A randomized controlled trial of sport helmet interventions in a pediatric emergency department. Evaluation of a subsidy program to increase bicycle helmet use by children of low-income families. Evaluation of a promotional strategy to increase bicycle helmet use by children. Cycle helmet ownership and use; a cluster randomised controlled trial in primary school children in deprived areas. Bicycle helmet promotion among low income preschool children. Evaluation of a school-based peer leader bicycle helmet intervention. Persuading school-age cyclists to use safety helmets: Effectiveness of an intervention based on the Theory of Planned Behaviour. Impact of a theory based intervention to increase bicycle helmet use in low income children. The effects of a 4-year program promoting bicycle helmet use among children in Quebec. Contracting with children and helmet distribution in the emergency department to improve bicycle helmet use. A pediatric, practice-based, randomized trial of drinking and smoking prevention and bicycle helmet, gun, and seatbelt safety promotion. A hospital led promotion campaign aimed to increase bicycle helmet wearing among children aged 11-15 living in West Berkshire 1992-98. Helmet promotion in the emergency room following a bicycle injury: a randomized trial. A school-based intervention to increase the use of bicycle helmets. Does sharing the cost of a bicycle helmet help promote helmet use? Non-helmeted motorcyclists: a burden to society? A study using the National Trauma Data Bank. Effect of a bicycle safety program and free bicycle helmet distribution on the use of bicycle helmets by elementary school children. Interventions with retailers to reduce cigarette sales to minors: a randomised controlled trial. Does office-based counseling of adolescents and young adults improve self-reported safety habits? A randomized controlled effectiveness trial. Bicycle safety helmet legislation and bicycle-related non-fatal injuries in California. Promotion of bicycle helmet use among schoolchildren: a randomized clinical trial. Evaluation of the Think First head and spinal cord injury prevention program. Effect of motorcycle rider education on changes in risk behaviours and motorcycle-related injuries in rural Thailand. Police enforcement as part of a comprehensive bicycle helmet program. Impact of mandatory helmet legislation on bicycle-related head injuries in children: a population-based study. Physicians promoting bicycle helmets for children: a randomized trial. Evaluation of a pilot program in rural schools to increase bicycle and motor vehicle safety.
To evaluate the effectiveness of 3 competing pediatric emergency department (ED) interventions aiming to increase sport helmet use in a state without helmet legislation.
                A randomized controlled clinical trial was conducted during the 7-month period between April and October 2003 at an urban pediatric ED in a state without current helmet legislation. We enrolled 200 assenting English-speaking children aged 5 to 16 years, admitted to the ED for treatment, and who did not currently own a helmet. Participants were randomized into 3 experimental arms. A control group received usual care, that is, verbal counseling regarding helmet use. Subjects in one treatment arm received a voucher to receive a free helmet that could be redeemed at a different location within the hospital. Subjects in a second treatment arm actually received a free helmet directly in the ED. The main outcome measure was reported helmet use at follow-up, assessed by telephone interviews of both the child and a parent.
                Directly receiving a free helmet in the ED significantly increased reported helmet use relative to the control group; the odds that a parent reported helmet use were nearly 16 times higher (P < 0.01), and the odds that a child reported helmet use were nearly 10 times higher (P < 0.01). Receiving a free helmet also significantly increased reported helmet use when compared with the voucher intervention group. Reported use between the control group and the voucher intervention group was not significantly different.
                Directly receiving a free helmet in the pediatric ED appears to be an effective hospital-based strategy to increase pediatric helmet use. We have previously shown that an educational program was not effective in increasing bicycle helmet use in children of low-income families. The objective of this study was to evaluate a combined educational and helmet subsidy program in the same population, while controlling for secular trends. The secondary objective was to complete a third year of surveying children's bicycle helmet use throughout the study community.
                A prospective, controlled, before-and-after study.
                Bicycling children 5 to 14 years of age from areas of low average family income.
                A defined geographic community within a large urban Canadian city.
