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Prevalence of helmet use by users of bicycles, push scooters, inline skates and skateboards in Toronto and the surrounding area in the absence of comprehensive legislation: an observational study
  1. Jessica L Page1,
  2. Alison K Macpherson2,
  3. Tara Middaugh-Bonney2,
  4. Charles H Tator3
  1. 1Faculty of Medicine, University of Toronto, Toronto, Canada
  2. 2School of Kinesiology and Health Science, York University, Toronto, Canada
  3. 3Department of Surgery, University of Toronto, Toronto, Canada
  1. Correspondence to Dr CH Tator, Toronto Western Hospital, McLaughlin Pavilion, 12th Floor Rm 423, 399 Bathurst St., Toronto, Ontario M5T 2S8, Canada; charles.tator{at}uhn.on.ca

Abstract

Background Legislation in the province of Ontario, Canada, mandates users under the age of 18 to wear a helmet when they ride a bicycle, and legislation has been shown to significantly increase rates of bicycle helmet use. Legislation does not exist in Ontario for older bicyclists or for users of other non-motorised modes of transportation, and there are no current data available regarding rates of helmet use in these categories. This study was designed to determine the prevalence of helmet use among users of bicycles, skateboards, push scooters and inline skates in Toronto, Ontario, and the surrounding area. Further analysis was performed to examine factors associated with helmet use.

Methods We performed a cross-sectional, observational study. Three trained, stationary observers captured 6038 users of bicycles (5783), skateboards (77), inline skates (165) and push scooters (13) in the summer of 2009. Observations were separated into three time periods capturing commuters, midday users and recreational users. A general linear model was used to assess the factors associated with helmet use among bicyclists.

Results Helmets were worn by 48.9% of all users observed and 50.0% of all bicyclists. Among bicyclists, females were more likely to wear helmets than males (prevalence ratio 1.27, 95% CI 1.17 to 1.36), while children were significantly more likely to wear helmets than adults (prevalence ratio 1.17, 95% CI 1.37 to 2.15). Significant behavioural variation was observed among users during the three observation periods (p<0.001), with commuters being the most likely to wear a helmet.

Conclusion In the absence of comprehensive legislation encompassing all ages of users, only half of users of non-motorised, wheeled transportation devices are choosing to wear a helmet to protect against traumatic brain injury. Implementation of evidence-based strategies to increase helmet use, such as the introduction of legislation encompassing all ages and all equipment, is required.

  • Bicycling/legislation & jurisprudence
  • bicycling/trends
  • head protective devices/utilization
  • cross-sectional studies
  • helmet
  • traffic
  • epidemiologic
  • pedestrian
  • bicycle
  • sports
  • spinal cord
  • preventative
  • head injury
  • concussion
  • behaviour change
  • public health
  • implementation/translation
  • legislation
  • community
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Introduction

Bicycles remain popular choices for transportation and recreation; however, crashes resulting in head injury can occur. Between 1991 and 2002, there were 362 bicycle-related deaths in the province of Ontario, Canada, the majority of which occurred when cyclists were not wearing helmets.1 In the USA, head injury was the cause for one third of cyclist visits to the emergency department and two thirds of hospital admissions.2 In 2004, the total cost to society of bicycle-related injuries in Canada was estimated at $443 million.3 Fortunately, the use of a properly fitted bicycle helmet has been shown to reduce the risk of head and brain injury by 63%–88% in bicyclists of all ages, as well as reduce upper facial injury.2 Head injuries are also seen in users of other non-motorised, wheeled devices such as skateboards, push scooters and inline skates. Gaines et al reported that head injuries were the most common push-scooter-related injury among children requiring hospitalisation.4 Although there is less extensive research on the impact of helmet use on injury rates in these other non-bicycle road activities, helmet use has been shown to be generally effective against head trauma.5

In the province of Ontario, Canada, head injuries represent 44% of all catastrophic injuries, defined as resulting in permanent or long-term disability or death, suffered by bicyclists in non-employment activities.6 In 4 years between 1986 and 1995 (1986, 1989, 1992 and 1995), this amounted to 186 affected recreational bicyclists.6 Provincial legislation enacted in 1995 requires bicyclists under the age of 18 to wear a helmet, and it does not extend to users of other non-motorised devices, such as skateboards, push scooters and inline skates. Numerous studies before and after the introduction of this legislation have examined the prevalence of helmet use within the province of Ontario, but these studies have primarily focused on the paediatric population. Self-reported data obtained by the Canadian Community Health Survey found that 40.6% of Ontarians use a bicycle helmet.7 Little current data on actual adult helmet use in Ontario are available.

