Learning nugget: Injury prevention and promoting physical activity

May 2013

On the face of it, injury prevention appears in conflict with strategies that aim to promote healthy lifestyles – more physical activity means more injuries. But a leading advocate of cycling argues that these tensions are being resolved and that wider public health debates are steering injury prevention in new directions.

Speaking at CAPT’s road safety seminar on March 2013, Rob Benington, Injury Prevention Manager from Bristol Public Health explained how acting on studies of cycling injuries can help make cycling easier, safer and more attractive. Bristol’s approach has been informed by an analysis of local data, a survey, and a review of the relevant literature.

This learning nugget explains the thinking and research behind Bristol’s injury prevention strategy and outlines future work and issues for research.

The benefits of cycling

Bristol Public Health wants more people to cycle more often and for longer. Physical activity is associated with improvements in:

  • mental wellbeing
  • decreased risk of cancer
  • weight management
  • cardiovascular health
  • reduced CO₂ emissions
  • improved community cohesion and reduced social isolation.

But with activity comes risk, and social policy faces a dilemma because, in order to increase the number of people getting the benefits of active lifestyles, we might expect to see an increase in the number of people getting injured.  

Powerful arguments support the case that, at a population level, the benefits of cycling greatly outweigh the risks. But Rob asserts that we must put individual interests at the heart of our approach to delivering these benefits.  

Rather than trading off injuries against benefits, by understanding and tackling the hazards, we will make cycling safer and more attractive, and encourage greater participation while managing the individual risk of injury.

Understanding the risks

When examining national and local injury data in detail, Rob identified a surprising fact – 70% of cyclist hospital admissions (all-ages) were the result of ‘non-collision incidents’ (NCIs). These incidents cause approximately five times as many serious injuries to cyclists (12,301 in 2011/12) as collisions between cyclists and cars, pick up trucks and vans (2,450).

The largest UK study of non-collision incidents was conducted by NHS Bristol and Bristol Cycling City in 2011. The results are most relevant to adult commuter cyclists and revealed that the majority of non-collisions cause no injury at all, but are still an inconvenience cyclists could do without. But whilst collisions are more likely to cause fatalities, non-collision incidents lead to a larger number of serious injuries.  Bristol’s review showed that the main causes of non-collision incidents are:

  • slippery road surfaces
  • poor road surfaces
  • kerbs and rail lines.

The cyclist’s level of skill or experience may also compound the three factors above.

Maximising benefits

Benington’s analysis of benefit maximisation is based on the premise that risk (and therefore incidence) of serious injury is a function of the level of exposure combined with the nature of the hazards faced, (injury risk = exposure x hazard). Increasing exposure will increase injury, unless we understand and reduce hazards at the same time.  If we are to increase exposure to a beneficial activity that has some inherent hazard without increasing the numbers of injuries, we must reduce the hazard in order to achieve a ‘win-win’ solution.

Hazards that are beyond our control restrict our freedom to enjoy the activity. Unless thrill-seeking participants are actively seeking exposure to hazard, managing hazards will make an activity easier to engage with and more sustainable.

Interventions to tackle improve the attractiveness of cycling as an activity and that reduce hazards at the same time will include:

  1. Engineering: Improving the infrastructure with better and safer direct cycling routes; dropped kerbs in key locations and improving road surfaces.
  2. Training: The revised Bikeability standard has significantly improved the attention paid to non-collision hazards, and will enable cyclists to manage them more confidently, but further skills could be taught to help cyclists even more. These additional elements might include a safe riding strategy incorporating alternative modes of travel when roads are unsafe for travel (for example when they are too slippery due to ice); how to traverse kerbs and rail lines, and ways to deal with uneven road surfaces.
  3. Awareness raising: We don’t want to discourage potential cyclists by highlighting potential hazards, but more confident and experienced cyclists are less likely to be put off. So raising awareness of hazards they may be underestimating is a more legitimate intervention with this group of cyclists.

In Bristol, the view has been that success then breeds success, as the image of cycling improves through better cycling and the number of cyclists on the roads increases. Reducing non-collision incidents helps make cycling a more attractive travel option.

Building on the learning

Future work in Bristol will include:

  • continuing to advocate cycling and improving the cycling infrastructure
  • continuing to integrate injury prevention with other public health agendas
  • testing interventions and learning from the local data
  • encouraging road safety officers to use hospital data alongside police road safety statistics to provide a more rounded picture of the issues
  • working with employers to make sure cyclists’ interests are properly addressed in Inclement Weather policies and Travel to Work policies.

Further research is required

While colleagues on mainland Europe have been working to reduce non-collision incidents for some time, work on this issue in the UK is still at a formative stage. The factors that increase the risks of child (0-18 years old) injuries from non-collision cycling incidents have not been well researched. The effectiveness of interventions also needs to be tested.


  1. Hospital Episode Statistics (HES) and the indicators in the Public Health Outcomes Framework are increasingly steering the injury prevention priorities for public health teams.
  2. Many of the ‘big number’ injuries recorded in HES are associated with physical activity. We need to promote active lifestyles in order to make progress against other Public Health Outcome Indicators and so public health teams and their partners must work together in an integrated way.
  3. Injury prevention is not necessarily in tension with the promotion of activity. We can maintain or reduce the numbers of people getting injured, while increasing participation in active lifestyles, if we understand and reduce the hazards.
  4. There are many benefits from the reduction of hazards including making the activity more attractive and reducing the likelihood that pain and injury will reduce future participation. Non-collision cycling incidents are an example of how integrating understanding of the epidemiology of injury can improve services, encourage participation and reduce injury at the same time.
  5. Important lessons from all-age populations also need to be supplemented with research that focuses on the developmental and societal issues specific to children and young people.

Related content

Notes for this feature


Updated December 2013