Attitude and Opinion of Neurosurgeons ConcerningProtective Bicycle-Helmet Use

Carla S. Jung, Klaus Zweckberger, Uta Schick, and Andreas W. Unterberg

Abstract

Wearing protective helmets decreases the risk of incurring traumatic brain injury (TBI) in bicycle accidents. In 2007,the German Neurosurgical Society advocated compulsory use of bicycle helmets. Although neurosurgeons are thespecialists who primarily treat patients with TBI in Europe, the distribution of helmet users among neurosurgeons(NS), as well as factors that influence the decision to wear helmets and whether professional knowledge orexperience in TBI influences the use or attitude concerning bicycle helmets, remains unclear. A total of 55 neu-rosurgical departments in Germany, Austria, and Switzerland were contacted and asked to answer anonymousquestionnaires concerning helmet use and TBI experience. To compare the neurosurgical attitude with that of a‘‘non-neurosurgical, non-TBI-educated’’ control group, people of the general public (PUB) were interviewed. Atotal of 465 NS and 546 PUB returned questionnaires, with 49.7% of the NS and 44.5% of PUB indicated that theywear helmets while bicycling. Trauma experience did effect the personal decision of whether to wear bicyclehelmets. Support of compulsory use was influenced by TBI experience. Furthermore, the incidence of helmet use inchildren was correlated to actual helmet use and disposition of their parents to make helmet use compulsory. NSand PUB behaved in similar ways. Only half wear protective helmets, while the others show cognitive dissonantbehavior. With respect to compulsory helmet use, NS are also split in half. Experience with TBI and traumaeducation has effects. However, education alone does not suffice in promoting the use of bicycle helmets.

Key words: bicycle; helmet; traumatic brain injury

Introduction

Worldwide, bicycles are the number-one vehicle,

and over 40 million Germans ride a bike. Each year inGermany, more than 23,000 people suffer severe traumaticbrain injury (TBI) after bicycle accidents. As TBI is consideredthe primary cause of fatal bicycle accidents among peopleaged 20 to 40 years (Rickels et al., 2006), accident preventionand protective measures are very important.

Although the use of helmets is reported to lead to a sig-nificant decrease in the risk of TBI after bicycle accidents(Abu-Zidan et al., 2007; Attewell et al., 2001; Rickels et al.,2006), only about 5% (2 million) people were reported to wearprotective helmets while bicycling in 2006. In this context, theGerman Neurosurgical Society (DGNC), during their annualmeeting in 2007, demanded the introduction of compulsoryhelmet use for all bicyclists in Germany. Over the past twoyears, no major legislative changes concerning bicycle-helmetuse took place in Germany or in any other European country.On the contrary, politicians and sports associations suggestedimproving education and increasing public awareness to

convince the general public that wearing helmets is in ev-erybody’s interest.

Considering the 2007 demand of the German NeurosurgicalSociety, neurosurgeons seem to be particularly suited to eval-uate whether neurotraumatological knowledge and experi-ence, and therefore education, has influenced personal attitudeand opinion over the past few years, leading to an increase inthe use of helmets while bicycling. As the distribution of hel-met users among neurosurgeons (NS), as well as their opinionand attitude in general, is not known, a survey was performedaddressing major neurosurgical departments in Germany,Austria, and Switzerland. To get a further idea if there aremajor differences in attitude compared to the general public(PUB), a representative cohort of persons of the non-TBI-edu-cated general population (PUB) were also interviewed.

Methods

Interviewees

From January to April 2009, 55 major neurosurgical de-partments (NS) in Germany, Austria, and Switzerland were

Department of Neurosurgery, University Heidelberg, Heidelberg, Germany.

JOURNAL OF NEUROTRAUMA 27:871–875 (May 2010)ª Mary Ann Liebert, Inc.DOI: 10.1089=neu.2009.1130

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contacted. Twenty anonymous questionnaires were mailedfor voluntary completion to each of the 35 German UniversityCenters, 11 Austrian University Clinics, and 9 Swiss Uni-versity and Canton Hospitals. To act as a comparison, a ‘‘non-neurotrauma-educated’’ general population control group(PUB) was also interviewed. People visiting sports-equipmentstores in Germany were asked to voluntarily complete theanonymous questionnaire. Only questionnaires answered bypeople aged 18 years or older were included.

Questionnaire

Participation in the survey was anonymous and voluntary.Thirteen closed questions were asked. Answers were pre-defined, mainly in ordinal categories. Neurosurgeons (NS)were asked about their experience in treating patients withbrain injury after bicycle accidents, whereas the generalpopulation (PUB) was asked if they knew of people who hadsuffered from head injury while riding a bike. Everybody wasasked whether they would favor compulsory use of helmetsfor bicyclists. In addition, topics such as age, gender, sportsskills, duration of helmet possession, personal wearing habits,and, if applicable, the habits of their children were covered.