                In April 1992, students in three schools located in the area of lowest average family income were offered $10 helmets and an educational program; three other low-income areas served as control areas.
                Helmet use was determined by direct observation of more than 1800 bicycling children.
                Nine hundred ten helmets were sold to a school population of 1415 (64%). Reported helmet ownership increased from 10% to 47%. However, observed helmet use in the low-income intervention area was no different from the rate in the three low-income control areas (18% versus 19%). There was no difference in the trend in helmet use during the period of 1990 through 1992 in the intervention area (4% to 18%) compared with the control areas (3% to 19%). Helmet use rates from all income areas have increased from 3.4% in 1990, to 16% in 1991, to 28% in 1992. In 1992, helmet use in the high-income areas was 48% and in the low-income areas was 20%.
                There has been a trend toward increasing helmet use in all income areas during the 3-year period. Despite encouraging helmet sales and increases in reported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy program in increasing helmet use in children residing in areas of low average family income. Strategies to increase helmet use in children of low average family income remain a priority. Bicycle-related head injuries are an important cause of death and disability, despite the availability of helmets. The objective of this study was to evaluate the effectiveness of a school-based bicycle helmet promotion program in increasing helmet use by children while controlling for secular trends. Two high-income and two low-income schools in an urban Canadian community were selected to receive a bicycle helmet promotion intervention, with the remaining 18 schools serving as controls. Approximately 1800 observations of bicycling children were made at randomly selected observational sites 2 to 5 months after the intervention to assess changes in behavior. Helmet use at all observation sites tripled from 3.4% (1990, preintervention) to 16% (1991, postintervention). In the high-income intervention area, observed helmet use rose dramatically from 4% to 36% in contrast to the more modest increase in the high-income control area from 4% to 15%. In the low-income intervention area, there was a modest increase from 1% to 7%, but it did not differ from the increase in the low-income control area from 3% to 13%. The program was highly successful in children of high-income families but not in children of low-income families. Developing strategies for low-income families remains a priority. To assess the effectiveness of two different educational interventions plus free cycle helmets, in increasing cycle helmet ownership and use.
                A cluster randomised controlled trial was carried out in 28 primary schools in deprived areas of Nottingham, involving 1213 year 5 schoolchildren (age 9 and 10). Children received either a helmet + educational pack (educational pack and order form for free cycle helmet) or a helmet + multifaceted intervention (educational pack, order form for free cycle helmet, school assembly, lesson devoted to cycle helmet education, and an invitation to a school based cycling event).
                The helmet + educational pack was as effective as the helmet + multifaceted intervention in terms of helmet ownership (OR 1.51, 95% CI 0.50 to 4.58) and wearing (OR 0.98, 95% CI 0.57 to 1.68). Helmet ownership significantly increased from baseline with both interventions, and wearing significantly increased from baseline with the helmet + educational pack. The interventions reduced the inequality in helmet ownership between children residing in deprived and non-deprived areas that had been present prior to the study.
                An educational pack plus a form to order a free cycle helmet is an effective way of increasing bicycle helmet ownership and use and reduces inequalities in helmet ownership among children in deprived areas. Further work is needed to determine the length of the effect of such interventions. To evaluate the effectiveness of a multifaceted bicycle helmet promotion program for low income children attending preschool enrichment programs throughout Washington State.
                Preschool Head Start programs that conducted routine home visits among their enrolled families at least five times during the school year were eligible. Eighteen sites and 880 children met this criterion and were able and willing to carry out evaluation activities. Two hundred children were from control sites where no helmet promotion activities were carried out.
                Classroom activities with children, education of parents during school meetings and home visits, fitting and distribution of helmets, a bicycle skills and safety "rodeo" event, and requiring children to wear helmets while riding on school grounds.
                Regularly scheduled home visits were used to observe helmet use of enrolled preschool children before and after the promotion program. Home visitors requested parental permission for enrolled children to ride, and then noted whether the child wore a helmet.
                Helmet use in the intervention group more than doubled, from 43% to 89%, while use in the control group increased from 42% to 60% (p < 0.05 for intervention group changes v control group changes).
