higher proportion of males reported driving after three or more glasses of alcohol at least once in the previous year compared to females. The prevalence of motorcycle helmet and seat belt wearing in this sample were higher than previously reported for Thailand.

Conclusions

The reported data provide the basis for monitoring changes in traffic crash risks and risk behaviours in a cohort of adults in the context of ongoing implementation of policy and programs that are currently being introduced to address the problem of transport-related injury in Thailand.     

Helmet use and motorcycle fatalities in Taiwan

Motorcycle deaths accounted for more than half of total traffic fatalities in Taiwan in 2002. This study uses the police-reported crash data from Taiwan between 1999 and 2001 to estimate the effectiveness of helmets, simultaneously taking into account of sample selection bias. Sample selection arises because helmet usage will affect the probability of death or injury, which in turn influences whether a crash is included in the data. The results show that sample selection does not seriously bias the estimate of helmet effectiveness and helmets reduce the probability of death in a crash by 40%, which is higher than what was previously found. Without helmets, the number of motorcyclists killed in 2001 would have jumped by 51%. The estimated proportion of helmeted motorcyclists has increased from 71 to 78% between 1999 and 2001, suggesting that helmet use is rising after the implementation of mandatory helmet law in 1997. Also, helmets significantly reduce the likelihood of head and neck injuries in a crash by 53%, and lead to a 71% reduction in the probability of death caused by head and neck injuries.     

Discrepancy in bicycle helmet use among college students between two bicycle use purposes: Commuting and recreation

Objectives

The purpose of the study was to examine associations between bicycle helmet use and attitudes among U.S. college students. Bicycle helmet use was assessed for two different bicycle use purposes: commuting to school and recreation.

Materials and methods

Student bicycle riders were recruited on the campus of a large public university in Colorado. Questionnaire development was guided by the Theory of Reasoned Action and Health Belief Model. Bicycle use and helmet use for the two purposes, attitudes toward helmet use and bicycle helmet regulations on campus, perceived risk of bicycle-related injury, subjective norms were asked. Bicycle helmet use was defined by current behaviors and intentions for the future, based on the Stages of Change model.

Results

A total of 192 questionnaires collected from students who rode bicycles for both commuting and recreation was used for the analysis. Bicycle helmet use differed depending on purposes of bicycle riding: 9.4% of bicycle riders wore bicycle helmets every time for commuting, while 36.5% did so for recreation. Different variables were associated with bicycle helmet use for commuting and recreation in logistic regression models, suggesting that psychosocial structures behind bicycle helmet use behaviors might differ between two bicycle use purposes, commuting and recreation.     

Effect of the helmet act for motorcyclists in Thailand

OBJECTIVES: This study investigated the effect of the helmet act for motorcyclists on increasing helmet use and reducing motorcycle-related deaths and severe injuries in Thailand. METHODS: Data were derived from a trauma registry at the Khon Kaen Regional Hospital in the northeast Thailand. Helmet use and outcome in motorcycle crashes were compared 2 years before (1994-1995) and after (1996-1997) enforcement of the helmet act. During the study period, there were 12002 injured motorcyclists including 129 death cases in the municipality of Khon Kaen Province who were brought to the regional hospital. RESULTS: After enforcement of the helmet act, helmet-wearers increased five-fold while head injuries decreased by 41.4% and deaths by 20.8%. Those who had head or neck injuries or died were less likely wearing a helmet. Compliance of helmet use was lower at night. Fatality of injured motorcyclists did not significantly decrease in the post-act period and among helmet-wearers. CONCLUSION: Enforcement of the helmet act increased helmet-wearers among motorcyclists but helmet use did not significantly reduce deaths among injured motorcyclists. Motorcyclists should be instructed to properly and consistently wear a helmet for their safety.     

Motorcycle helmet use in relation to legal requirements

Helmet use by motorcyclists was observed in late 1978 in cities in six U.S. states with varying legal requirements regarding their use. In two cities (Baltimore, Maryland and Miami, Florida) in which all motorcyclists are legally required to wear helmets, virtually all wore helmets. In three cities (New Orleans, Louisiana, Phoenix, Arizona and Houston, Texas) where helmet use laws requiring use by all motorcyclists were changed in 1976 or 1977 so that use is required only by those less than 18 years old, wearing rates were 39, 46 and 63%, respectively. In Los Angeles, California, which has never had a law requiring helmet use, 46% wore helmets.

