Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis

Background The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels. Methods and findings A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle–Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg’s and Egger’s tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case–control study, and 5 pre–post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present. Conclusions In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.

Mandatory Bicycle Helmet Laws in the United States: Origins, Context, and Controversies

This article examines the origins and context of mandatory bicycle helmet laws in the United States. Localities began to enact such laws in the early 1990s, having experimented with helmet laws for motorcycles previously. As cycling became increasingly popular in the 1970s and 1980s because of a variety of historical trends, from improved cycle technology to growing environmental consciousness, cycling-related injuries also increased. Bicycle safety advocates and researchers alike were particularly troubled by head injuries. National injury surveillance systems and a growing body of medical literature on bicycle-related injuries motivated a number of physicians, cyclists, children, and other community members to advocate helmet laws, which they argued would save lives. Controversy over these laws, particularly over whether they should apply universally or only to children, raised public health ethics concerns that persist in contemporary debates over bicycle helmet policies. (Am J Public Health. 2020;110:1198–1204. doi: 10.2105/AJPH.2020.305718)

Are Organizations' Religious Exemptions Democratically Defensible?

Theorists of democratic multiculturalism have long defended individuals' religious exemptions from generally applicable laws. Examples include Sikhs being exempt from motorcycle helmet laws, or Jews and Muslims being exempt from humane animal slaughter laws. This essay investigates religious exemptions for organizations. Should organizations ever be granted exemptions from generally applicable laws in democratic societies, where those exemptions are justified by the organization's religion? This essay considers four arguments for such exemptions, which respectively rely on the “transferring up” to organizations of individuals' claims to autonomy or recognition; organizations' own claims to autonomy or recognition; organizations' status in the accountability community; and organizations' procedural constraints. The essay concludes that only the last argument holds up – and then, only with caveats.

Policing mandatory bicycle helmet laws in NSW: Fair cop or unjust gouge?

Australia was the first country to introduce laws mandating the wearing of helmets by bicyclists with the aim of enhancing road safety for cyclists. Examining the law and its administration in NSW, we point to some serious problems and anomalies with the law. We argue safety concerns have been relegated and the fine for the offence has lost any sense of proportionality with offending, parity with penalties imposed in other states and with penalties for other road safety offences in NSW. We also discuss concern over potential police misuse of the law and of its collateral consequences for the vulnerable.

Primary prevention of road traffic accident–related traumatic brain injuries in younger populations: a systematic review of helmet legislation

OBJECTIVERoad traffic accidents are the most frequent cause of severe traumatic brain injury (TBI), particularly among young populations worldwide. Helmets are proven to prevent injuries; however, estimates of helmet compliance are low globally. Surgical/critical care management of TBI is often used to treat these injuries, but primary prevention should be recommended. A key component in promoting TBI prevention among pediatric and young populations is through helmet legislation. The authors investigated helmet policies for motorcycles and bicycles globally to provide recommendations for how related legislation may impact TBI and guide advocacy in pediatric neurosurgery.METHODSThe authors conducted a systematic review of helmet laws and/or policies by using the National Library of Medicine PubMed and SCOPUS databases. Additional articles were identified using citation searches of key publications. Abstracts from articles of all sources were read and selected for full-text review. Details of relevant full articles were extracted and analyzed for the following: bibliographic data, study aim, design and duration, study participants, intervention characteristics, and intervention effect data.RESULTSOf 618 search results, 53 full-text articles were analyzed for recommendations. Helmet legislation is associated with increased helmet use among bicyclists and decreased road traffic accident–related head injuries and fatalities among motorcyclists and bicyclists. Laws are more effective if comprehensive and inclusive of the following: both primary riders and passengers, all age groups, all modes of transportation made safer by helmets, a proper use clause, and standardized helmet quality measures. Cultural, socioeconomic, and infrastructural circumstances are important as well, and legislation must consider enforcement mechanisms with penalties significant enough to incentivize behavioral changes, but proportional to community socioeconomic status.CONCLUSIONSCompulsory use laws are the optimal primary intervention; however, concurrent programs to support financial access to helmets, change cultural attitudes, increase health literacy, and improve road infrastructure will augment legislative benefits. Pediatric neurosurgeons are caretakers of children suffering from TBI. Although extensive study has explored the surgical management of TBI, the authors believe that primary prevention is instrumental to improving outcomes and reducing injury. All helmet laws are not equal; based on these findings, a comprehensive, context-specific approach is the key to success, especially in resource-limited countries.

Allocating Scarce Organs: How a Change in Supply Affects Transplant Waiting Lists and Transplant Recipients

Vast organ shortages motivated recent efforts to increase the supply of transplantable organs, but we know little about the demand side of the market. We test the implications of a model of organ demand using the universe of US transplant data from 1987 to 2013. Exploiting variation in supply induced by state-level motorcycle helmet laws, we demonstrate that each organ that becomes available from a deceased donor in a particular region induces five transplant candidates to join that region's transplant wait list, while crowding out living-donor transplants. Even with the corresponding demand increase, positive supply shocks increase post-transplant survival rates. (JEL D47, I11, I18)