Published online September 1, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. 605-610 (doi:10.1542/peds.2007-1776)
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ARTICLE

Trends in Pediatric and Adult Bicycling Deaths Before and After Passage of a Bicycle Helmet Law

David E. Wesson, MD, FRCSCa, Derek Stephens, MScb, Kelvin Lam, MScc, Daria Parsons, MScd, Laura Spence, BScNe and Patricia C. Parkin, MD, FRCPCb,f,g

a Baylor Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
b Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
c Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
d Daria Parsons Consulting, Toronto, Ontario, Canada
e Okanagan Health Surgical Centre, Kelowna, Canada
f Division of Pediatric Medicine
g Pediatric Outcomes Research Team, Hospital for Sick Children and University of Toronto Faculty of Medicine, Toronto, Ontario, Canada


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. The goals were to examine bicycle-related mortality rates in Ontario, Canada, from 1991 to 2002 among bicyclists 1 to 15 years of age and 16 years of age through adulthood and to determine the effect of legislation (introduced in October 1995 for bicyclists <18 years of age) on mortality rates.

METHODS. The average numbers of deaths per year and mortality rates per 100000 person-years for the prelegislation and postlegislation periods, and the percentage changes, were calculated for each of the 2 age groups (1–15 years and ≥16 years). Differences before and after legislation in the 2 age groups were modeled in a time series analysis.

RESULTS. There were 362 bicycle-related deaths in the 12-year period (1–15 years: 107 deaths; ≥16 years: 255 deaths). For bicyclists 1 to 15 years of age, the average number of deaths per year decreased 52%, the mortality rate per 100000 person-years decreased 55%, and the time series analysis demonstrated a significant reduction in deaths after legislation. The estimated change in the number of deaths per month was –0.59 deaths per month. For bicyclists ≥16 years of age, there were only slight changes in the average number of deaths per year and the mortality rate per 100000 person-years, and the time series analysis demonstrated no significant change in deaths after legislation.

CONCLUSIONS. The bicycle-related mortality rate in children 1 to 15 years of age has decreased significantly, which may be attributable in part to helmet legislation. A similar reduction for bicyclists 16 years of age through adulthood was not identified. These findings support promotion of helmet use, enforcement of the existing law, and extension of the law to adult bicyclists.

Key Words: bicycle helmet • death • legislation

Abbreviations: CI—confidence interval

Bicycling is a common activity for children. In our community, 85% of children own bicycles, and more than one half spend ≥100 hours per year riding their bicycles.1 Children are at risk for bicycle-related fatal injuries. Bicycle helmets have been found to be effective in reducing bicycle-related fatalities,2,3 and legislation mandating the use of bicycle helmets by cyclists has been shown to be effective in increasing helmet use.4

For the 5-year period from 1985 to 1989, we identified 81 bicycle-related deaths in our community, the province of Ontario, Canada.5 In 74 cases (91%), the injuries sustained were not survivable; 89% of those were head injuries. Beginning in 1989, we participated in the development of a coalition with the following specific objectives: to reduce the number of bicycling deaths by 50%, to increase helmet use to 40% by 1995, and to explore the feasibility of mandatory helmet use by 1995.6 Program evaluation was an explicit goal of the coalition. We evaluated factors associated with helmet use7,8 and the effectiveness of nonlegislative strategies to increase helmet use.9,10 Bill 124, an act to amend the Highway Traffic Act, requiring all persons <18 years of age riding a bicycle on a public highway in Ontario to wear a helmet, was passed by the legislature in 1993 and enforced beginning October 1, 1995.11 Under this law, the parents of violators <16 years of age are subject to a fine; 16- to 17-year-old bicyclists who do not comply are fined directly. The law does not apply to bicyclists ≥18 years of age. We have evaluated parental attitudes toward legislation,12 the effectiveness of legislation in increasing helmet use,13,14 the impact of legislation on children's cycling rates,15 and the impact of legislation on nonfatal, bicycle-related, head injuries.16