Based on these survey results, and on the known efficacy of helmets in reducing injuries to motorcyclists, the repeal of helmet laws that occurred in 26 states in 1976–1978 can be expected to result in major increases in motorcyclist deaths in succeeding years.     

Does wearing helmets reduce motorcycle-related death? A global evaluation

Background

The high risk of injury and death of motorcycle riders is a major global health problem. This study aimed to evaluate the effect of helmet wearing on motorcycle riders’ death rates on a global level.

Methods

Data for motorcycle riders were collected from 70 countries. These data included motorcycle-related death rates per 100 000 population, helmet non-usage percentage, Gross National Income per capita (GNI), number of registered motorized 2–3 wheelers, the effectiveness of law enforcement in each country, and whether there was standards for helmets use or not. Correlations between studied variables were done using Pearson correlation. Multiple linear regression models were used to define factors affecting motorcycle-related death rates.

Results

The correlation between motorcycle-related death rate and helmet non-usage, was almost significant (p = 0.056, r = 0.28). Helmet non-usage percentage was significantly correlated with GNI (p < 0.0001, r = −0.61) and effectiveness of the law (p < 0.0001, r = −0.73). A multiple linear regression model which was highly significant (adjusted R-squared = 0.3, F = 6.69, p < 0.001) has shown that helmet non-usage percentage (p = 0.003), motorcycle per person ratio (p = 0.01) and the presence of helmet standards (p = 0.05) were positively associated with motorcycle-related death rates. A simple linear regression model between helmet usage and road traffic death rate has shown that for each 10% increase in helmet usage, one life per 1 000 000 inhabitants can be saved per year.

Conclusion

Helmet non-usage percentage was the most significant factor affecting motorcyclists’ death rate. Wearing a motorcycle helmet reduces the risk of death from a motorcycle crash. Enforcement of motorcycle helmet laws should be effectively supported by motorcycle safety programs.     

Bicycle helmet legislation: can we reach a consensus?

Debate continues over bicycle helmet laws. Proponents argue that case-control studies of voluntary wearing show helmets reduce head injuries. Opponents argue, even when legislation substantially increased percent helmet wearing, there was no obvious response in percentages of cyclist hospital admissions with head injury-trends for cyclists were virtually identical to those of other road users. Moreover, enforced laws discourage cycling, increasing the costs to society of obesity and lack of exercise and reducing overall safety of cycling through reduced safety in numbers. Countries with low helmet wearing have more cyclists and lower fatality rates per kilometre. Cost-benefit analyses are a useful tool to determine if interventions are worthwhile. The two published cost-benefit analyses of helmet law data found that the cost of buying helmets to satisfy legislation probably exceeded any savings in reduced head injuries. Analyses of other road safety measures, e.g. reducing speeding and drink-driving or treating accident blackspots, often show that benefits are significantly greater than costs. Assuming all parties agree that helmet laws should not be implemented unless benefits exceed costs, agreement is needed on how to derive monetary values for the consequences of helmet laws, including changes in injury rates, cycle-use and enjoyment of cycling. Suggestions are made concerning the data and methodology needed to help clarify the issue, e.g. relating pre- and post-law surveys of cycle use to numbers with head and other injuries and ensuring that trends are not confused with effects of increased helmet wearing.     

Burden of road traffic injuries: Disability-adjusted life years in relation to hospitalization and the maximum abbreviated injury scale

Background

The consequences of non-fatal road traffic injuries (RTI) are increasingly adopted by policy makers as an indicator of traffic safety. However, it is not agreed upon which level of severity should be used as cut-off point for assessing road safety performance. Internationally, within road safety, injury severity is assessed by means of the maximum abbreviated injury scale (MAIS). The choice for a severity cut-off point highly influences the measured disease burden of RTI. This paper assesses the burden of RTI in terms of disability adjusted life years (DALYs) by hospitalization status and MAIS cut-off point in the Netherlands.