Statistical analysis

Data are presented as either percentage of persons or asmedian and range. Statistical analysis of the data was per-formed using SPSS 11.5 for Windows statistical software(SPSS, Inc., Chicago, IL). In comparisons, Pearson’s chi-squaretest was used. Statistical significance was defined as p< 0.05.

Results

Of the 55 neurosurgical centers that were contacted, 46centers (27 in Germany, 10 in Austria, and nine in Switzer-land) answered, and 465 questionnaires (NS) were returned.In the general population group (PUB), 546 questionnaireswere filled out.

The NS and PUB groups did not differ significantly con-cerning gender, age, and sports skills; 77.6% of the inter-viewed NS and 63.7% in the PUB group were male. In bothgroups, the majority of questioned people were aged 45 yearsor younger. A total of 94% of the NS group and 87% in thePUB group cycled. Both groups mainly rode their bikes inroad traffic (60.3% NS and 54.8% PUB), while 7.5% (NS) and15.9% (PUB) only did mountain biking. Approximately onethird of NS (32.2%) and PUB (29.3%) used bikes for bothtransportation and mountain biking. Furthermore, more than80% of each group were convinced that they retained controlover their bicycles all the time.

A total of 48.1% of the neurosurgical population and 60.5%of the interviewed general population had children, of whichmore than 80% rode bikes.

Experience with traumatic brain injury

A total of 89.4% of all NS had treated patients with TBI afterbicycle accidents. However, neurosurgeons from Germanyand Switzerland were more experienced in treating patientswith TBI after bicycle accidents than their colleagues fromAustria ( p¼ 0.01): the majority of German and Swiss neuro-surgeons had treated more than five patients with TBI after

bicycle accidents during the last year, whereas Austrianneurosurgeons typically claimed to have treated between oneand five patients ( p¼ 0.01). As expected, neurosurgeons hadsignificantly more experience with TBI after bicycle accidents,and knew more cases of brain and head injury than the gen-eral population ( p< 0.001). In comparison to the NS group,only 23.2% of the PUB group knew of somebody who hadsuffered from head trauma while bicycling.

Attitude to wearing helmets

Neurosurgeons did not differ significantly in their behaviorand attitude to wearing and owning protective bicycle hel-mets from the general population: 49.7% of NS and 44.5% ofPUB always wore their helmets while bicycling. One third ofall bicyclists bought their helmet more than 5 years ago (32.4%NS; 34.2% PUB). Less than 4% bought a new helmet thisseason (3.8% NS; 0.6% PUB; p> 0.05). A total of 14.6% of NSand 10.1% of PUB plan to buy and use a helmet, while about20% do not want to buy or wear a helmet in the future (18.8%NS; 20.9% PUB).

However, the fraction of bicyclists who refused to wear abicycle helmet is significantly greater in the TBI-uneducatedPUB group than among neurosurgeons (37.1% of NS vs.45.8% of PUB; p¼ 0.036).

Furthermore, the use of bicycle helmets depended on thebicyclists’ skills: mountain bikers started to use helmets earlierand for a longer time period (1–5 years) than those who usedtheir bike mainly as a means of transportation in road traffic( p< 0.001; Fig. 1).

In the NS group, the use of helmets was neither corre-lated with the experience with TBI nor the number of pa-tients treated after bicycle accidents. Independent ofwhether NS had formerly treated patients after bike acci-dents and had TBI experience, 37.1% of NS refused to weara helmet, indicating, at least in a subgroup of NS, cognitivedissonance on protective helmet use. Furthermore, nocountry-dependent differences could be detected. However,in the PUB group, persons who had knowledge of peoplewith injuries after bicycle accidents in their acquaintanceused helmets more often than those who did not knowanybody with TBI ( p¼ 0.02). Furthermore, comparing ‘‘TBI-knowledge after bicycle accidents’’ with ‘‘TBI-missing-knowledge,’’ despite the NS or PUB group, revealed thatthose who had experience with TBI after bicycle traumaused helmets significantly more often ( p< 0.001), whilethose who were inexperienced refused to wear a helmet inthe future ( p< 0.005; Fig. 2).

Children of the NS group wore helmets in 88% of caseswhile riding a bicycle, whereas PUB children used helmets in60.9% ( p< 0.001). The use of helmets by children of bothgroups was dependent on the attitude of their parents withrespect to their own use of helmets, and was further correlatedto their opinion on compulsory helmet use ( p< 0.001).Therefore, most of the children who did not wear a helmetwhile bicycling had parents who did not wear helmetsthemselves.