Two of our initial objectives have been achieved, that is, increased helmet use and the introduction of helmet legislation. In our study community, helmet use increased to 45% in 1995 before legislation and exceeded 65% in the 2 years following the introduction of legislation.13 We have not yet examined bicycle-related deaths in our community, after more than a decade of nonlegislative and legislative strategies. The objectives of this study were to examine bicycle-related mortality rates in Ontario from 1991 to 2002, among bicyclists 1 to 15 years of age and 16 years of age through adulthood, and to determine the effect of legislation (introduced in October 1995) on mortality rates.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Data were abstracted from the database of the Office of the Chief Coroner of Ontario. This office investigates all sudden and unexpected deaths in the province, including those that occur in prehospital and hospital settings. This database was used for our previous study of bicycling fatalities for the period from 1985 to 1989.5 Subjects were bicyclists who died in a crash, including all injury mechanisms, types (that is, body regions), and levels of severity. Data were collected according to month and year for the period from January 1991 to December 2002, resulting in 12 yearly time periods and 144 monthly time periods. Subjects were categorized into 2 age groups, that is, 1 to 15 years of age and 16 years of age through adulthood. This age categorization was chosen because it was expected that the manner in which the sanction is imposed would influence the effectiveness of the law. The law holds parents responsible for children up to 15 years of age, and these children were grouped together. Bicyclists 16 to 17 years of age may be fined directly, and the law does not apply to bicyclists 18 years of age through adulthood; therefore, 16- to 17-year-old bicyclists were grouped together with bicyclists 18 years of age through adulthood. In addition, this allowed comparison with our previous study.

To estimate mortality rates (deaths per 100000 person-years), we used the death counts from the coroner's office and population estimates from Statistics Canada.17 Average numbers of deaths per year and mortality rates per 100000 person-years for the prelegislation years (1991–1995) and the postlegislation years (1996–2002), as well as percentage changes, were calculated for each of the 2 age groups. The year 1995 was included as a prelegislation year, because the law was enforced beginning October 1 and the bicycling season in Ontario is limited to April to October because of weather conditions.

Time series analysis was used to determine whether the introduction of legislation was associated with significant changes in numbers of deaths in the 2 age groups (1–15 years and ≥16 years). Standard methods of inference for regression are not valid for time series data, because the error terms of the observations are not independent, a key assumption of regression. In contrast, observations in time series are often autocorrelated, that is, outcomes measured close together in time are similar to each other. Time series analysis is able to detect whether an intervention has an effect significantly greater than the underlying secular trend.18,19 Time series analysis has been used extensively in the evaluation of legislation in public health outcomes20–22 and changes in health care and services.23,24

The data from the 144 monthly time periods were modeled as a time series.25,26 The time period before October 1995 (enforcement of the legislation) was compared with the time period including and after October 1995. Death counts showed seasonal variation (that is, deaths were more common in summer than in winter). Seasonal autocorrelation was adjusted for by using seasonal dummy values (indicators) for calendar months. When this procedure was applied to the series, seasonal autocorrelation was removed. Subsequently, a step function for the legislation intervention (October 1995) was fit. The final model was checked for autocorrelation. The Ljung-Box goodness-of-fit measure was applied to the final time series model.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
During the 12-year period of 1991–2002, there were 362 bicycle-related deaths in Ontario. Of those, 107 (30%) involved children (1–15 years of age) and 255 (70%) adults (≥16 years of age). Only 9 (8%) of the 107 children who died were reported to have been wearing a helmet at the time they were injured (3 in the prelegislation period and 6 in the postlegislation period).

Death counts, population estimates, and mortality rates per 100000 person-years are shown in Table 1 for bicyclists 1 to 15 years and ≥16 years of age for the time period 1991–2002. For bicyclists 1 to 15 years of age, the average number of deaths per year decreased 52% (95% confidence interval [CI]: 42%–62%), from 13 deaths per year in the prelegislation period (1991–1995) to 6 deaths per year in the postlegislation period; the mortality rate per 100000 person-years decreased 55% (95% CI: 46%–64%), from 0.59 deaths per 100000 person-years to 0.27 deaths per 100000 person-years. For bicyclists ≥16 years of age, the average number of deaths per year increased 5% (95% CI: 2%–8%), from 21 deaths per year in the prelegislation period to 22 deaths per year in the postlegislation period; the mortality rate per 100000 person-years decreased 3% (95% CI: 1%–5%), from 0.20 deaths per 100000 person-years to 0.19 deaths per 100000 person-years.


