3. HELMET USE AT CITY FACILITIES

LE PORT DU CASQUE AUX INSTALLATIONS MUNICIPALES

Committee RecommendationS

That Council :

1. Approve a comprehensive strategy to develop community-based interventions that raise awareness and promote helmet use among children and youth. The strategy will be led by Ottawa Public Health, in partnership with Parks, Recreation and Cultural Services and community stakeholders, and will include:

a. Enhanced helmet promotion interventions across public health and recreation programming;

b. Community partnerships to make helmets more accessible to low-income families;

c. A youth engagement strategy

d. Engagement of community skating rink operators in the promotion of helmet use; and

e. Monitoring rates of youth helmet use over time to gauge effectiveness of the youth engagement strategy.

RecommandationS DU Comité

Que le Conseil :

1. approuve une stratégie globale afin de planifier des interventions communautaires visant à promouvoir le port du casque chez les enfants et les jeunes. Dirigée par Santé publique Ottawa, en collaboration avec le Service des parcs, des loisirs et de la culture et des intervenants communautaires, cette stratégie va consister à :

a. Accroître les interventions faisant la promotion du port du casque dans les programmes récréatifs et de santé publique;

b. Établir des partenariats communautaires visant à rendre les casques plus accessibles pour les familles à faible revenu;

c. Élaborer et mettre en œuvre une stratégie de mobilisation des jeunes;

d. Faire participer les exploitants des patinoires communautaires à la promotion du port du casque;

e. Évaluer la proportion de jeunes portant un casque au fil du temps afin de connaître l’efficacité de la stratégie de mobilisation des jeunes.

Documentation

1. Deputy City Manager's report, City Operations dated 4 March 2010 (ACS2010-COS-OPH-0001).

2. Extract of Draft Minutes, 4 March 2010.

Report to/Rapport au :

Community and Protective Services Committee

Comité des services communautaires et de protection

and Council / et au Conseil

March 4, 2010 / le 4 mars, 2010

Submitted by/Soumis par :

Steve Kanellakos, Deputy City Manager/Directeur municipal adjoint,

Community and Protective Services/Services communautaires et de protection

Contact Person/Personne ressource : Dr. Isra Levy, Medical Officer of Health

Ottawa Public Health/Santé publique Ottawa

613-580-2424 x 23681, isra.levy@ottawa.ca

City Wide/à l'échelle de la Ville

Ref N°: ACS2010-COS-OPH-0001

SUBJECT:	helmet use at city facilities

OBJET :	LE PORT DU CASQUE AUX INSTALLATIONS MUNICIPALES

REPORT RECOMMENDATIONS

That the Community and Protective Services Committee recommend that Council:

a. Enhanced helmet promotion interventions across public health and recreation programming;

b. Community partnerships to make helmets more accessible to low-income families;

c. A youth engagement strategy

d. Engagement of community skating rink operators in the promotion of helmet use; and

e. Monitoring rates of youth helmet use over time to gauge effectiveness of the youth engagement strategy.

RECOMMANDATIONS DU REPORT

Que le Comité des services communautaires et de protection recommande au Conseil :

1. D’approuver une stratégie globale afin de planifier des interventions communautaires visant à promouvoir le port du casque chez les enfants et les jeunes. Dirigée par Santé publique Ottawa, en collaboration avec le Service des parcs, des loisirs et de la culture et des intervenants communautaires, cette stratégie va consister à :

a. Accroître les interventions faisant la promotion du port du casque dans les programmes récréatifs et de santé publique;

b. Établir des partenariats communautaires visant à rendre les casques plus accessibles pour les familles à faible revenu;

c. Élaborer et mettre en œuvre une stratégie de mobilisation des jeunes;

d. Faire participer les exploitants des patinoires communautaires à la promotion du port du casque;

e. Évaluer la proportion de jeunes portant un casque au fil du temps afin de connaître l’efficacité de la stratégie de mobilisation des jeunes.

EXECUTIVE SUMMARY

Ottawa Public Health (OPH) recognizes that the best way to prevent head injuries due to high risk sporting activities is to wear a helmet. In order to review the evidence and determine the most effective options for promoting helmet use at City facilities, OPH lead a cross-departmental advisory group. This group had representation from Parks, Recreation and Cultural Services, By-Law and Regulatory Services, Parks, Building and Grounds Operation and Maintenance,and the City Operations Deputy City Manager’s Office.