                This multifaceted helmet promotion program successfully increased helmet use. Similar home visit protocols may be useful to evaluate the impact of other injury intervention programs. Bicycle-related injury remains a major cause of death and injury hospitalization among Australian children. The study aimed to assess the effectiveness of a whole-school intervention to increase the correct wearing of bicycle helmets by primary school children.
                A randomized intervention trial was conducted in 27 Western Australian primary schools. A major component of the intervention was a peer-led classroom curriculum for 10-12 year old children. Helmet use by cyclists was observed as children were leaving school at baseline (May 2000) and after the first year and second year of the intervention. A cohort of 10-11 year old children in study schools completed a self-administered questionnaire at the same three data collection points.
                Over the 2 years of the study, observed helmet wearing rates declined by 13% in the control group (from 93% at baseline to 80% at post-test 2) and by 5% in the intervention group (from 89% to 84%) (F = 1.745, p = 0.185). Among the Grade 5/6 cohort students who were regular riders, the likelihood of reporting always wearing a helmet was 1.9 times higher at post-test 1 (z = 2.51, p = 0.012) and 1.7 times higher at post-test 2 (z = 2.13, p = 0.033) for the intervention group than the control group students who did not always wear a helmet at baseline.
                The data suggest that school-based activities can arrest the rate of decline in helmet use by children. Using peer teachers is a useful strategy to engage students in normative-based protective behaviours. The logistical challenges this strategy presents appear to be worth the outcomes. OBJECTIVES: To design and evaluate a theory-based intervention to encourage the use of protective helmets in school-age cyclists. DESIGN: Two-by-three mixed design on 97 cyclists who did not initially use a helmet: Condition (intervention/control) x Time (pre-intervention/immediately post-intervention/5-month follow-up). METHOD: The intervention builds on a previous study using the Theory of Planned Behaviour in which we identified a small number of salient beliefs that predict intention to use a safety helmet and helmet use (Quine et al., 1998). Participants were randomly assigned to intervention or control conditions. The intervention group was presented with a booklet containing a series of persuasive messages based on the identified salient beliefs, and the control group was presented with a different series of messages concerning a cycling proficiency and bicycle maintenance course. Initial beliefs were measured just before the intervention at Time 1, by questionnaire. The immediate effects of the intervention were evaluated by questionnaire at Time 2. Five months later, at Time 3, the long-term effects of the intervention on beliefs, intentions, and behaviour were assessed. RESULTS: The behavioural, normative and control beliefs and intentions of intervention participants became more positive than those of control participants, and the effect was maintained over time. There was also a significant effect on behaviour: at 5-month follow-up, none of the 49 control children had taken up helmet wearing, while 12 (25%) of the 48 intervention children had. CONCLUSIONS: The results suggest that in order to promote lasting helmet use in young cyclists, we need to change their beliefs. The intervention reported here may present an inexpensive solution to the problem of persuading adolescents to use safety helmets. The results point to the value of social cognition theories such as the Theory of Planned Behaviour in the design of effective interventions to change health behaviours. While community interventions to increase bicycle helmet use have increased markedly, few of these studies are theoretically based. The purpose of this study was to determine relationships among PRECEDE model predictors and self reported helmet use among 407 fourth graders from nine low income, non-urban schools.
                Low income schools, with high minority populations in eight nonmetropolitan Central Texas counties were chosen.
                Schools were randomly assigned in a repeated measures design to either classroom only, parent-child, or control groups. School nurses were educated by the researchers to present a head injury prevention program in all but the experimental schools. Researchers made contact by phone with the parents of children in the parent-child group.
                Participation in either of the educational interventions, followed by belief that helmets protect your head (a predisposing factor), and participation in the parent intervention condition, added significant unique variance to the prediction of helmet use after helmet ownership is accounted. These four variables, taken together, account for 72% of the variance in predicting bicycle helmet use. This study assessed the effectiveness of a 4-year program of bicycle helmet promotion that targeted elementary school children in one region of Quebec. The program revolved primarily around persuasive communication and community organization, combining standard educational activities and activities to facilitate helmet acquisition and use.