Compulsory helmet use

Independent of their country of origin (Germany, Austria,or Switzerland) or the different use of bicycles (mountainbiking vs. traffic), 63.8% of all NS and 50% of PUB favored

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compulsory use of helmets for bicycling. A total of 27.2% ofNS and 35% of PUB rejected this option. The remaining in-terviewees of the NS and PUB group either did not respond tothis question or had no opinion on this subject.

NS and PUB followed the same pattern: those who al-ready used a helmet were more likely to vote for compul-sory use than those who did not ( p< 0.001). The opinion ofwhether the use of helmets should be made compulsory forbicyclists was influenced by TBI experience ( p¼ 0.003).Furthermore, sports skills influenced the decision for com-pulsory helmet use in NS and PUB: those who practicedmountain biking favored compulsory use, while the ma-jority of those who used their bicycles mainly as means oftransportation in general traffic stood against compulsoryhelmet use ( p¼ 0.001).

Discussion

Traumatic brain injury (TBI) is considered the primarycause of fatal injuries after bicycle accidents (Rickels et al.,2006; Rosenkranz and Sheridan, 2003; Silverberg et al., 1992;Sosin et al., 1996; Tsai et al., 2004). Therefore, accident pre-vention and protective measures are very important. Protec-tive helmet use is reported to reduce the risk of brain injuryafter bicycle accidents by a factor of five (Attewell et al., 2001;Barkow, 1991; D.C. Thompson et al., 1996; R.S. Thompsonet al., 1989). This is the reason why emergency response per-sonnel and medical organizations, including the GermanNeurosurgical Society (DGNC), have advocated protectivehelmet use for bicyclists during recent years.

Neurosurgeons educated in brain-trauma treatment andwith greater proven experience in TBI than the general pop-ulation were scarcely affected by their TBI experience in theirown decision to wear protective helmets: only one half of theneurosurgeons wore helmets while bicycling. In this, they didnot differ from the general public. More than one third (37.1%)of NS show cognitive dissonant behavior by not wearingprotective helmets while bicycling. A recent survey on skipatrollers showed similar signs of cognitive dissonance intheir attitude with respect to the use of helmets. Even thoughthey knew that helmets reduce serious injuries, most did notwear their helmets regularly (Evans et al., 2009). However,knowledge and information do influence helmet acceptance:comparing ‘‘TBI-knowledge after bicycle accidents’’ with‘‘TBI-missing-knowledge,’’ irrespective of the NS or PUBgroup, revealed that those who had experience with TBI afterbicycle trauma used helmets significantly more often, whilethose who were inexperienced refused to wear a helmet in thefuture. Furthermore, significantly fewer NS, who are morehighly TBI-educated than PUB, refused momentarily to weara helmet. This correlates well with other results. Children ofNS used helmets significantly more than children of PUB.However, those PUB who did know persons in their ac-quaintance who had suffered from TBI did use protectivehelmets significantly more often or planned to wear one in thefuture than those who did not.

However, considering the cognitive dissonant behavior ofone third of NS, education alone, when it is based solely on theappeal to reason, might not lead to complete acceptance anduse of helmets. Consequently, education on TBI, as favored bysome groups, seems to be of significant value in increasing theacceptance of helmets, but it might need to be complementedwith other factors such as, for example, emotional elements.

Overestimation of one’s ability and a deceptive sense ofsecurity are other factors preventing full helmet acceptancewhile bicycling. In our survey, both NS and PUB tended tooverestimate their own capabilities while bicycling. Whenasked if they believed they have permanent control over theirbikes—a question that can truly only be answered with‘‘NO’’—more than 80% of the bicycling NS and PUB answered‘‘YES.’’ Especially surprising was the fact that this was alsotrue for those who favored mountain biking, because thissubgroup seemed to be more risk aware, favored compulsoryhelmet use, and wore helmets earlier and for a longer timeperiod than those who used their bikes mainly as a means oftransportation in road traffic.

Some members of both groups commented on their refusalto wear a helmet when they returned the questionnaire. The

FIG. 1. The percentage of neurosurgeons (NS) and of thegeneral population (PUB) who always or never wear a hel-met while bicycling in street traffic (street) or while mountainbiking (mountain).* p< 0.001.

FIG. 2. The percentage of neurosurgeons (NS) and of thegeneral population (PUB) who always or never wear a hel-met while bicycling compared to the attitude of all NS andPUB who have TBI education and experience. All those whoare TBI educated wear helmets significantly (*) more often.* p< 0.005.