Evidence from both research and practice supports an approach to injury prevention that carefully considers the timing and sequencing of policy development and public education. The implementation of mandatory helmet use by-laws or policies, when there is a lack of adequate helmet subsidy programs or community readiness, can potentially create barriers to physical activity. At this time, a municipal by-law is not recommended. A strategy that balances youth injury prevention with physical activity promotion is under development and is recommended.

Ottawa Public Health (OPH) is developing a comprehensive youth engagement strategy, which aims to prevent head injuries, raise awareness of the importance of helmet use and increase helmet use by youth, without creating barriers to physical activity. In partnership with Parks, Recreation and Cultural Services as well as community stakeholders, OPH will lead the following initiatives:

· Enhanced helmet promotion interventions across public health and recreation programming;

· Community partnerships to make helmets more accessible to low-income families;

· Community development efforts to engage skateboarders and skateboarding advocates in helmet promotion;

· Engagement of community skating rink operators in the promotion of helmet use; and

· Monitoring rates of youth helmet use over time to gauge effectiveness of the youth engagement strategy.

In complement to the youth engagement strategy, the Parks, Recreation and Cultural Services Department is planning to implement a broader mandatory helmet use policy at City of Ottawa operated indoor skating rinks. Beginning in 2011, patrons under the age of 13 years participating in all supervised indoor public skating sessions, including open skates, will be required to wear helmets. Currently, the City has a mandatory helmet use policy for minors participating in City-operated indoor skating programs and for patrons of one supervised indoor skateboard park and one supervised BMX park. OPH endorses this policy change.

The prevention of head injuries remains a cornerstone of OPH injury prevention programs and services. OPH will continue to work with youth as well as City partners and community stakeholders to reduce head injuries and increase helmet use among youth.

RÉSUMÉ

Le présent rapport a pour but de présenter une analyse indiquant s’il est possible d’adopter une politique ou un règlement municipal rendant le port du casque obligatoire dans le cas des mineurs se servant des installations exploitées par la Ville. Il vise également à recommander une stratégie de réduction des traumatismes crâniens par la promotion du port du casque qui soit fondée sur des données locales et qui comporte des pratiques exemplaires justifiées par des recherches.

Santé publique Ottawa (SPO) reconnaît que le port du casque constitue la meilleure méthode de prévention des traumatismes crâniens associés à des activités sportives à risque élevé. Afin d’examiner les données sur la question et de déterminer les meilleures façons de promouvoir le port du casque aux installations municipales, SPO a mis sur pied un groupe consultatif composé de représentants de plusieurs services, dont le Service des parcs, des loisirs et de la culture, les Services des règlements municipaux, la Direction des opérations et de l’entretien relatifs aux parcs, aux immeubles et aux terrains, et le Bureau du directeur municipal adjoint des Opérations municipales.

Les données provenant de la recherche et de l’expérience favorisent l’adoption d’une méthode de prévention des blessures qui tient compte de l’opportunité et de l’exécution par étapes de l’élaboration des politiques et de l’éducation du public. En l’absence de programmes adéquats de subventions pour l’acquisition de casques ou de préparation de la collectivité, les règlements ou les politiques rendant le port du casque obligatoire risquent de créer des obstacles à l’activité physique. Pour le moment, il n’est pas recommandé d’adopter un règlement municipal sur la question. Il est plutôt recommandé de mettre en œuvre la stratégie en voie d’élaboration, qui fait à la fois la promotion de la prévention des blessures et celle de l’activité physique chez les jeunes.

Santé publique Ottawa (SPO) s’affaire à élaborer une stratégie globale de mobilisation des jeunes, qui vise à prévenir les traumatismes crâniens, à souligner l’importance du port du casque et à accroître le port du casque chez les jeunes, sans créer d’obstacles à l’activité physique.

En collaboration avec le Service des parcs, des loisirs et de la culture et des intervenants communautaires, SPO mènera des initiatives consistant à :

- Accroître les interventions faisant la promotion du port du casque dans les programmes récréatifs et de santé publique;

- Établir des partenariats communautaires visant à rendre les casques plus accessibles pour les familles à faible revenu;

- Déployer des efforts de développement communautaire ayant pour but de faire participer des planchistes et des porte-parole des adeptes de la planche à roulettes à la promotion du port du casque;

- Faire participer les exploitants des patinoires communautaires à la promotion du port du casque;

- Évaluer la proportion de jeunes portant un casque au fil du temps afin de connaître l’efficacité de la stratégie de mobilisation des jeunes.

