We’re getting on our bikes, but what about helmets?

Girls are getting on their bikes in greater numbers than ever, according to a report by the UK charity Sustrans, which says that women made 176 million cycling trips on the National Cycle Network last year, over a quarter of all journeys. Cycling offers benefits to our health and our environment, of course, and for those women not ready to embrace the lycra look they can buy all sorts of accessories for the girly cyclist, including a cycle helmet disguised under a straw hat! They’ve gone one better in Sweden, with a scarf or snood which conceals an inflatable ‘airbag’ helmet. Sensors detect movements specific to crash scenarios and sends the airbag over the cyclist’s head like a hood, in 0.1 seconds. It meets the EU’s CE standards and provides as much protection as a standard helmet.

But will you wear one?

There is much controversy around helmet wearing by cyclists and an article in the Journal of Medical Ethics, published earlier this year, puts forwards some arguments against making helmet wearing compulsory. British Cycling recommends that a correctly fitted hard shell helmet should be worn, the British Medical Association supports compulsory helmet wearing for cyclists and the NHS Choices site advises that wearing a helmet can help prevent head injury. Evidence brought together in a Cochrane review on helmets for preventing head and facial injuries in bicyclists supports this, with the finding that “helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes, including those involving motor vehicles”. However, this review was last updated in 2006 and the more recent report from the BMA said that that helmets are more effective when ‘a cyclist falls from a cycle without the involvement of other vehicles.’

Promoting helmet wearing

A new report on child safety policies in 31 European countries says that only 13 countries have a law requiring use of a helmet while cycling and only eight fully implement and enforce it. The Cochrane Injuries Group has produced systematic reviews on the effectiveness of both legislation to enforce helmet wearing and non-legislative measures to encourage children to wear them. The review on non-legislative interventions included 29 relevant studies of people aged 18 years and under and found that:

  • Non-legislative interventions increased observed helmet wearing (11 studies: Odds ratio (OR) 2.08, 95% Confidence Interval (CI) 1.29 to 3.34)
  • This effect was most marked for community-based interventions (four studies: OR 4.30, 95% 2.24 to 8.25) and those providing free helmets (two studies: OR 4.35, 95% CI 2.13 to 8.89)
  • Significant effects were also found amongst school-based interventions (eight studies: OR 1.73, CI 95% 1.03 to 2.91)
  • Providing education only was less effective than providing free helmets and possibly less effective than providing subsidised helmets
  • Interventions provided to children aged under 12 may be more effective than those with children of all ages

But:

  • The studies were at high risk of bias with only three being randomised controlled trials and the follow-up periods were short
  • Studies all came from high-income countries so it is not known whether the findings are likely to apply to lower-income countries
  • Only one study was in a country where there is legislation to enforce helmet-wearing, so the additional impact of non-legislative interventions where such laws are in place is unknown

The review on the impact of legislation found only six, non-randomised, before-and-after studies suitable for inclusion. Helmet legislation applied to children only. Adults were used as controls in five of the studies, and areas with no helmet legislation were used as controls in the sixth. Here’s what they found:

  • Bicycle helmet use increased statistically significantly following legislation in all three of the studies reporting on helmet use
  • Statisically significant reductions in death and head injury from cycle accidents were reported following legislation compared to controls

But:

  • No studies reported changes in bicycle use or other negative effects of legislation
  • The inability to measure actual helmet use, or missing information on helmet use in studies looking at injury rates, mean that it is difficult to clearly show that lower head injury rates resulted from increased helmet use

The authors concluded:

“Bicycle helmet legislation appears to be effective in increasing helmet use and decreasing head injury rates in the populations for which it is implemented. However, there are very few high quality evaluative studies that measure these outcomes, and none that reported data on possible declines in bicycle use.”

As so often, these systematic reviews have highlighted significant gaps in the evidence, and patchy evidence is one reason why those opposing the introduction of laws to enforce helmet wearing do so.

I’m off on my bike now, wearing a bespoke helmet designed to fit neatly under my elf hat.

Links:

Hooper C, Spicer J. Liberty or death; don’t tread on me. J Med Ethics 2012.

British Medical Association. Promoting Safe Cycling. British Medical Asociation; London, 2010.

NHS Choices Benefits of cycling 

Thompson DC, Rivara F, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD001855. DOI: 10.1002/14651858.CD001855. Cochrane summary of this review.

Owen R, Kendrick D, Mulvaney C, Coleman T, Royal S. Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD003985. DOI: 10.1002/14651858.CD003985.pub3 Cochrane summary of this review.

Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD005401. DOI: 10.1002/14651858.CD005401.pub3. Cochrane summary of this review.

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Sarah Chapman

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My name is Sarah Chapman. I have worked on systematic reviews and other types of research in many areas of health for the past 17 years, for the Cochrane Collaboration and for several UK higher education institutions including the University of Oxford and the Royal College of Nursing Institute. I also have a background in nursing and in the study of the History of Medicine.

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