title: 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.
abstract: BACKGROUND
  Legislation in the province of Ontario, Canada, mandates users under the age of 18 to wear a helmet when they ride a bicycle, and legislation has been shown to significantly increase rates of bicycle helmet use. Legislation does not exist in Ontario for older bicyclists or for users of other non-motorised modes of transportation, and there are no current data available regarding rates of helmet use in these categories. This study was designed to determine the prevalence of helmet use among users of bicycles, skateboards, push scooters and inline skates in Toronto, Ontario, and the surrounding area. Further analysis was performed to examine factors associated with helmet use.
  
  
  METHODS
  We performed a cross-sectional, observational study. Three trained, stationary observers captured 6038 users of bicycles (5783), skateboards (77), inline skates (165) and push scooters (13) in the summer of 2009. Observations were separated into three time periods capturing commuters, midday users and recreational users. A general linear model was used to assess the factors associated with helmet use among bicyclists.
  
  
  RESULTS
  Helmets were worn by 48.9% of all users observed and 50.0% of all bicyclists. Among bicyclists, females were more likely to wear helmets than males (prevalence ratio 1.27, 95% CI 1.17 to 1.36), while children were significantly more likely to wear helmets than adults (prevalence ratio 1.17, 95% CI 1.37 to 2.15). Significant behavioural variation was observed among users during the three observation periods (p<0.001), with commuters being the most likely to wear a helmet.
  
  
  CONCLUSIONS
  In the absence of comprehensive legislation encompassing all ages of users, only half of users of non-motorised, wheeled transportation devices are choosing to wear a helmet to protect against traumatic brain injury. Implementation of evidence-based strategies to increase helmet use, such as the introduction of legislation encompassing all ages and all equipment, is required.
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Page
authors.forename: Alison K
authors.initials: AK
authors.lastname: Macpherson
authors.forename: Tara
authors.initials: T
authors.lastname: Middaugh-Bonney
authors.forename: Charles H
authors.initials: CH
authors.lastname: Tator
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D001642:Bicycling / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D002648:Child; D006259:Craniocerebral Trauma / Q000517:prevention & control*; D003430:Cross-Sectional Studies; D005260:Female; D006260:Head Protective Devices / Q000706:statistics & numerical data*; D015438:Health Behavior; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009864:Ontario; D012861:Skating / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D055815:Young Adult