Legislation has consistently been shown to improve the prevalence of helmet use and reduce the rate of head injury.7 8 However, there is evidence that, in the absence of enforcement, legislation requiring children in Ontario to wear helmets has been ineffective over the long term, particularly in low- and mid-range socioeconomic areas.9 Children are positively influenced to wear a helmet if they are accompanied by an adult, and this influence increases significantly if the adult companion is also wearing a helmet.10 Critics of mandatory helmet legislation argue that helmet use may encourage risky cycling practices or result in decreased cycling rates, thus decreasing exposure to the health benefits of physical activity.11 12 However, studies in Canada have not found a reduction in bicycling associated with the introduction of legislation.7 13

The objective of the present investigation was to determine the prevalence of helmet use among users of bicycles, skateboards, inline skates and push scooters (hereafter referred to as ‘users’) in the province of Ontario, focusing on metro Toronto and surrounding smaller cities. We also examined factors associated with helmet use among bicyclists, such as gender and time of day. We were particularly interested in capturing adult users, as there are little current data available for this demographic.

Methods

We recorded observations of users of bicycles, push scooters, skateboards and inline skates during 37 observation periods at 28 sites in the province of Ontario, Canada. Most sites were located within or near the City of Toronto (including downtown Toronto, Etobicoke, East York, Scarborough, North York and Richmond Hill), while four observation sites were located in smaller communities of southern Ontario: Barrie and Niagara-On-The-Lake. Sites were purposefully chosen based on popular known cycling routes used by adults or the presence of dedicated bike lanes and paths. Of the 12 sites in downtown Toronto, six were selected to compare prevalence of helmet use observed in a previous, unpublished pilot study by ThinkFirst Canada in 2006. Additionally, the current study included observations made in three public skateboard parks. Observations were made on sunny or cloudy days between June 27 and August 24, 2009, but not on rainy days or when the threat of rain was deemed high.

Three trained, stationary observers collected data independently during various time periods and days of the week in order to capture different subpopulations of the users of these non-motorised wheeled devices. The subpopulations were loosely based on those identified by Beirness et al and consisted of commuters, recreational users, general midday users and stunt users.5 Data were collected using a standardised tool which was modified from a similar study examining child bicyclists. It was modified to improve speed and ease of use. Observers were provided with training in the use of the recording tool and inclusion criteria.

Commuter

Commuter observations were collected for 90 min between 7:30 and 9:00 on weekdays along main routes used by bicyclists travelling to work. Users travelling in all directions were recorded, under the assumption that commuters were travelling to a single destination and would not be returning past the observation point during the data collection period. In the instance where a user was recognised as passing the observer twice, he/she was not recorded a second time.

Recreational

Recreational user observations were collected for 120 min in the early afternoon on weekends along multi-use pathways in parks. Users travelling in a single direction only were recorded in order to avoid double-sampling of those who had doubled-back.

General midday

General midday user observations were collected for 90 min between 14:30 and 16:00 on weekdays at nine of the sites selected for commuter observations. Users travelling in all directions were recorded in order to correspond with data collected for the commuter observations.

Stunt

Stunt user observations were collected at the skateboard parks. Due to the infrequent changeover of users in the park, data were collected by capturing all users in the park during one brief interval of approximately 5 min, rather than observing over a longer time period.

Only individuals actively using the wheeled device were recorded. For example, individuals walking a bike or carrying a skateboard were excluded. Children riding in attached bike seats or bike trailers were not recorded.

Based on appearance, users were recorded as belonging to one of three age categories: child, adolescent and adult. Adults were considered to be 18 years of age or older, in line with helmet legislation for Ontario. Those under 18 years of age were further stratified into ‘child’ and ‘adolescent’ as previous work has shown behavioural differences in these two groups regarding bicycle helmet use.14 ‘Children’ were deemed to be prepubescent, while ‘adolescents’ were considered to be pubescent but under the age of 18. All users appearing over the age of 18 were recorded as ‘adults’. Helmet use was recorded as ‘yes, correct use’, ‘yes, incorrect use’ or ‘no use’. The use of a helmet was recorded as ‘incorrect’ if a helmet was present, but was deemed to be largely ineffective or unsafe in the case of a fall. Examples of incorrect use included the following: forehead completely exposed, baseball cap worn underneath or chin strap undone. There were 36 observations where gender was not able to be determined, and these were removed from the multivariate analysis.