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most frequent comments corresponded to those reported byFinnoff et al. (2001): ‘‘uncomfortable,’’ ‘‘annoying,’’ ‘‘it’s hot,’’‘‘don’t need it,’’ and ‘‘don’t own one.’’ Arguments in favor ofwearing helmets were: ‘‘increased safety,’’ as well as ‘‘ourchildren have worn helmets for years because we enforcedit—now we also wear a helmet as a role model.’’ The first threearguments show that there is further need for technical im-provement of helmets.

Parents of both the NS and PUB groups reported that theirchildren wore protective helmets significantly more often (80–90%) than they did themselves. However, parental percep-tions about the use of helmets by their children may notaccurately reflect the truth. Ehrlich et al. (2001) found out thatparents, influenced by their expectations of the use of bicyclehelmets by their children, tend to overestimate compliance. Inour study, the incidence of helmet use in children correlatedwith two factors: (a) the actual helmet use of their parents and(b) the disposition of the parents to make helmet use com-pulsory. The first factor shows the effectiveness of role modelsfor increasing the use of protective equipment, which is basedon emotion and a well-known and important fact (Bolen et al.,1998; Dannenberg et al., 1993). Therefore, role models em-ployed in campaigns might help to improve helmet use withcarefully chosen personalities. The second factor relates moreto parental authority than to their influence as role models,and is therefore connected to the problem of compulsory use.

The German Neurosurgical Society demanded compulsoryuse of protective helmets for bicyclists, which has to be con-trolled and enforced with legal measures. If not accepted bya great majority of the population, this will be difficult,personnel-intensive, and therefore costly. Furthermore, legis-lation will hardly act if the majority of their voters oppose sucha move. Therefore, prior to the decision to make helmet usecompulsory, one should evaluate the acceptance of compulsoryhelmet use, and the implementation has to be accompanied bycampaigns using all available means to increase acceptance. ACochrane meta-analysis on bicycle-helmet legislation effec-tiveness showed that making helmet use compulsory effec-tively increased the incidence of helmet use and decreasedhead-injury rates in the populations where it was implemented.However, none of the included studies measured actual bicycleuse, so it was not possible to evaluate the claim that fewerindividuals were cycling because of the implementation of thehelmet laws (Macpherson and Spinks, 2008).

Our survey shows that compulsory helmet use was favoredby those who themselves wore helmets. TBI experience in-creased the support, which is surprising, since no such in-fluence could be found on their own helmet use. It seems thatthose who are experienced with TBI but do not use protectivehelmets are to some extend aware of their cognitive dissonantbehavior and feel that some outside pressure is needed tochange it. A higher percentage of mountain bikers wear hel-mets and are in favor of compulsory use than bicycling par-ticipants of general road traffic. A look on German roadsshows that most bikers cycling for exercise and fun wearsports apparel with fashionable helmets similar to profes-sional bikers. They may be more risk aware but clearly theywant to be lookers. This is an important hint to how helmetwear could be promoted and the acceptance of compulsoryuse improved. But it will only be really successful if it istransferred from the sport bicyclers to those who use theirbikes merely for transportation.

Conclusions

Neurosurgeons present a well-educated group in neuro-traumatology. Half of them wear helmets, while one thirdshows cognitive dissonance between their knowledge of braintrauma and their attitude to wearing protective helmets. De-spite some cognitive dissonant behavior, knowledge and ed-ucation do play a significant role in the decision to wearbicycle helmets. However, rational education alone might notalways be sufficient for future helmet promotion. It has to becomplemented with more emotional approaches. Makinghelmet wear a matter of fashion and part of the apparel bikerslike to wear, even while participating in general traffic, isanother promising and important approach.

Compulsory use of bicycle helmets, as favored by theGerman Neurosurgical Society and supported by more thanhalf of the questioned neurosurgeons and those of the generalpopulation group, has to be implemented, controlled, andenforced with legal measures. If it is not accepted by a greatmajority of the population, this will be difficult, personnel-intensive, and expensive. Our results show that neurosur-geons and the general public are split in half on this matter.Therefore, increasing the rate of bicycle-helmet users has to beaccompanied by continuing campaigns using all availablemeans to increase acceptance, which have to be based onapproaches that have been outlined above.

Acknowledgment

We wish to thank the families of the first and second au-thors for their enthusiasm and help in distributing question-naires. Furthermore, we would like to thank everybody whovoluntarily took the time to fill out the questionnaire.

Author Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Carla S. Jung, M.D.

Department of NeurosurgeryUniversity of Heidelberg

Im Neuenheimer Feld 40069120 Heidelberg

E-mail: carla.jung@med.uni-heidelberg.de

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