                Helmet use was compared between more than 8000 young cyclists in municipalities exposed or not exposed to the program. Factors influencing helmet use were controlled through the use of multivariate analyses.
                Helmet use increased from 1.3% before program implementation to 33% in 1993. The program was clearly effective in most cycling circumstances and for various groups of children. However, the benefits of the program were unequally distributed; the program was one third as effective in poorer municipalities as in "average-rich" ones.
                This community-based program that combined various types of activities appeared to be effective. New intervention models are needed to ensure an equitable distribution of benefits. To determine whether injury prevention counseling and behavioral counseling delivered in the emergency department (ED) could result in increases in self-reported bicycle helmet use.
                The authors undertook a trial of counseling in 222 children recruited in an urban ED between August 2000 and October 2001. All consenting patients in the ED aged 5 to 15 years who did not have life-threatening conditions were eligible. One hundred nine children were assigned to the control group on the basis of attendance on an odd-numbered day, and they received a photocopied photograph of the hospital. One hundred thirteen children were assigned to the intervention group, and they received a personal counseling session and signed a contract promising to wear their bicycle helmets. In addition, 57 of the intervention children were assigned (based on having an even-numbered birthday) to be fitted with helmets if they did not already own them. Parents were telephoned four weeks after the ED encounter for follow-up.
                Follow-up data were obtained for 148 children (67% follow-up rate), of whom only 69 reported riding a bicycle in the four weeks after their ED visit. Of the final sample of 69 children, 38 belonged to one of the intervention groups, and 25 of these (66%) reported always wearing a helmet while cycling during the four weeks after their ED visit, versus 13 of 31 (42%) in the control group (odds ratio, 2.66; p < 0.05). The effect of the intervention was independent of whether the children owned a helmet at baseline.
                Injury prevention counseling in the ED using "The Injury Prevention Program" (TIPP) sheet, behavioral contracting, and helmet distribution may have a significant effect on reports of subsequent bike helmet use. To prevent early adolescent health risk behaviors and to maintain or improve safety behaviors, we compared the effects of 2 interventions, delivered through pediatric primary care practices. The interventions, based on an office systems' approach, sought to prevent early drinking and smoking or to influence bicycle helmet use, gun storage, and seatbelt safety for children who were followed from fifth/sixth grades through eighth/ninth grades.
                Settings and Participants. Twelve pediatric practices in New England were paired according to practice size and assigned randomly within pairs to deliver the multicomponent interventions, which built on pediatric primary care clinicians performing as counselors and role models during health supervision visits and other office encounters.
                One intervention arm focused on alcohol and tobacco use. The other intervention arm focused on gun safety, bicycle helmet, and seatbelt use. Office systems provided infrastructure that supported the clinician's role. Clinician messages encouraged family communication and rule setting about the issues of the middle school years. The intervention was initiated during a health supervision visit and continued for 36 months. Both child and parent received quarterly newsletters to reinforce the clinician messages.
                The primary outcomes were ever drinking alcohol, ever smoking, ever using smokeless tobacco, using a bicycle helmet in the previous year, using a seatbelt in the previous 30 days, and guns in the child's home in locked storage.
                The pediatric practices recruited 85% (N = 3525) of the practices' fifth/sixth grade children and their responding parents. We obtained 36 months' follow-up data on 2183 child-parent pairs. Chart audit verified that the intervention was implemented. Additional data from interviews and surveys showed that parents, children, and pediatric clinicians found the intervention useful. Despite this, comparisons between the 2 study arms show no significant intervention effects in the prevention of alcohol and tobacco use or gun storage or seatbelt safety. There was a negative effect in the alcohol arm. Only bicycle helmet use showed a positive outcome.
                With rigorous evaluation, 2 office interventions failed to produce desired outcomes. Coordinated multiple settings for prevention interventions are probably necessary. To evaluate the effect of a bicycle helmet promotion campaign on helmet wearing among cyclists less than 16 years of age from 1992-98.