For the purposes of data analysis, the individuals recorded as ‘wearing a helmet incorrectly’ were pooled with those recorded as ‘wearing a helmet correctly’. Data are presented as frequencies of helmet use by type of rider, gender and estimated age. A general linear model was used to estimate the prevalence ratio for helmet use among bicyclists only controlling for age, location and gender. Other equipment users were removed from the multivariate analysis due to small cell sizes for adult riders. All analyses were conducted using SAS V.9.0.

Results

A total of 6038 users of non-motorised transportation devices were recorded. The characteristics of this study population are summarised in table 1. The majority of observed users, 96% (n=5783), were bicyclists, while 3% (n=164) used inline skates, 1% (n=77) rode skateboards and <1% (n=13) used push scooters. More male users (n=4011) were encountered than female users (n=1989), for a male:female ratio of 2.02. For 36 observations, the user's gender was unknown. Approximately 2% (n=125) of captured users were observed as incorrectly wearing a helmet.

Table 1

Helmet prevalence in non-motorised recreational vehicles by gender, age, location and equipment type

Of all users observed, helmet use (including correct and incorrect use) was 48.5% (n=2925), although helmet use varied significantly with age, location and equipment. The highest prevalence of helmet use compared with other groups in their category was in commuters (58%), children (77%) and bicyclists (50%), while the lowest prevalence was observed in midday users (33%), adolescents (25%) and skateboard users (8%). The prevalence of helmet use in males was lower than that in females (43% vs 58%).

The results of the multivariate regression examining only bicyclists, presented in table 2, indicate that female bicyclists were more likely to wear helmets than males (prevalence ratio (PR) 1.27, 95% CI 1.17 to 1.36). Compared with adults, children were significantly more likely to wear helmets (PR 1.72, 95% CI 1.37 to 2.25) while bicycling, while adolescent bicyclists had significantly lower helmet use than adults (PR 0.74, 95% CI 0.57 to 0.96). Commuters were more likely to bike helmeted than recreational users (PR 1.13, 95% CI 1.02 to 1.25), while for midday users, helmet use was lower (PR 0.68, 95% CI 0.60 to 0.76).

Table 2

Multivariate general regression analysis of factors associated with helmet use among bicyclists in Ontario (n=5747)

The metro Toronto and area observation sites had higher numbers of non-motorised transportation device use than the surrounding cities. Of the 6038 total observations, 2% (n=121) were recorded in the surrounding municipalities of Niagara-On-The-Lake and Barrie. However, helmet use prevalence was not determined to be significantly different between Toronto and the other two municipalities (p value=0.22).

Discussion

Despite the well-documented and widely known protective effect of bicycle helmets against head injury, this study indicates that half the metro Toronto population of bicyclists continues to ride without head protection. Similar results in the smaller communities of Barrie and Niagara-On-The-Lake suggest that low helmet use remains an issue outside of major urban centres in Ontario as well. This finding is of concern as catastrophic bicycle-related injuries are not restricted to large urban centres.15 ThinkFirst's unpublished pilot study conducted in 2006 found that 44% (n=1446) of downtown Toronto cyclists rode without a helmet, which is comparable to what was observed in the present study. Thus, the rate of helmet use in metro Toronto appears relatively stable in the absence of legislation or major education campaigns.

We found a large gender difference in helmet use and cycling rates. Only one third of the bicyclists were female, yet they were more likely to ride helmeted than males. In our 2006 study, helmet use among females was also higher (44% female vs 40% male). The higher prevalence of helmet use in female bicyclists suggests that fewer females are willing to ride a bike without head protection. Further examination should be given to barriers impeding females from riding bicycles and thereby obtaining the health benefits of this active form of transportation. Helmet use was observed to be lowest among the adolescent population (25.2%), despite the existence of legislation applying to this group. Further effort is needed to examine the barriers to helmet use within the adolescent population.

