Investigating helmet promotion for cyclists: results from a randomised study with observation of behaviour, using a semi-automatic video system

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Head protection in electric micromobility: A critical review, recommendations, and future trends

Traffic jams are a burden in urban areas, being time-consuming and contributing to stressful driving and CO₂ emissions. To implement the United Nations' 2030 agenda for sustainable development, governmental strategies aim to accelerate the shift to sustainable and smart mobility. Consequently, e-micromobility (EMM) appeared as a practical solution for short-distance commuters, and it is growing at upsetting rates thanks to the introduction of sharing services. In fact, urban mobility has drastically changed over the last decade, and electric mobility and micromobility changed the panorama in larger metropolises, given their accessibility, large availability, and the potential to be a time saver in short trips and a potentially sustainable alternative in particular scenarios. The downside of portable e-transportation is the rapid increase in injuries and fatalities. Focusing on standing e-scooters, head injuries are becoming one of the most common as shown by research conducted in different urban emergency departments, alongside bone fractures, skin abrasions, and lacerations. In this work, a comprehensive review is carried out focusing on head protection for EMM, mostly for e-scooters, and the respective target markets, safety measures, and existing regulations. In the end, a critical assessment is given with recommendations for legislators and future research. Users are mostly males from 18 to 40 years old, upper-to-middle income, with elevated levels of educational attainment. Their motivation to use e-scooters is mainly to replace short walking trips. EMM, in particular e-scooters, will continue to grow thanks to its potential to substitute other micromobility alternatives. The evolution of safety measures and regulations did not keep pace with such a drastic change in mobility trends. This is evident considering how some countries are struggling with vehicle categories and regulations for helmet use and testing. The lack of legal obligation to wear a helmet and the absence of an adequate and feasible concept of protective equipment for sharing services are the main barriers to helmet use among riders. Mitigation measures have been implemented by the EMM sharing companies to improve the safety of its users by checking if they wear helmets and by offering vehicle-integrated solutions.

Cycling in one of the most polluted cities in the world: Exposure to noise and air pollution and potential adverse health impacts in Delhi

Background

In India, many cities struggle with extreme levels of air pollution and noise. Delhi, in particular, has the notorious reputation of being one of the most polluted cities in the world. Cyclists constitute a particularly exposed population, since they cycle among motor vehicles without any protection. This paper modeled the cyclists’ exposure to nitrogen dioxide (NO₂) and noise in Delhi, India.

Methods

Using primary data collected on 1,229 kms of roads in Delhi, Generalized Additive Mixed Models with Auto-Regressive terms (GAMMAR) are constructed for noise exposure, NO₂ exposure and NO₂ inhalation doses.

Results

Results show that cyclists are exposed to 47 µg/m³ of NO₂ and 3.3 dB(A) more when cycling on a primary road than on a residential street. Using WHO guideline values for noise and air pollution, we assessed how many minutes of inhaling doses and noise doses become potentially harmful to cyclists’ health in Delhi. Such thresholds are quickly exceeded: after cycling one hour in an area with moderate predicted values of noise and air pollution, the noise dose and inhaled dose of NO₂ will reach 212% and 403 µg on residential streets, and 459% and 482 µg on primary roads, respectively.

Conclusion

Policy makers should take these results into account to minimize cyclists’ exposure, especially for the most deprived people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12942-021-00272-2.

The Prevalence of Helmet Use and Predictive Factors Among Motorcyclists in Shahrekord, Iran in 2018

Background and aims: Motorcycle accidents are a major concern for countries. One of the most important risk factors for motorcyclists is the lack of helmet use. This study aimed to measure the rate of the helmet use and predictive factors in Shahrekord, Iran. Methods: Using simple random sampling method, this cross-sectional study was conducted in 2018 with a sample size of 350 motorcyclists. A researcher-made questionnaire was used to collect data, and the SPSS software version 24 was used to analyze the data. Results: The mean age of participants was 28.8 ± 10.1 years. Out of 350 participants, 15.1% and 1.4% of motorcyclists and their passengers used helmets. The most important predictors of helmet use were age more than 35 years, high education, and having a driving license. The most important reason for using the helmet was protection against injuries in accidents. Conclusion: According to our results, the rate of helmet use was low. Thus, more efforts should be made to intervene and train for the helmet use among community members with an emphasis on younger people, individuals with governmental jobs, and people with lower education level.

Helmet retention system types as a risk factor to properly attach the chin strap

OBJECTIVES

This study aimed to determine the factors associated with the incorrect use of a helmet retention system (loose or open) and how often this happens.

METHODS

This was an observational transversal study conducted in Curitiba, Brazil. Trained observers positioned at traffic lights collected information about the helmet fixation mode, the helmet model (full-face, open-face, modular, half), and the helmet retention system model (micrometric, double-D, fast-release). Additional data including position on the motorcycle, gender, and function of the motorcycle (as a work vehicle) were collected. The observers, collection site, and periods were randomly selected by lots.