Pour compléter la stratégie de mobilisation des jeunes, le Service des parcs, des loisirs et de la culture compte adopter une politique rendant le port du casque obligatoire pour un plus grand nombre de personnes aux patinoires intérieures exploitées par la Ville d’Ottawa. À compter de 2011, les clients de moins de 13 ans participant aux séances de patinage supervisées aux patinoires intérieures, y compris aux séances de patinage libre, devront porter un casque. Actuellement, le port du casque n’est obligatoire que dans les cas suivants : mineurs participant à des programmes de patinage dans des installations intérieures exploitées par la Ville; clients d’un parc intérieur supervisé pour la pratique de la planche à roulettes; clients d’un parc supervisé pour la pratique du BMX. SPO appuie le changement à la politique.

La prévention des traumatismes crâniens demeure l’un des principaux volets des services et programmes de prévention des blessures de SPO. SPO va continuer de collaborer avec les jeunes, ses partenaires municipaux et les intervenants communautaires afin de réduire le nombre de traumatismes crâniens et d’accroître le port du casque chez les jeunes.

BACKGROUND

In April 2009, Dr. Michael Vassilyadi, a neurosurgeon at the Children’s Hospital of Eastern Ontario (CHEO) and the Chapter Director for ThinkFirst Ottawa and Dr. Isra Levy, Medical Officer of Health for Ottawa Public Health (OPH) presented to the City of Ottawa, Community and Protective Services Committee (CPSC) regarding the issue of head and brain injuries in children.

Dr. Vassilyadi informed the CPSC that falls are the leading cause of traumatic brain injury in children and youth. He stressed that proper use of helmets during high risk sporting endeavours can prevent traumatic brain injuries, and mandatory helmet use is an important strategy in increasing helmet compliance.

Dr. Levy presented the role of OPH in head injury prevention. OPH engages community partners in the development and implementation of healthy policies and programs, as well as the creation of safe and supportive environments to address local needs in terms of injuries. This includes working with priority populations to increase their capacity to prevent injury.(1)

Upon consideration of the information presented, CPSC and Council passed the following motion:

“Whereas falls are the leading cause of traumatic head injuries among children and youth; and

Whereas many of those injuries occur during sports and recreational activities;

Therefore be it resolved that staff be directed to prepare a report outlining current regulations and policies respecting mandatory helmets including the feasibility of a municipal by-law or policy to require mandatory use of helmets by minors in facilities such as skateboard parks.” (2)

The purpose of this report is to provide an analysis of the feasibility of a municipal by-law or policy regarding mandatory helmet use by minors at City-operated facilities, as well as provide a recommended strategy to reduce head injuries by promoting helmet use that is informed by local data and incorporates researched best practices. The overall goal of the recommended strategy is to increase the uptake of helmet use without decreasing physical activity levels or interfering with the provision of accessible and safe opportunities for physical activity.

A cross departmental advisory group, with representation from Public Health; Parks, Recreation and Cultural Services; By-law and Regulatory Services; Parks, Building and Grounds Operation and Maintenance; and, the City Operations Deputy City Manager’s Office, was established to review the evidence and develop options for consideration.

City-operated facilities where high risk sporting activities regularly take place were determined to be the most significant sites for the consideration of by-law and policy impacts. The following facilities were considered: skateboard parks, indoor and outdoor skating rinks and sledding hills. The population under consideration, as defined in the motion is children and youth, under 18 years of age.

DISCUSSION

Consideration of the feasibility of a municipal by-law or policy requiring helmet use by minors at City-operated facilities included:

· Conducting an extensive literature review to examine the evidence regarding the incidence of head injuries among children and youth engaged in selected sports activities, the use of helmets in wheeled and winter sports and the impact of both legislative and non-legislative strategies on helmet use;

· Examining legal and risk management implications;

· Performing a jurisdictional scan of City of Ottawa policies and other Canadian municipalities;

· Assessing potential community impact and readiness for change including consulting stakeholders such as youth involved in skateboarding; and

· Assessing the implications of proposed City program enhancements.

The Issue

In Ottawa, children and youth less than 18 years of age make up just over one fifth of the population.(3) Children and youth spend a significant amount time participating in sports and recreation activities, the benefits of which include physical fitness, improved motor skills, increased self esteem and the development of social skills. However, participation in these activities does carry the risk of injury. Safety equipment, such as helmets, is an important component of injury prevention for many sport and recreational activities such as cycling, hockey, skating and skateboarding.

Head injuries are a leading cause of permanent disability in children, and are preventable nine times out of ten with interventions as simple as wearing a helmet.(4) Approximately 5,700 children and youth under the age of 20 visit Ottawa emergency rooms (ER) every year for head injury and 400 are hospitalized. Sport and recreational activities represent the second leading cause of head injuries among children and youth, after falls. (5; 6; 7)

In Ottawa, cycling, hockey, ice skating, tobogganing, and skateboarding represented 9% of all ER visits for head injuries in children and youth in 2008. Cycling had the highest number of head injury hospitalizations in those under 20 years, while hockey, ice skating, tobogganing and skateboarding all had 5 or fewer head injury hospitalizations.