It was interesting to note the large variation in helmet prevalence at the same location at different times of the day. Bicyclists riding between 7:30 and 9:00 had significantly more helmet use than those observed between 14:30 and 16:00 at the same location, and this result was consistent for all locations compared. While we cannot be sure of the destination of the users without actually surveying them directly, the vast majority of the users observed during the morning period appeared to be commuters (ie, presence of briefcases and backpacks), while more of the users observed at midday appeared to be on casual outings (ie, non-work clothing, slower speed, etc). We are unsure why this behavioural variation exists.

Of additional concern is the 2% of bicyclists with incorrect use of helmets that potentially would reduce the protection provided by the helmet in the event of a fall or collision. The 2% is likely a conservative estimate because we used a high threshold for ‘incorrect’ use. Further education on correct fit and use of helmets appears to be required. It was noted qualitatively that children and adolescents who wore the ‘skater’ or bucket-style, full-coverage helmets rarely had a proper fit for the smaller size of their head. These children and youth often had to push the helmet up with their hands after it had fallen forward, covering their eyes. Rivera et al reported that children who wore improperly fitted helmets had a 1.96-fold increase in the risk of head injury as compared to children who wore properly fitting helmets.16 Parents and helmet retailers should ensure that minors' helmets fit correctly and are appropriate for the size of their head.

A final concern is the lack of helmet use for other wheeled sports. For example, only 33% of children on push scooters and 12% of adults using inline skates wore helmets, while no adolescent skateboarders wore helmets. Comprehensive legislation to include all wheeled sports may be indicated, as has been initiated in the province of Nova Scotia.

The present study has some limitations. Although attempts were made to include observation sites in suburban areas and smaller communities, the sheer volume of users of non-motorised recreational devices in downtown Toronto resulted in the majority of observations coming from population-dense areas. For the data to be representative of the entire province of Ontario, more sites in rural and remote areas need to be included. Generally, all users passing through the observation site were captured; however, at the extremely high traffic sites, occasional users would pass by uncounted while previous observations were being recorded. It is estimated that less than 30 users were missed; however, if helmet use was substantially different in bicyclists not counted, there is a potential for a bias in the results. Additionally, this study was targeted towards adults and examined sites such as downtown intersections frequented by adult bicyclists; therefore, few adolescents and children were encountered at the selected observation sites. The age-group stratification was based on appearance as perceived by the observer and thus was subject to inaccuracy and possible observer bias. Interobserver bias was likely minimal as greater than 95% of the observations were conducted by the same observer (JLP) and specific criteria for inclusion in each observation category were outlined in the training of the other two observers.

Bicycle helmet use among adults in Ontario remains unacceptably low. We found that 50% of bicyclists are choosing to leave themselves open to an increased risk of head injury and traumatic brain injury by not wearing a bicycle helmet when they ride. Analysis of self-reported data from the Canadian Community Health Survey found that Ontario had higher self-reported rates of helmet use than provinces without bicycle helmet legislation, but lower bicycle helmet use than provinces which required the use of a bicycle helmet by all ages.7 Head and brain injuries are devastating in terms of cost to society, the healthcare system, and friends and family of victims. Prevention of these injuries is key. Data suggest that bicyclist safety increases as the number of bicyclists on the road increases, and thus evidence-based strategies to promote bicycling and safe bicycling habits among adults are warranted.17 Evidence from this study and others suggests that the expansion of mandatory bicycle helmet legislation in Ontario to include bicyclists of all ages and all types of wheeled equipment, the enforcement of that legislation by law enforcement officers and a comprehensive strategy to promote bicycling would have a positive public health effect.

What is already known on this subject

  • Bicycle helmets reduce the risk of head and brain injury by 63%–88%.

  • Legislation, when enforced, improves the prevalence of bicycle helmet use.

  • Legislation mandating helmet use in the province of Ontario, Canada, only applies to bicyclists under 18 years of age. It does not apply to users of skateboards, inline skates or push scooters.

What this study adds

  • In the absence of legislation applying to all age groups, 50% of bicyclists in Greater Toronto and surrounding area wear helmets.

  • A temporal variation in helmet prevalence was observed, with bicyclists cycling during midday being the least likely to wear a helmet.

  • Users of skateboards, inline skates and push scooters were less likely to wear a helmet than bicyclists.

Acknowledgments

This study was made possible by a summer scholarship for JL Page from the Ontario Neurotrauma Foundation. Thank you to Ajay Nadar for his assistance with data collection. Thanks to Dr Marieke Gardner for permitting inclusion of data from her 2006 study.

References

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Footnotes

  • Competing interests None.

  • Ethics approval York University Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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