                Reading, West Berkshire, UK.
                A hospital led bicycle helmet promotion campaign targeted at 5-15 year olds. The campaign focused on education with active involvement of the children, parents, schools, and safety organisations. Local media and children's celebrities raised the profile of the campaign and a low cost helmet purchase scheme was also set up. A self administered questionnaire survey of 3,000, 11-15 year olds was carried out over the period of the campaign. A control group of 3,000 teenagers was obtained from a neighbouring area without a helmet campaign. Accident and emergency (A&E) figures were obtained from the local hospital within the campaign area on all children aged under 16 years, attending with bicycle injuries. Unfortunately, no figures were available from the A&E department in the control area.
                Self reported helmet use among 11-15 years olds living in the campaign area increased from 11% at the start of the campaign to 31% after five years (p<0.001), with no change in the control group. Hospital casualty figures in the campaign area for cycle related head injuries in the under 16 years age group, fell from 112.5/100,000 to 60.8/100,000 (from 21.6% of all cycle injuries to 11.7%; p<0.005).
                This hospital led community bicycle helmet promotion campaign directed at young people showed an increase in the number of children reporting that they "always" wore their helmet while cycling. There was a significantly higher rate of helmet wearing than in the control area, and a significant reduction in head injuries. Head injury is the leading cause of serious morbidity and mortality in bicycle accidents. There is good evidence to recommend helmets, yet few children wear them. Following a survey of children presenting to the emergency room with a bicycle injury, helmet promotion was evaluated in a randomized trial. The intervention consisted of physician counseling and take-home pamphlets. The study involved 334 children: 161 in the intervention group and 173 in the control group. In a follow-up telephone call, 2 to 3 weeks later, only 9.3% of the intervention group had purchased helmets, compared with 8.0% of the control group. Families in the intervention group received further counseling during the telephone contact, resulting in one additional purchase at 6-week follow-up. Evidence that a bike injury motivates cyclists to purchase helmets, and the influence of the self-administered questionnaire most likely account for the high purchase rate in the control group. Surprisingly, the helmet promotion intervention, including follow-up phone counseling, made no further impact. The results probably are best explained by a "double threshold" effect. Certain families were easily encouraged to buy a helmet, whereas others were far from ready to adapt this fairly recent innovation as routine cycling equipment. The findings suggest that physicians interested in helmet promotion would do better to participate in the design and implementation of multidisciplinary community campaigns. Four family practice resident physicians provided a school-based educational intervention designed to increase the use of bicycle helmets by elementary school children in three of six public schools and to produce more favorable parental attitudes toward bicycle helmets. The effect of the one-week intervention was assessed by two parent surveys and direct observation of children riding bicycles to school. Results indicate that 60 helmets were purchased. Parents reported a change in barriers to helmet purchase, an increase in helmet ownership (13% to 27%), but observed helmet use did not increase. Both helmet ownership and use were reported to be more frequent among families with higher income and educational levels. To determine whether asking for a $5.00 donation for bicycle helmets, compared with distribution free of charge, would affect helmet use among children receiving helmets and an educational intervention from public health clinics.
                Six public health clinic sites in King County, Washington.
                Six participating clinic sites were randomly assigned to either free helmet distribution or to a $5.00 suggested donation for the helmets, stratified by whether a helmet law was in place. Three sites were assigned to each arm. Children who were between 6 and 12 years of age and who reported riding bicycles, but having no bicycle helmets, were eligible. Clinicians distributed helmets and delivered an educational intervention to 506 eligible children, or siblings of children seen at the clinic between March and July 1993. Parents were contacted after helmet distribution to ascertain helmet use.
                82% of children whose parents were asked for a copayment and 77% of children who received free helmets were reported to wear their helmets every time they rode their bicycles (p=0.20). The adjusted odds ratio for the association between copayment compared with free helmets and helmet use was 1.66 (95% confidence interval 0.94 to 2.92).