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  		TABLE 1 Death Counts, Population Estimates, and Mortality Rates for Bicyclists 1 to 15 Years and ≥16 Years of Age in 1991–2002

 
The time series analyses for bicyclists 1 to 15 years and ≥16 years of age are shown in Figs 1 and 2. For bicyclists 1 to 15 years of age, the time series analysis demonstrated a significant reduction in the number of deaths after October 1995. The estimated change in the number of deaths per month was –0.59 deaths per month (95% CI: –0.29 to –0.89 deaths per month; P = .001). For bicyclists ≥16 years of age, the time series analysis demonstrated no significant change in the number of deaths after October 1995. The estimated change in the number of deaths per month was +0.09 deaths per month (95% CI: –0.35 to +0.53 deaths per month; P = .7). The Ljung-Box goodness-of-fit measure showed that there was no evidence to reject the model.


Figure 1
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  		FIGURE 1 Time series analysis of bicycle-related deaths among bicyclists 1 to 15 years of age, before and after legislation, showing monthly variation.

 

Figure 2
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  		FIGURE 2 Time series analysis of bicycle-related deaths among bicyclists ≥16 years of age, before and after legislation, showing monthly variation.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
During the 12-year period of 1991–2002, there were 362 bicycling-related deaths in Ontario. Although the majority (70%) of those deaths involved older adolescents (≥16 years of age) and adults, there were substantial decreases in the numbers of deaths and the mortality rate among children (1–15 years of age), with no changes for those 16 years of age through adulthood. The mortality rate for children 1 to 15 years of age decreased from 0.81 deaths per 100000 person-years in 1985–19895 to 0.27 deaths per 100000 person-years in 1995–2002.

The time series analysis demonstrated significant reductions in the numbers of deaths per month in children after October 1995, the month in which helmet legislation was enforced in Ontario. This legislation was intended to apply to bicyclists of all ages. However, the regulations to implement the bill stipulated that it would apply only to bicyclists <18 years of age. The time series analysis did not demonstrate changes in the numbers of deaths for bicyclists 16 years of age through adulthood after October 1995. This suggests that the reduction in the mortality rate in the younger age group was attributable, at least in part, to the introduction of the helmet legislation.

The results of this study may be limited by the data source. The accuracy of the data collected by the Office of the Chief Coroner of Ontario is not known. However, it is unlikely that there would be differences in the accuracy of data collection for individuals <16 years or >16 years of age. It is possible that some bicycle-related deaths occurred late in the hospital stay and were not captured by the coroner's office. In our previous study, we found that 90% of deaths occurred at the scene of the crash.5

The findings of our study are supported by previous research. Attewell et al2 conducted a meta-analysis of studies from several countries that were published in the period from 1987 to 1998. Six studies reported results of fatal injuries.27–32 Those case-control studies from Australia,27 the United Kingdom,28 and the United States29–32 examined fatalities among 7302 cyclists of all age groups presenting to hospital emergency departments. Death occurred for 47 cyclists (0.6%), of whom 4 were helmeted and 43 nonhelmeted. The combined estimate of the odds ratio for fatal injury for helmeted versus nonhelmeted cyclists was 0.27 (95% CI: 0.10–0.71).

More recently, Cummings et al3 modeled changes in traffic crash mortality rates in the United States over the 20-year period from 1982 to 2001 that were attributable to 5 factors, including the use of bicycle helmets. Using data from the National Highway Traffic Safety Administration Fatality Analysis Reporting System and risk ratios from the case-control study by Thompson et al,31 the authors found that rates of deaths attributable to not wearing a bicycle helmet decreased 39%, from 0.26 deaths per 100000 person-years in 1982 to 0.16 deaths per 100000 person-years in 2001.