RESULTS

From a total of 3,050 motorcyclists, 1,807 (59.2%) had their helmets fastened correctly, 907 (29.7%) had the retention system fastened loosely, and in 336 (11.0%), the retention system was completely open. Increased odds of incorrect use were observed for the fast-release and double-D buckles compared to the micrometrics buckles, with a fixed odds ratio (OR) of 4.62 (95% confidence interval [CI], 3.89-5.51) and 3.54 (95% CI, 2.46-5.09), respectively (P <.0001). Full-face helmets had a higher chance of incorrect use (P <.0001), and passengers had a higher incidence of incorrect use of the helmet than drivers (P <.0001).

CONCLUSION

An important risk factor related to the incorrect use of the helmet was the type of retention system. The helmet model and being a passenger had a secondary influence on incorrect use of helmets.

Infrastructural and Human Factors Affecting Safety Outcomes of Cyclists

The increasing number of registered road crashes involving cyclists during the last decade and the high proportion of road crashes resulting in severe injuries and fatalities among cyclists constitutes a global issue for community health, urban development and sustainability. Nowadays, the incidence of many risk factors for road crashes of cyclists remains largely unexplained. Given the importance of this issue, the present study has been conducted with the aim of determining relationships between infrastructural, human factors and safety outcomes of cyclists. Objectives: This study aimed, first, to examine the relationship between key infrastructural and human factors present in cycling, bicycle-user characteristics and their self-reported experience with road crashes. And second, to determine whether a set of key infrastructural and human factors may predict their self-reported road crashes. Methods: For this cross-sectional study, a total of 1064 cyclists (38.8% women, 61.2% men; M = 32.8 years of age) from 20 different countries across Europe, South America and North America, participated in an online survey composed of four sections: demographic data and cycling-related factors, human factors, perceptions on infrastructural factors and road crashes suffered. Results: The results of this study showed significant associations between human factors, infrastructural conditions and self-reported road crashes. Also, a logistic regression model found that self-reported road crashes of cyclists could be predicted through variables such as age, riding intensity, risky behaviours and problematic user/infrastructure interactions. Conclusions: The results of this study suggest that self-reported road crashes of cyclists are influenced by features related to the user and their interaction with infrastructural characteristics of the road.

The approaches to measuring the potential spatial access to urban health services revisited: distance types and aggregation-error issues

BACKGROUND

The potential spatial access to urban health services is an important issue in health geography, spatial epidemiology and public health. Computing geographical accessibility measures for residential areas (e.g. census tracts) depends on a type of distance, a method of aggregation, and a measure of accessibility. The aim of this paper is to compare discrepancies in results for the geographical accessibility of health services computed using six distance types (Euclidean and Manhattan distances; shortest network time on foot, by bicycle, by public transit, and by car), four aggregation methods, and fourteen accessibility measures.

METHODS

To explore variations in results according to the six types of distance and the aggregation methods, correlation analyses are performed. To measure how the assessment of potential spatial access varies according to three parameters (type of distance, aggregation method, and accessibility measure), sensitivity analysis (SA) and uncertainty analysis (UA) are conducted.

RESULTS

First, independently of the type of distance used except for shortest network time by public transit, the results are globally similar (correlation >0.90). However, important local variations in correlation between Cartesian and the four shortest network time distances are observed, notably in suburban areas where Cartesian distances are less precise. Second, the choice of the aggregation method is also important: compared with the most accurate aggregation method, accessibility measures computed from census tract centroids, though not inaccurate, yield important measurement errors for 10% of census tracts. Third, the SA results show that the evaluation of potential geographic access may vary a great deal depending on the accessibility measure and, to a lesser degree, the type of distance and aggregation method. Fourth, the UA results clearly indicate areas of strong uncertainty in suburban areas, whereas central neighbourhoods show lower levels of uncertainty.

CONCLUSION

In order to accurately assess potential geographic access to health services in urban areas, it is particularly important to choose a precise type of distance and aggregation method. Then, depending on the research objectives, the choices of the type of network distance (according to the mode of transportation) and of a number of accessibility measures should be carefully considered and adequately justified.

The effect of stricter licensing on road traffic injury events involving 15 to 17-year-old moped drivers in Sweden: A time series intervention study

INTRODUCTION

This study aimed to evaluate and quantify the effect of the introduction of the AM driving license on non-fatal moped-related injuries in Sweden. With the introduction of the new license category in October 2009, prospective moped drivers are now required to pass a mandatory theory test following a practical and theoretical course. In addition, obtaining a license to operate a moped is now considerably more costly.

METHODS

Time series intervention analysis on monthly aggregated injury data (1st Jan 2007-31st Dec 2013) was performed using generalized additive models for location, shape and scale (GAMLSS) to quantify the effect size on injury events involving teenage (15-17 years) moped drivers, while controlling for trend and seasonality. Exposure was adjusted for by using the number of registered mopeds in traffic as a proxy.