                Helmet use was not significantly different among children whose parents were asked for a small copayment, compared with those who received helmets free. Use of copayments can increase helmet use by increasing the number of helmets given to low income children. Helmet laws remain controversial. Opponents believe negative findings are a result of biased statistical analyses that fail to account for the impact of alcohol and drugs. In this study, we evaluated the effect that helmet use had upon injury severity, outcome controlling for alcohol or drug use, resource utilization, and financial burden using the National Trauma Data Bank (NTDB).
                Two groups of patients, helmeted and non-helmeted motorcyclists, were identified using the NTDB over an 8-year period. Group differences were compared using nonparametric Wilcoxon tests for continuous variables and Fisher's exact test for dichotomous outcomes. To evaluate the effect that alcohol or drug use had on mortality, logistic regression models were created.
                A total of 9,769 patients were identified by the NTDB of which 6756 (69.2%) were helmeted and 3013 (30.8%) were non-helmeted. Helmet use was associated with lower injury severity, mortality, and resource utilization. Non-helmeted motorcyclists accrued greater hospital charges and were significantly less likely to have health insurance. When controlling for alcohol or drug use, mortality continued to be significantly associated with non-helmet use.
                Non-helmeted motorcyclists have worse outcomes than their helmeted counterparts independent of the use of alcohol or drugs. Furthermore, they monopolize more hospital resources, incur higher hospital charges, and as non-helmeted motorcyclists frequently do not have insurance, reimbursement in this group of patients is poor. Thus, the burden of caring for these patients is transmitted to society as a whole. Each year in the United States, 300,000 children are treated in emergency departments for bicycle injuries; one third have head injuries. The purpose of this study was to determine the effectiveness of educational interventions and free helmet distribution in increasing the use of helmets by elementary school children.
                Self-report questionnaires on the use of bicycle helmets were used for students at two elementary schools (n = 1610). Testing was done both before and after the administration of a bicycle safety program and the distribution of free helmets. Pretest and posttest answers were then compared for changes in helmet use.
                Helmet usage increased significantly after the bicycle safety program, from 38% to 46% overall (p < 0.005). Children who were given free helmets were significantly more likely to wear their helmets (61.4%) than children who already owned helmets (43.4%) (p > 0.016). Children who attended the school in which free helmets were distributed showed a significant increase in helmet use (p < 0.01), whereas those at the school that had a safety program alone did not show a significant increase (p > 0.17).
                The results of this study suggest that bicycle safety programs and free helmet distribution may increase the consistent use of helmets in elementary school children. We aimed to determine the relative effectiveness of an education intervention and a threat-of-enforcement intervention in reducing sales of cigarettes to under-age youth by randomly allocating 300 retailers in a nonmetropolitan region of New South Wales to: a control group with no intervention; a minimal-intervention group, which received an educational letter; and a maximal-intervention group, which received a threat of enforcement followed by a visit from a public health officer. Retailers were checked for compliance at pretest and post-test, six months apart, by twelve 18-year-olds who were judged by independent raters to look younger. The retailers were surveyed by telephone at both times for knowledge, attitudes and self-reported sales practices. Neither intervention achieved significant improvements for the two key behavioural outcomes: requiring proof of age and display of a warning sign. Neither was there an intervention effect on knowledge about the law. The greatest improvement in the proportion of retailers who believed that the legal age should be 18 or over was in the minimal-intervention group, and both intervention groups were less likely than the control group at post-test to think that it was acceptable to sell to a person who was nearly 18. There was poor overall compliance with the revised legislation at pre-test. The finding of a pretest-to-post-test improvement but no differential intervention effect highlights the methodological difficulties of such research. The interventions may, however, have been partly successful in modifying the attitudes of retailers. The purpose of this study was to evaluate brief physician advice regarding seatbelt and bicycle helmet use in adolescents and young adults.