Available data on head injuries in Ottawa is likely an under-representation of the true burden of head injuries because many go unreported. Since participation rates are unknown for each activity, injury rates are likely further underestimated.

Data from the Children’s Hospital of Eastern Ontario from 2002 through 2007 indicate that helmet use at the time of injury was low with only 6% of all ice skating injuries reporting wearing a helmet, 1% of all tobogganing injuries, and less than one percent of all skateboarding injuries.(8) Data on reported helmet use does not account for proper helmet fit.(4)

Although skateboarding and tobogganing are well-established sports, little research has been done to date on the culture surrounding these sports, and the causes behind the injuries themselves.

The literature review conducted by OPH found that helmet legislation promotes helmet use among cyclists. However, findings also indicate that comprehensive approaches to promoting helmet use, including community-based interventions can help to sustain helmet use over time, remove barriers to compliance and address other factors that can increase the risk of head injury such as the built environment.

Currently, helmet use is highly recommended for all clients at all City of Ottawa facilities. This recommendation is included in the signage regarding rules of conduct and safety messages at all facilities.

Feasibility of mandatory helmet use

There are two regulatory tools that can be used to mandate helmet use at City facilities:

Municipal by-law; and
Helmet use policies.

Municipal by-law

There are currently no by-law provisions requiring helmet use in city facilities. Legal Services advises that the City does have the ability to pass a by-law under s. 10(2), paragraph 6, of the Municipal Act, 2001 for the purposes of health safety and well-being of persons. Therefore, there would be sufficient legal authority for Council to pass a by-law, or amend an existing by-law, to require that individuals wear a helmet while engaging in particular sporting activities or while attending at certain City properties such as skateboard parks.

A jurisdictional scan of Canadian municipalities reveals that mandatory helmet use by-laws have been enacted in only three municipalities. These by-laws address small-wheeled vehicles only (skateboards, scooters and in-line skates) and have been applied primarily to city streets and sidewalks or have been limited to a single municipal facility such as a skateboard park. It is also worth noting that, in Ontario, the Highway Traffic Act, R.S.O. 1990, addresses helmet use on highways (including City streets) for cyclists.

Legal Services further advises that enforcement of a municipal by-law mandating helmet use may present an increased risk of liability in unsupervised or unmonitored facilities.

Canadian insurance industry standards are consistent with the recommendation of the City’s insurance carrier in suggesting that “strongly recommending helmet use”, rather than mandating helmet use, carries the lowest risk of liability for City facilities that are unsupervised or for which access is not strictly monitored. (9) City-owned facilities where helmet use is obligatory would ideally need to be supervised and contained with controlled entry in order to meet the expectation of enforcement.

The By-law and Regulatory Services Branch advises that the enactment of a by-law would be accompanied by the expectation of enforcement, which would require significant resources to cover the cost of monitoring and enforcement.

The Parks, Recreation and Cultural Services Department has provided the following information on the financial implications of a mandatory helmet by-law. To meet the City’s insurance carrier’s recommendations regarding containment, controlled entry and supervision, additional funds would be required to:

· Plan, purchase, install and maintain physical modifications such as fencing at approximately 300 different sites;

· Purchase, install and maintain new signage;

· Hire and train additional front-line staff to provide supervision and enforcement at each facility;

· Put in place a supervision and management structure to support the work;

· Accommodate the impact of these changes on other activities taking place at these varied sites e.g. community consultation; and

· Accommodate expected annual cost increases.

In addition, Parks, Buildings and Grounds Operation and Maintenance staff have advised that in the event that a by-law is enacted, detailed roles and requirements would have to be assessed to determine potential resource and funding requirements for operations and maintenance support.

A significant concern, highlighted in the literature regarding the introduction of a mandatory helmet by-law or policy, is the potential to negatively impact physical activity levels of priority populations. Families with lower incomes, new immigrants and adolescents are target groups for health promotion interventions designed to educate, support and remove barriers to physical activity access. Barriers to mandatory helmet compliance include the affordability of helmets, peer and parental influence and the lack of knowledge regarding the risk and potential severity of injury as well as the protection provided by a helmet. (10)

In addition, stakeholder consultations conducted with skateboarders at City of Ottawa facilities, indicated that the introduction of a mandatory helmet use by-law would likely cause them to move their activities to non-City facilities such as streets and parking lots.

