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Long-Term Effects of Education and Legislation Enforcement on All-Age Bicycle Helmet Use: A Longitudinal Study

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Bicycle-related injuries are a leading cause of child and youth hospitalizations in Canada. The use of helmets while bicycling reduces the risk of brain injuries. This study investigated the long-term effect of legislation coupled with enforcement to improve helmet use rates. We conducted a longitudinal observational study of helmet use at 9, 11, and 14 years after bicycle helmet legislation was enacted. Data were compared to baseline observations collected after legislation was passed in 1997. A comprehensive enforcement and educational diversion program, Operation Headway–Noggin Knowledge (OP–NK), was developed and implemented in partnership with regional police during the study period. Helmet use was sustained throughout the post-legislation period, from 75.3 % in the year legislation was enacted to 94.2 % 14 years post-legislation. The increase in helmet use was seen among all age groups and genders. Helmet legislation was not associated with changes in bicycle ridership over the study years. OP–NK was associated with improved enforcement efforts as evidenced by the number of tickets issued to noncompliant bicycle riders. This observational study spans a 16-year study period extending from pre-legislation to 14 years post all-age bicycle helmet legislation. Our study results demonstrate that a comprehensive approach that couples education and awareness with ongoing enforcement of helmet legislation is associated with long-term sustained helmet use rates. The diversion program described herein is listed among best practices by the Public Health Agency of Canada.

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  1. Canadian Institute for Health Information. (2014). The Hospital Morbidity Database (HMDB).

  2. Canadian Institute for Health Information. (n.d.). Trauma registries: Cycling injury hospitalizations in Canada.

  3. Thompson, D. C., Rivara, F. P., & Thompson, R. (2000). Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews (Online), (2), CD001855. doi:10.1002/14651858.CD001855.

  4. Macpherson, A., & Spinks, A. (2008). Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD005401.pub3.

  5. Lindsay, H., & Brussoni, M. (2014). Injuries and helmet use related to non-motorized wheeled activities among pediatric patients. Chronic Diseases and Injuries in Canada, 34(2–3), 74–81.

    CAS  PubMed  Google Scholar 

  6. Dennis, J., Ramsay, T., Turgeon, A. F., & Zarychanski, R. (2013). Helmet legislation and admissions to hospital for cycling related head injuries in Canadian provinces and territories: interrupted time series analysis. BMJ (Clinical Research Ed.), 346((may14_1)), f2674. doi:10.1136/bmj.f2674.

    Google Scholar 

  7. Parachute Canada. (n.d.). Bike Helmet Legislation Chart. Helmet Legislation Chart-2014.pdf.

  8. Province of Nova Scotia. Motor Vehicle Act (amended), & Pub. L. No. Bill No. 111 (2002). Canada.

  9. Fenerty, L., Thibault-Halman, G., Bruce, B. S., Landry, J., Young, J., Walling, S., et al. (2013). Helmets for skiing and snowboarding: Who is using them and why. The Journal of Trauma and Acute Care Surgery, 74(3), 895–900. doi:10.1097/TA.0b013e31827e19ca.

    Article  PubMed  Google Scholar 

  10. Province of Nova Scotia. Snow Sport Helmet Act, & Pub. L. No. Bill No.131 (2011). Canada.

  11. Dennis, J., Potter, B., Ramsay, T., & Zarychanski, R. (2010). The effects of provincial bicycle helmet legislation on helmet use and bicycle ridership in Canada. Injury Prevention, 16(4), 219–224. doi:10.1136/ip.2009.025353.

    Article  PubMed  Google Scholar 

  12. LeBlanc, J. C., Beattie, T. L., & Culligan, C. (2002). Effect of legislation on the use of bicycle helmets. CMAJ, 166(5), 592–595.

    PubMed  PubMed Central  Google Scholar 

  13. Gilchrist, J., Schieber, R. A., Leadbetter, S., & Davidson, S. C. (2000). Police enforcement as part of a comprehensive bicycle helmet program. Pediatrics, 106(1 Pt 1), 6–9. doi:10.1542/peds.106.1.6.