                We recruited 200 patients ages 11-24 years presenting for all visits to a primary care clinic in the Southwestern United States from January 2000 to March 2001. Patients were randomized to control or a single 2- to 3-minute scripted motivational counseling intervention delivered by physicians with an educational brochure and discount helmet coupon. We conducted telephone follow-up evaluation at 3 months. Main outcome measures were self-reported seatbelt and bicycle helmet use assessed on a 4-point Likert scale and attitudes toward these behaviors assessed on a 5-point Likert scale and analyzed by the Wilcoxon signed-rank test.
                For the intervention group, mean Likert scores precounseling and postcounseling for self-reported seatbelt use were 1.3 and 1.4, respectively, with a mean difference of .04 (95% confidence interval [CI], -.1 to .2). For self-reported bicycle helmet use, scores were 3.1 and 3.0, respectively, with a mean difference of .1 (95% CI, -.3 to .2). Combined mean Likert scores measuring subject's attitudes about seat belt use were 13.8 and 14.0, respectively, with a mean difference of .2 (95% CI, -.3 to .6). For bicycle helmet use, scores were 20.0 and 20.9, respectively, with a mean difference of .9 (95% CI, -1.4 to 3.3).
                We were unable to detect a significant improvement in safety behaviors or attitudes by adolescents and young adults after a brief intervention by physicians during routine office visits. The objective of this study was to determine whether the bicycle safety helmet legislation in California, enacted in 1994, was associated with statistically significant reductions in head injuries among bicyclists aged 17 years and under who were subjected to the law. The study used 44,069 patient discharge cases from all public hospitals in California, from 1991 through 2000, and a case-control design to make direct comparisons between those subjected to the law (Youth) and those who were not (Adult) across the pre- and post-legislation periods. An aggregate data analysis approach and a pooled disaggregate data fitting technique using multinomial logit models were applied. The legislation was found to be associated with a reduction of 18.2% (99% confidence interval: 11.5-24.3%) in the proportion of traumatic brain injuries (Head-TBI) among Youth bicyclists. The proportions of other head, face, and neck injuries were not significantly changed across the pre- and post-legislation periods in this age group but there was a corresponding increase of 9% (5-13%) in the proportion of all other injuries. On the other hand, there was no statistically significant change in the proportions of injury outcomes for Adult bicyclists. The youngest riders, aged 0-9 years, had the greatest decrease in the proportion of Head-TBI. The reduction was the same for motor vehicle and non-motor-vehicle-related incidents. The bicycle safety helmet legislation was associated with a decrease in the likelihood of Head-TBI for non-urban residents but not for urbanites, for males but not for females, and for Whites, Asians, and Hispanics, but not Blacks and others. Although bicycle helmets have been shown to reduce the rates of head injuries and brain injuries from bicycle mishaps, use of helmets is very uncommon. We compared a comprehensive awareness program to increase bicycle helmet use among schoolchildren to the impact of that same awareness program plus a bicycle helmet subsidy. Results showed no impact of the educational program (no children observed riding to school wore helmets before or after the program). The proportion of helmet wearers at the school that obtained the subsidy increased from 0% to 22% (p = 0.036). An educational program in conjunction with a subsidy may have a significant impact on bicycle helmet use. Evaluation of the impact of the Think First head and spinal cord injury prevention program on knowledge, attitudes, and behavior of 11-15 year old students toward injury risks and preventive strategies.
                Three junior high and three senior high schools in rural and urban areas of Washington state.
                Questionnaire survey before intervention, two weeks and three months after intervention to assess knowledge, attitude, and self reported behavior change. Observations of students as they left school property to determine bicycle helmet and seat belt use.
                Little impact on attitudes and no consistent change in knowledge or self reported behaviors. Too few students rode bicycles to accurately assess helmet use; no consistent change in seat belt use.