Helmet use policy

Legal Services advises that the Trespass to Property Act (TPA) enables the introduction of helmet use policies on a site-by-site basis. Under this legislation, the rules for entry onto a property or use of a facility may be tailored to the particular place or activity, and to particular classes of users. As owner, the City can prohibit entry onto a property or use of the particular facility without a helmet. Such a prohibition (as well as any other safety rule) can be indicated on visible signs that are posted on the premises. The effect of this prohibition is that any individual who engages in an activity contrary to posted signs is committing an offence and may be asked to leave by authorized personnel.

Currently the City has an existing policy requiring helmet use for:

· Minors participating in City-operated programs at City-operated indoor skating rinks;

· Patrons of one supervised City indoor skate park; and

· Patrons of one supervised BMX Park.

Expanding the use of municipal policy has considerations similar to a by-law, regarding financial implications, enforcement, risk of liability and barriers to physical activity.

The Parks, Recreation and Cultural Services Department has identified an existing opportunity for policy change, requiring helmet use by patrons under the age of 13, during supervised public skating sessions at City operated indoor skating rinks.

When compared to sledding and skateboarding, ice skating accounts for the highest rate of Ottawa ER visits for head injury in children. Children between the ages of 5 to 14 years represent the highest rate of head injury while ice skating.

Most indoor skating rink facilities currently meet the containment, controlled access and supervision requirements recommended by the City of Ottawa’s insurer.

This policy revision builds on community readiness for change, has the potential to increase helmet use for children under the age of 13 years, can be implemented with minimal cost, and poses no increased risk of liability. These factors make this facility and sports activity a good choice for the introduction of policy change. The Parks, Recreation and Cultural Services Department are pursuing this helmet use policy change for the 2011-12 skating season. Ottawa Public Health endorses this policy change.

It will be important to ensure that the implementation of this helmet use policy does not negatively impact the physical activity levels of patrons who cannot afford helmets. Currently the preferred approach is the provision of helmets as opposed to helmet lending. Actual helmet ownership is a predictor of helmet use and the challenges posed by the storage, fitting and cleaning required for helmet lending are resource intensive and carry a risk of additional liability. (11) Helmet lending programs, however, may be quite appropriate for some sites and sports activities and will therefore be included in intervention planning.

Comprehensive youth engagement and injury prevention strategy

Evidence from the literature supports an approach to injury prevention that carefully considers the timing and sequencing of policy development and public education. Promising results have been obtained when multiple complementary strategies are used. Interventions combining community development, legislative action, persuasive communication, education and increasing helmet access, have been shown to increase helmet use and also have the potential to minimize barriers to helmet use among children and youth. (11 - 16)

Reducing the barriers to helmet use among adolescents is a critical factor to consider in the development of effective helmet use promotion strategies. Peer-led programs for youth, promoting helmet use by addressing concerns such as style and comfort, have demonstrated promising results. (11; 12; 15)

The City of Ottawa is currently involved in a number of youth engagement initiatives and the issue of helmet use in sports would provide an excellent opportunity to engage youth in dialogue and action around issues of particular relevance to this age group.

The recommended strategy will include initiatives designed to engage youth, build on existing community partnerships and advocate for healthy public policy.

This comprehensive youth engagement strategy will include:

· The integration of helmet use promotion into the current youth programming pilot project. This project is currently implemented in community houses and school settings at sites representative of the Ottawa community; and

· An ongoing community development effort to engage youth skateboarders and with skateboarding advocates to create a supportive environment that values the skateboarding culture.

· Exploring community partnerships to make helmets more accessible to priority populations i.e. low income families, adolescents and new immigrants.

· Enhanced helmet promotion interventions across public health and recreation programming, particularly in existing youth-facilitated public education programs;

· Enhanced helmet use promotion messages at sledding hills;

· Engagement of community skating rink operators in the promotion of helmet use; and

· The monitoring of head injuries occurrences and helmet use in youth over time.

CONCLUSION

Ottawa Public Health, in collaboration with partners across the City of Ottawa, is developing an action plan that will improve the uptake of helmet use while minimizing potential negative impacts to both physical activity levels and access to City-operated recreational facilities.

RURAL IMPLICATIONS

There are no specific rural implications associated with the recommendations.

CONSULTATION

Injury prevention advocacy groups, Safe Kids Canada and Dr. Michael Vassilyadi, the Chapter Director for ThinkFirst Ottawa, were consulted on the development of this report. Parks, Recreation and Cultural Services; By-law Services; and Parks, Building and Grounds Operations and Maintenance were contributors to the development of this report.