RESULTS

The introduction of AM license was associated with a 41% reduction in the rate of injury events involving 15-year-old moped drivers (IRR 0.59 [95% CI: 0.48-0.72]), and a 39% and 36% decrease in those involving 16-year-old (IRR 0.61 [95% CI: 0.48-0.79]) and 17-year-old drivers (IRR 0.64 [95% CI: 0.46-0.90]), respectively. The effect in the 15-year-old stratum was decreased roughly by half after adjusting for exposure, but remained significant, and the corresponding estimates in the other age groups did not change noticeably.

CONCLUSIONS

This study provides quasi-experimental evidence of an effect on non-fatal moped-related injuries as a result of stricter licensing rules. Only part of the effect could be explained by a reduction in the number of mopeds in traffic, indicating that other mechanisms must be studied to fully understand the cause of the reduction in injuries.

Assessing the reliability and validity of direct observation and traffic camera streams to measure helmet and motorcycle use

There is a need to develop motorcycle helmet surveillance approaches that are less labour intensive than direct observation (DO), which is the commonly recommended but never formally validated approach, particularly in developing settings. This study sought to assess public traffic camera feeds as an alternative to DO, in addition to the reliability of DO under field conditions. DO had high inter-rater reliability, κ=0.88 and 0.84, respectively, for cycle type and helmet type, which reinforces its use as a gold standard. However, traffic camera-based data collection was found to be unreliable, with κ=0.46 and 0.53 for cycle type and helmet type. When bicycles, motorcycles and scooters were classified based on traffic camera streams, only 68.4% of classifications concurred with those made via DO. Given the current technology, helmet surveillance via traffic camera streams is infeasible, and there remains a need for innovative traffic safety surveillance approaches in low-income urban settings.

Evolution of bicycle helmet use and its determinants in France: 2000-2010

This paper aims to analyse helmet use in France, as a voluntary behaviour rather than a legal requirement, promoted by public awareness campaigns. It aims to investigate the determinants of helmet wearing and to explore its evolution from 2000 to 2010. The analysis relies on data from a series of general population surveys called "Health Barometers": 2000 (n=13,163), 2005 (n=25,651) and 2010 (n=8573). Multivariate logistic regressions were used to identify factors associated with helmet use and time trends. Nearly half of the 15-75 year olds surveyed reported that they rode a bicycle, and among these cyclists, 22.0% reported that they wore a helmet on their last ride. Further analysis by gender reveals that twice as many men than women wore helmets. Over the last decade, helmet use among cyclists has clearly increased, from 7.3% in 2000 to 22.0% in 2010, whereas the influence of social and economic factors, such as unemployment and wage disparities, appears to have decreased. Several determinants of bicycle helmet use were highlighted. To improve the effectiveness of further public information campaigns on helmet use, the key target groups should include women, under 25 year olds and people living in urban areas. Promoting the wearing of helmets among families should also be enhanced, given the higher rate of helmet use by parents as well as children.

Gender stereotypes and superior conformity of the self in a sample of cyclists

In the field of driving, people tend to think they are more competent and more cautious than others. This is the superior conformity of the self (SCS). Our main hypothesis was that, among cyclists, women would show a higher SCS on cautiousness, though men would show a higher SCS concerning competence. 1799 cyclists provided a self-assessment of their own cautiousness and of other people's cautiousness. The same procedure was used for competence. Consistent with the hypothesis, the SCS was gender-specific: it was more prominent for women concerning cautiousness and more prominent for men concerning competence. These results could explain why people tend to ignore the safety campaigns. They also indicate the importance of adapting messages concerning safety measures to gender.

Risk compensation: a male phenomenon? Results from a controlled intervention trial promoting helmet use among cyclists

Prevention tools are challenged by risky behaviors that follow their adoption. Speed increase following helmet use adoption was analyzed among bicyclists enrolled in a controlled intervention trial. Speed and helmet use were assessed by video (2621 recordings, 587 participants). Speeds were similar among helmeted and nonhelmeted female cyclists (16.5 km/h and 16.1 km/h, respectively) but not among male cyclists (helmeted: 19.2 km/h, nonhelmeted: 16.8 km/h). Risk compensation, observed only among male cyclists, was moderate, thus unlikely to offset helmet preventive efficacy.

Helmet use in BIXI cyclists in Toronto, Canada: an observational study

OBJECTIVE

To investigate the use of helmets for cyclists choosing to use BIXI bikes in comparison to personal bike riders in the City of Toronto.

DESIGN

Cross-sectional study design.

SETTING

Cyclists were observed in Toronto, Canada.

PARTICIPANTS

Of the 6732 sample size, 306 cyclists on BIXI bikes and 6426 personal bike riders were observed.

OUTCOME MEASURE

The outcome of interest was helmet use.

RESULTS

Overall, 50.3% of cyclists wore helmets. The proportion of BIXI bike riders using helmets was significantly lower than the proportion of helmet users on personal bikes (20.9% vs 51.7%, respectively, p<0.0001).

CONCLUSIONS

Although the BIXI bike programme has provided an alternate means for Torontonians to use a bicycle, cyclists using BIXI bikes are much less likely to wear a helmet. Since the prevalence of helmet use in cyclists in general is already low, helmet use should be especially promoted in BIXI bike riders in order to promote a safe and healthy environment for cyclists.