    Article  CAS  PubMed  Google Scholar 

  14. Karkhaneh, M., Kalenga, J.-C., Hagel, B. E., & Rowe, B. H. (2006). Effectiveness of bicycle helmet legislation to increase helmet use a systematic review. Injury Prevention Journal of the International Society for Child and Adolescent Injury Prevention, 12(2), 76–82. doi:10.1136/ip.2005.010942.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Karkhaneh, M., Rowe, B. H., Duncan Saunders, L., Voaklander, D., & Hagel, B. (2011). Bicycle helmet use after the introduction of all ages helmet legislation in an Urban Community in Alberta, Canada. Canadian Journal of Public Health, 102(2), 134–138.

    PubMed  Google Scholar 

  16. Macpherson, A. K., Macarthur, C., To, T. M., Chipman, M. L., Wright, J. G., & Parkin, P. C. (2006). Economic disparity in bicycle helmet use by children six years after the introduction of legislation. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 12(4), 231–235. doi:10.1136/ip.2005.011379.

    Article  CAS  Google Scholar 

  17. Oppel, L. (2008). Bike helmets—Can we improve on a good thing? BCMJ, 50(10), 571.

    Google Scholar 

  18. Finch, C. F. (1996). Teenagers’ attitudes towards bicycle helmets three years after the introduction of mandatory wearing. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 2(2), 126–130. doi:10.1136/ip.2.2.126.

    Article  CAS  Google Scholar 

  19. Page, J. L., Macpherson, A. K., Middaugh-Bonney, T., & Tator, C. H. (2012). Prevalence of helmet use by users of bicycles, push scooters, inline skates and skateboards in Toronto and the surrounding area in the absence of comprehensive legislation: An observational study. Injury Prevention, 18(2), 94–97. doi:10.1136/injuryprev-2011-040029.

    Article  PubMed  Google Scholar 

  20. Grenier, T., Deckelbaum, D. L., Boulva, K., et al. (2013). A descriptive study of bicycle helmet use in Montreal, 2011. Canadian Journal of Public Health, 104(5), e400–e404.

    Article  PubMed  Google Scholar 

  21. Lerin, E. (2004). Helmet law difficult to enforce among skateboarders. Nova News Net.

  22. Teschke, K., Koehoorn, M., Shen, H., & Dennis, J. (2015). Bicycling injury hospitalisation rates in Canadian jurisdictions: Analyses examining associations with helmet legislation and mode share. BMJ Open, 5(11), e008052. doi:10.1136/bmjopen-2015-008052.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Molina-Garcia, J., & Queralt, A. (2016). The Impact of Mandatory Helmet-Use Legislation on the Frequency of Cycling to School and Helmet Use Among Adolescents. Journal of Physical Activity & Health. doi:10.1123/jpah.2015-0566.

    Google Scholar 

  24. Public Health Agency of Canada, & Canadian Best Practices Portal. (n.d.). Operation Headway.

  25. Kraemer, J. D., Zaccaro, H. N., Roffenbender, et al. (2015). Assessing the potential for bias in direct observation of adult commuter cycling and helmet use. Injury Prevention, 21(1), 42–46.

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Constable Regan Fong (Halifax Regional Police) for his leadership, collaboration and innovative Operation Headway design. Many Partners in Policing (Halifax Regional Police and Halifax District Royal Canadian Mounted Police) who supported OP–NK and tirelessly continue to provide enforcement of all-age helmet legislation in NS.


Funding from the Nova Scotia Department of Health and Dalhousie University’s Division of Neurosurgery provided helmet giveaways and sustained research support.

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Correspondence to Lynne Fenerty.

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Huybers, S., Fenerty, L., Kureshi, N. et al. Long-Term Effects of Education and Legislation Enforcement on All-Age Bicycle Helmet Use: A Longitudinal Study. J Community Health 42, 83–89 (2017).

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