LEGAL/RISK MANAGEMENT IMPLICATIONS

There are no legal or risk management implications with respect to the implementation of the recommendations of this report.

FINANCIAL IMPLICATIONS

During 2010 and in the initial phase of the youth engagement strategy, OPH will assess the long-term financial requirements of the helmet use promotion initiative and will bring forward an operational budget pressure in 2011 if warranted.

SUPPPORTING DOCUMENTATION

Document 1 - Literature review

DISPOSITION

Ottawa Public Health, in consultation with other appropriate Branches/Departments, will action any direction received as part of consideration of this report.

REFERENCES

(1) Health Protection and Promotion Act, Ontario Ministry of Health and Long-Term Care, (2008).

(2) Minutes 41. Community and Protective Services Committee (CPSC), City of Ottawa, (Apr 16, 2009). Available from: URL: http://www.ottawa.ca/calendar/ottawa/citycouncil/cpsc/2009/04-16/minutes41.htm

(3) Statistics Canada. Population Estimates [2004-2008]. 2010. Ontario Ministry of Health and Long-Term Care IntelliHEALTH. 1-7-0100.
Ref Type: Data File

(4) Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev 2000;(2):CD001855.

(5) National Ambulatory Care Reporting System. ER Visits 2004-2008. Ontario Ministry of Health and Long-Term Care Provincial Health Planning Database . 1-7-2010.
Ref Type: Data File

(6) Canadian Institute for Health Information Discharge Abstract Database. Hospital In-Patient Data [2004-2008]. 2010. Ontario Ministry of Health and Long-Term Care: IntelliHEALTH. 1-7-0100.
Ref Type: Data File

(7) Canadian Institute of Health Information. Injury, poisoning and certain other consequences of external causes: Injuries to the head. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada. 2006.

(8) Children's Hospital of Eastern Ontario. Canadian Hospitals Injury Reporting and Prevention Program [2002-2007]. 2009. 20090.
Ref Type: Data File

(9) Barnum J. Skateboard Parks: Insurance and Liability. Goldbridge, BC: Spectrum Skatepark Creations Ltd; 2002.

(10) Finnoff JT, Laskowski ER, Altman KL, Diehl NN. Barriers to bicycle helmet use. Pediatrics 2001 Jul;108(1):E4.

(11) Kendrick D, Royal S. Cycle helmet ownership and use; a cluster randomized controlled trial in primary school children in deprived areas. Arch Dis Child 2004 Apr;89(4):330-5.

(12) Royal S, Kendrick D, Coleman T. Promoting bicycle helmet wearing by children using non-legislative interventions: systematic review and meta-analysis. Inj Prev 2007 Jun;13(3):162-7.

(13) Wesson D, Spence L, Hu X, Parkin P. Trends in bicycling-related head injuries in children after implementation of a community-based bike helmet campaign. J Pediatr Surg 2000 May;35(5):688-9.

(14) Coffman S. Promotion of safety helmets for child bicyclists: 2002 update. Online J Knowl Synth Nurs 2002 Mar 25;9:1.

(15) Van HR, Van HJ, Malenfant JE. Impact of a comprehensive safety program on bicycle helmet use among middle-school children. J Appl Behav Anal 2007;40(2):239-47. (3)

(16) Hendrickson SG, Becker H. Impact of a theory based intervention to increase bicycle helmet use in low income children. Injury Prevention 1998; 4:126-131.

(17) Office of the Auditor General. A Guide to Policy Development. Manitoba. January 2003.

(18) Karkhaneh M, Kalenga JC, Hagel BE, Rowe BH. Effectiveness of bicycle helmet legislation to increase helmet use: a systematic review. Inj Prev 2006 Apr;12(2):76-82.

Document 1

LITERATURE REVIEW

Methods

A literature review was conducted in order to determine what research was currently available regarding the use of helmets in small-wheeled and winter sports, and the impacts of both legislative and non-legislative strategies on helmet compliance. Several research questions were developed to guide the literature search as follows:

What effect does mandatory helmet legislation have on children and youth regarding:

o Compliance to legislation

o Incidence of injuries

o Participation in physical activity

What barriers may prevent children and youth complying with mandatory helmet legislation?
What best practices promote helmet compliance and other safe strategies (built environment, education, other protective equipment) in conjunction with the introduction of legislation for children and youth?
What non-legislative strategies promote helmet use and/or safe behaviours for children and youth?