Methods

Hospital discharge register (HDR) and emergency department (ED) data for RTI in the Netherlands were selected for the years 2007–2009, as well as mortality data. The incidence, years lived with disability (YLD), years of life lost (YLL) owing to premature death, and DALYs were calculated. YLD for admitted patients was subdivided by MAIS severity levels.

Results

RTI resulted in 48,500 YLD and 27,900 YLL respectively, amounting to 76,400 DALYs per year in the Netherlands. The largest proportion of DALYs is related to fatalities (37%), followed by admitted MAIS 2 injuries (25%), ED treated injuries (16%) and admitted MAIS 3+ injuries (18%). Admitted MAIS 1 injuries only account for a small fraction of DALYs (4%). In the Netherlands, the diseases burden of RTI is highest among cyclists with 39% of total DALYs. One half of all bicycle related DALYs are attributable to admitted MAIS 2+ injuries, but ED treated injuries also account for a large proportion of DALYs in this group (28%). Car occupants are responsible for 26% of all DALYs, primarily caused by fatalities (66%), followed by admitted MAIS 2+ injuries (25%). ED treated injuries only account for 5% of DALYs in this group.

Conclusions

When using admitted MAIS 3+ or admitted MAIS 2+ as severity cut-off point, 54% and 80% of all DALYs are captured respectively. Assessing the influence of different severity cut-off points by MAIS on the proportion and number of DALYs captured gives valuable information for guiding choices on the definition of serious RTI.     

Road traffic crashes on the Yaoundé-Douala road section, Cameroon

Objective

Developing countries account for more than 85% of all road traffic deaths in the world. Our aims were to estimate road morbidity and mortality and to describe the main characteristics of road traffic crashes on a heavy traffic road section in Cameroon.

Methods

We conducted a study of police reports of the 2004-2007 period retrieved from the 13 police stations in charge of the 243 km Yaoundé-Douala road section in Cameroon.

Results

The estimated overall number of people killed per 100 million kilometres driven was 73, more than 35 times higher than on similar roads in the US or Europe. The most severe crashes were those involving vulnerable road users (97 deaths) and vehicles travelling in opposite directions (136 deaths). The main causes of fatal crashes were mechanical failures (28%), two-thirds being tyre problems, hazardous overtaking (23%), and excessive speed (20%).

Conclusions

The burden of road traffic injuries on heavy traffic roads in Cameroon calls for urgent interventions. Traffic calming measures and control of vehicle condition appear to be the most cost-effective interventions.     

Driver characteristics associated with child safety seat usage in Malaysia: A cross-sectional study

Background

The rapidly motorizing environment in Malaysia has made child occupant safety a current public health concern. The usage of child safety seats (CSS) is a widely regarded intervention to enhance child occupant safety, yet no study has been conducted on CSS in Malaysia. This study aims to determine the CSS usage rates in Malaysia and to assess driver characteristics that are associated with CSS usage.

Methods

Nine variables - urban versus rural study location, age, gender, marital status, educational status, monthly family income, number of children present in the vehicle, distance traveled to the study location, and attitude - were examined through a cross-sectional study of interviewing drivers of 230 vehicles transporting at least one child <10 years of age at the time of the study. The vehicles were also observed for whether or not there was a CSS present. The interviews were conducted at six sampling locations - three urban and three rural - in the state of Melaka.

Results

27.4% of the drivers were found to be using at least one CSS at the time of the survey. Among the nine variables studied, three of the driver characteristics showed statistical significance (p < 0.05) with CSS usage: age (p = 0.047), educational status (p = 0.009), and attitude (p = 0.009).

Discussion

This study begins to create knowledge on child occupant safety in Malaysia. The results indicate that interventional efforts should focus on educational programs geared toward drivers that are less educated or extended family members who inconsistently transport young children. Furthermore, any educational efforts could be strongly enhanced by legislation mandating the use of CSS. Every effort should be made to thoroughly assess the effectiveness of any educational or legislative activities that are implemented.