New research highlights barriers to helmet use among cyclists

Wearing a helmet can prevent brain injury and deaths in cyclists, yet many do not wear a helmet. New research presented at the European Emergency Medicine Congress today (Tuesday) suggests that this is largely due to issues of convenience and comfort.

The study also suggests that more adult cyclists would wear helmets if they were encouraged and incentivised to do so, for example if they were provided with a free helmet, education, and periodic reminders.

The research was presented by Dr. Steven Friedman, an emergency doctor at Toronto General Hospital and associate professor at the University of Toronto, Canada. He said: "Towns and cities need to create protected routes and infrastructure for people to get around safely on bikes. However, crashes will still occur, and helmets are important for preventing cycling-related head injuries.

"As an emergency physician, I frequently see injured adult cyclists and many of them were not wearing helmets at the time of the crash. I wanted to understand why some cyclists don't wear helmets and to empower more cyclists to consistently wear a helmet."

Dr. Friedman carried out a review of previous research looking at non-legislative measures to get more adult cyclists to wear helmets. Although the evidence he found was limited, it suggested that cyclists are more likely to use a helmet, given the right encouragement.

He then tested out a set of incentives to see if they would persuade more cyclists to wear helmets. A group of 72 injured cyclists, who had not been wearing a helmet and were treated at Toronto General Hospital, took part in the research. Their ages ranged from 18 to 68 years and there was an even split of women and men.

All participants were asked about their cycling habits. The majority said they planned to cycle on the day they were injured and that they cycled most days outside of the winter months. However, most said they never or rarely wore a helmet (76%), even though very few thought that helmets were unnecessary or ineffective, and around half believed that cycling in Toronto is dangerous.

Female cyclists were marginally more likely to report wearing a helmet most of the time or always when cycling on their own bike. Women and men gave broadly the same reasons for not wearing a helmet, with the most common being that they did not own a helmet, that it was inconvenient, or that it was uncomfortable.

Approximately one third of the injured cyclists were randomly assigned to a protocol to promote wearing a helmet with the others randomised to be controls. The protocol included: an explanation of the value of wearing a helmet given by the study research coordinator, a voucher to get a free helmet, scheduled email reminders with brief survey regarding helmet use, a social media group, and the opportunity to refer a friend for a free helmet after a year.

All participants were asked to complete questionnaires over the following 12 months to see whether or not they were using bike helmets.

Half of those given a voucher for a free cycle helmet redeemed their voucher. Although many participants were no longer responding to the questionnaires after a year, of those who did (17 out of the 72 people), 75% of cyclists given the incentives said they always wore a helmet, compared to 22% of controls.

This research helps us better understand who are the cyclists that end up in our emergency department and why they are not wearing helmets, and it enabled us to try a new protocol to promote sustained helmet use.

The people we treated in this study were frequent commuter cyclists making planned trips, who generally do not regard cycling in the city as safe yet chose not to wear helmets for reasons largely related to convenience and comfort. Initiatives to increase helmet use should address these perceived barriers, and further explore cyclists' perceptions of the risk of injury and death. The interventions we tested, which are based on principles of adult education and behavioural economics, may be effective for achieving sustained helmet use in adult cyclists. We now need larger studies to confirm our findings and refine our protocol."

Dr. Steven Friedman, emergency doctor at Toronto General Hospital and associate professor at the University of Toronto

Dr. Barbra Backus is chair of the EUSEM abstract selection committee. She is an emergency physician in Rotterdam, The Netherlands, and was not involved with the research. She said: "Cycling is generally very good for our health, and an increased use of bikes instead of cars helps to reduce air pollution and to tackle climate change. Safe cycling is important and depends both on crash prevention - with better cycling infrastructure - and appropriate use of helmets to minimise injuries when crashes do occur.

"This research helps us understand why cyclists don't wear helmets and what might promote them to choose to do so. When cyclists are seen in the emergency department following a collision, that's a unique opportunity for doctors to explain why helmets are important, and this study suggests that such an intervention may be effective. I hope that future research will verify and build on this work to help make cycling safer for everyone."