Ottawa Public Health staff searched CINAHL, Cochrane Database of Systematic Reviews and Medline for articles published until June 2009 using the following keywords: helmet legislation, helmet safety, helmet compliance, skateboarding safety, and skateboarding legislation. Two hundred and seventy-four (274) articles were found. Abstracts were then reviewed for the purposes of classifying each article as high, medium, or low relevance to the research questions. Eighty-one (81) studies were classified as high relevance and systematically appraised.(1)

Limitations

Although skateboarding and tobogganing are well-established sports, little research has been done to date on the culture surrounding these sports, and the causes behind the injuries themselves. Much of the information available has had to be generalized from other sports; for example, risk-taking behaviours have been more thoroughly studied among skiers and snowboarders.

Most of the research conducted to date pertains to the introduction of bicycle helmet legislation. Although some locations in Canada have enacted bylaws mandating the use of helmets for recreational activities such as skateboarding, the impact on injury prevention and compliance levels has not been sufficiently studied.

Most studies were conducted at a single point in time, and did not examine long-term effects or changes in patterns of behaviour. Studies that did conduct follow-ups found fairly significant changes in their observations (2), indicating the importance of examining trends in behaviour over extended periods of time.

Impact of Mandatory Helmet Legislation

Bicycle helmets provide effective protection against head injury with no increase in risk-taking behaviour or adverse effect on physical activity levels

Research conducted into the impact of bicycle helmet use has demonstrated that the use of a properly fitted helmet can reduce the risk of head injury by up to 85%.(3;4) Investigations into the impact of helmet use among skiers and snowboarders have also shown significant reductions in head injury risk of between 30% and 60%.(5)

A 2008 study by Wesson et al (7) found a 52% decrease in the annual incidence of bicycle-related deaths after the introduction of helmet legislation for bicyclists one to 15 years of age in Ontario. This research has been supported by others’ findings(6-8), including a 2002 cross-Canada study by MacPherson et al.(6) The researchers compared child and youth hospitalization data from 4 provinces with legislation to 8 provinces/territories without legislation. They found that helmet legislation resulted in a 45% decrease in head injuries, while areas without helmet legislation experienced only a 27% decrease in head injuries. After controlling for potential confounders, helmet legislation was the only variable significantly associated with the additional reduction in head injury.

Risk compensation has been identified as a major concern for mandatory helmet use. Risk compensation theory asserts that individuals who use personal protective equipment will act more aggressively, thereby increasing their risk of injury (9). However, a 2006 study by Sulheim et al (10) found that, contrary to risk compensation theory, risk-taking skiers and snowboarders were more likely to wear helmets regardless of age or skill level; this research followed a 2005 study by Hagel et al (11) that found no correlation between helmet use and an increase of severe injury risk or high-energy crash circumstances in skiers and snowboarders on a Quebec hill. This contradicted 2004 research by Hagel et al (12), which offered evidence for risk compensation in a study that found 35% of fatally-injured skiers and snowboarders had been wearing helmets, a number that is higher than their estimated helmet use for the general population. However, a 2006 study by Pless and Hagel found no evidence of an association between personal protective equipment use and risk-taking behaviour or injury severity.(9) The authors concluded that the theory of risk-compensation has little supporting evidence. Although there are some conflicting studies, the balance of evidence suggests that mandatory helmet use does not increase risk-taking behaviour, nor does it increase risk of severe injury.(9-13)

Contrary to data from a study completed in Australia in 1991-2 (13), MacPherson et al. demonstrated that in the four years following introduction of mandatory helmet legislation in Ontario, there was no negative impact on child cycling in the community.(14)

They found that cycling rates varied from year to year and were actually highest four years post-introduction of legislation.

These findings were replicated in British Columbia.(15) Participation in cycling is influenced by many factors and is difficult to accurately and reliably measure.(16) More high-quality research is needed on the subject.(16;17)

Bicycle helmet legislation increases helmet use

Bicycle helmet legislation appears to be effective in increasing helmet use in the populations for which it was implemented. A 2006 systematic review by Karkhaneh et al(18) compared results of 11 before and after legislation studies in Canada and abroad; they found that overall, the range of helmet use increased from 4-59% prior to legislation to 37-91% following legislation. Furthermore, they found that the effects were more visible over time, and are more significant in areas of higher socio-economic status.

A multinational 2005 study by Klein et al(19) found that countries with higher per capita GDPs had higher rates of helmet use among children; they also noted that these countries were more likely to have helmet promotional programs such as regional helmet giveaways. Finally, a comprehensive survey of 7,693 Ontarians by Irvine et al in 2002 (20) found that helmet use increased by 10% after the introduction of Ontario’s legislation;

Economic, social, and knowledge barriers may prevent children and youth from complying with mandatory helmet legislation.