The effectiveness of legislation in increasing helmet use was examined by Karkhaneh et al,4 who conducted a systematic review of 11 studies from several countries with various designs. Helmet use was >4 times greater after legislation (odds ratio: 4.6; 95% CI: 2.87–7.36). The largest effect sizes were observed in studies where helmet laws applied to all ages, rather than children only.

Grant and Rutner33 modeled the effect of helmet legislation on bicycling fatalities in the United States from 1975 to 2000, using data from the Fatality Analysis Reporting System. Among children, bicycle fatality rates decreased to one third over the study period. Among adults, bicycling fatality rates increased modestly. Using 3 regression models, the authors concluded that statewide helmet laws reduced fatality rates by 15% to 16%.

It is possible that nonlegislative factors are responsible for the reductions in children's bicycle-related fatality rates. Factors associated with helmet use, helmet trends, and community-specific nonlegislative initiatives were studied in several regions of the province of Ontario in the early 1990s.6,9,10,34–38 This activity was undertaken largely in the years before the introduction of helmet legislation. It is likely that nonlegislative strategies and legislation work jointly, rather than independently.

It has been postulated that there may be an association between helmet legislation and reductions in bicycling.39–40 Such an association might lead to an apparent reduction in bicycling-related injury and mortality rates. We examined data from our longitudinal observation survey in one urban community in Ontario (in 1993–1997, 1999, and 2001) and did not identify a systematic reduction in children's rates of bicycling (cyclists per hour).14,15 In the same urban community, helmet use increased from 3.4% in 19908 to 45% in 1995 before legislation, exceeded 65% in the 2 years after the introduction of legislation,13 and reached 85% in high-income areas 6 years after the introduction of legislation.14

Adults are important role models for healthy, active, and safe living for children. In an examination of data for >2000 children in our longitudinal observational study, children were 9 times more likely to wear a helmet when riding with helmeted adults, compared with riding with nonhelmeted child companions (relative risk: 9.18; 95% CI: 7.04–11.98).8 Even nonhelmeted adults had a significant influence on children's helmet wearing (relative risk: 3.93; 95% CI: 2.86–5.40). Therefore, increasing helmet use among adults may further increase children's helmet use. Furthermore, Hagel et al41 found that legislation for bicyclists <18 years of age in Alberta, Canada, was associated with a significant increase in helmet use among bicyclists in that age group (adjusted prevalence ratio: 3.96; 95% CI: 2.65–5.14) but not among those ≥18 years of age (adjusted prevalence ratio: 1.17; 95% CI: 0.95–1.43).


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Bicycle-related mortality rates for children 1 to 15 years of age decreased significantly during the 12-year period from 1991 to 2002. It is most likely that multiple factors, including education, promotion, and secular trends, contributed to this decrease. The analysis suggests that the introduction of legislation mandating helmet use for bicyclists <18 years of age made a significant contribution; legislation was found to be temporally associated with the reduction in fatalities among child bicyclists (1–15 years of age), whereas a similar reduction in fatalities among adult bicyclists (≥16 years of age) was not identified. These findings provide support for extending the law to include adults. The findings also argue for continued enforcement of the existing law as it applies to bicyclists <18 years of age.


   ACKNOWLEDGMENTS
 
The Pediatric Outcomes Research Team is supported by a grant from the Hospital for Sick Children Foundation. This funding body had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

We gratefully acknowledge the Office of the Chief Coroner of Ontario for providing the data.


   FOOTNOTES
 
Accepted Dec 12, 2007.

Address correspondence to Patricia C. Parkin, MD, FRCPC, Division of Pediatric Medicine and the Pediatric Outcomes Research Team, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: patricia.parkin{at}sickkids.ca

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Bicycling is a common activity for children, who are at risk for bicycle-related fatal injuries. Helmets are effective in reducing bicycle-related fatalities, and legislation mandating the use of helmets by cyclists is effective in increasing helmet use.

 

What This Study Adds

Bicycle-related deaths among children (1–15 years of age) decreased significantly, and the introduction of legislation mandating helmet use for bicyclists <18 years of age made a significant contribution. A similar reduction among bicyclists ≥16 years of age was not identified.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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