An important concern regarding mandatory helmet legislation is its affordability for users in lower and middle-income brackets. There is some evidence to indicate that the positive impact of legislation on helmet use may be greater in low and mid income neighbourhoods that typically start with lower helmet use. However, ongoing, alternative helmet promotion strategies may be more needed in low and mid income neighbourhoods to maintain these increases in helmet use. (2;7)

An observational study conducted between 1990 and 1997 in East York found an increase in helmet use for the 2 years post-legislation.(2) A 2006 study by MacPherson et al(7) found that helmet legislation only temporarily raised helmet use among lower and middle-income neighbourhoods in East York; within 2 years, helmet use had returned to pre-legislation levels. The authors concluded that ongoing, alternative helmet promotion strategies might be more needed in low and mid income neighbourhoods to maintain these increases in helmet use.

Peer and parental influence can be barriers to helmet use, as can a lack of knowledge of the protection afforded from wearing a helmet and the risk and potential severity of injury when not wearing a helmet.(21)

Children are heavily influenced by social norms and peer pressure (2;21-24); a 2001 study by Finoff et al found that bicycle helmet use increased in all tested age categories when associated with peer helmet use(21) but that these pressures could be minimized by the existence of supportive social climates(24), indicating a need to normalize helmet use in all relevant sporting activities. Parkin et al(2) also found that girls were more likely to wear helmets than boys both pre and post-legislation (47% vs. 33% respectively).

Irvine et al.(20) identified resistance among youth and helmet cost as potential barriers for helmet use. Furthermore, the team found that drinking alcohol and smoking were strongly associated with helmet non-use; this research is also supported by a 2008 study by Kroncke et al.(22). Additionally, Kroncke et al. found that bicycle helmet use was correlated with personal protective equipment (PPE) use in all other sports; however, they also noted that nearly half of adolescent respondents indicated that they would not wear PPE in any situation. Using results of the 1996 Ontario Health Survey, they also found that youths aged 15-18 were least likely to wear helmets, with 33.3% reporting use, while 71.7% of 12-14 year-olds reported helmet use. Irving et al. noted that 12-14 year olds were approximately 3 times more likely to wear helmets than 15-18 year olds.

Non-legislative strategies promote helmet use and safe behaviours for children and youth.

Initial research into the topic of non-legislative helmet interventions was first conducted in 1992 by Cushman et al.(25) The authors found that interventions such as media coverage, bulk-buying projects in schools, and the distribution of discount coupons contributed to an overall increase in bicycle helmet use from 10.7% to 32.2% over a 3-year period.

Peer-led programs that address concerns such as style and comfort appear more effective at increasing helmet use among children and youth.(21;26;27) In a 2007 study Van et al.(27) found that 3 middle schools with peer-led helmet programs demonstrated an increase in helmet use.

Community-based interventions have been shown to be more successful than educational interventions. A meta-analysis by S. Royal and D. Kendrick in 2007(26) found that community-based interventions were generally more successful than educational interventions; the authors found that free helmet giveaways were more successful than subsidized helmets, supporting their results from an earlier study(28) in which they found that helmet giveaways, in combination with educational packs and/or other interventions such as school assemblies, increased helmet use while minimizing the disparities between children of different economic situations. Wesson et al(29) also found that a community-based campaign had a positive effect on bike helmet use, increasing the rate from 4% to 67% over a 6-year period. It was further noted that head injury admissions fell by 22% over the same time period. Wesson et al also noted that legislation was introduced during the final 2-year period of the campaign, further increasing helmet use rates on top of an increase from successful community programming. This is supported by later research from Coffman et al (30), whose 2002 review concluded that legislation, in combination with community education and helmet promotion campaigns, is the most cost-effective approach for increasing helmet use.

Individual level factors such as skill level, gender, use of helmet in other sports, the propensity for risk-taking behaviour and self-esteem have also been noted as important factors to consider when seeking to understand and promote helmet use among children and youth (7).

Conclusion

Head injuries can be prevented or reduced in severity with helmet use. Helmet use is influenced by many factors, including age, gender, skill-level, socio-economic status, peer pressure, and social norms.

Legislation is one strategy to promote helmet use that has been shown to be effective in cycling; however, a comprehensive approach including community education and helmet promotion will be required to effectively address the multi-faceted nature of head injuries due to sport and recreational activities. Ongoing supplementary strategies may be necessary to sustain helmet use and to take into account other factors which can increase the risk of head injury, such as the built environment.

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