                The Think First program appears to have little impact on changes in knowledge, self reported behavior, or observed behavior. Other strategies to decrease injuries in adolescents may be more successful. A community-based programme for motorcycle rider education was provided for motorcyclists in all villages of 3 randomly selected subdistricts in Mae Sot District, Tak Province, northern Thailand, between January and March 1995. To determine the extent of changes in risk-taking behaviours, we conducted an interview survey of motorcyclists in 3 villages selected by systematic sampling from the 3 intervention subdistricts and in 3 control (without intervention) villages for comparison in March 1997, 2 years after the programme. Motorcyclists in the intervention villages (69.7%) were significantly more likely to have valid licences than those in the control villages (46.5%). The proportion of motorcyclists who always or often wore helmets was significantly greater in the intervention sample (46.0%) than in the control sample (20.5%). In 1994, the annual incidence rate of motorcycle-related injuries was slightly higher in the intervention areas than in the control areas Following the education programme, the injury rates for 1995 and 1996 were significantly lower in the intervention than in the control population. The annual number and rate of fatal motorcycle injuries decreased after the intervention although there was no significant difference between the two populations. Motorcycle rider education may be a promising intervention for prevention of motorcycle-related injuries in rural areas where road safety measures, particularly enforcement activities, are commonly limited. Bicycle-related head injuries cause >150 deaths and 45 000 nonfatal injuries among children in the United States annually. Although bicycle helmets are highly effective against head injury, only 24% of US children regularly wear one. Georgia mandated bicycle helmet use for children, effective July 1993. During that summer, 1 rural Georgia community passed an ordinance instructing police officers to impound the bicycle of any unhelmeted child. We evaluated the effect of active police enforcement of this ordinance, combined with a helmet giveaway and education program.
                During April 1997, approximately 580 children in kindergarten through grade 7 received free helmets, fitting instructions, and safety education. Police then began impounding bicycles of unhelmeted children. We conducted an observational study, unobtrusively observing helmet use just before helmet distribution, several times during the next 5 months, and once 2 years later.
                Before the program began, none of 97 observed riders wore a helmet. During the next 5 months, helmet use among 358 observed children averaged 45% (range: 30%-71%), a significant increase in all race and gender groups. In contrast, adult use did not change significantly. Police impounded 167 bicycles during the study, an average of 1 per day. Two years after program initiation, 21 of 39 child riders (54%) were observed wearing a helmet.
                Without enforcement, the state and local laws did not prompt helmet use in this community, yet active police enforcement, coupled with helmet giveaways and education, was effective and lasting. Childhood bicycle-related head injuries can be prevented through the use of helmets. Although helmet legislation has proved to be a successful strategy for the adoption of helmets, its effect on the rates of head injury is uncertain. In Canada, 4 provinces have such legislation. The objective of this study was to measure the impact of helmet legislation on bicycle-related head injuries in Canadian children.
                Routinely collected data from the Canadian Institute for Health Information identified all Canadian children (5-19 years) who were hospitalized for bicycling-related injuries from 1994-1998. Children were categorized as head or other injury on the basis of International Classification of Diseases, Ninth Revision, codes. Rates of head injuries and other injuries were compared over time in provinces that adopted legislation and those that did not.
                Of the 9650 children who were hospitalized because of a bicycle-related injury, 3426 sustained injuries to the head and face and the remaining 6224 had other injuries. The bicycle-related head injury rate declined significantly (45% reduction) in provinces where legislation had been adopted compared with provinces and territories that did not adopt legislation (27% reduction).
                This country-wide study compared rates of head injury in regions with and without mandatory helmet legislation. Comparing head injuries with other non-head-injured children controlled for potential differences in children's cycling habits. The strong protective association between helmet legislation and head injuries supports the adoption of helmet legislation as an effective tool in the prevention of childhood bicycle-related head injuries. Head injury is the leading cause of death and serious morbidity in bicycle accidents. There is good evidence to recommend helmets, yet few children wear them. We evaluated helmet promotion in a randomized trial targeting children presenting to primary care settings for routine ambulatory care. The intervention consisted of physician counseling and take-home pamphlets. The study involved 339 families, 167 in the intervention group and 172 in the control group. In a follow-up telephone call, 2 to 3 weeks later, only 7.2% of the intervention group had purchased helmets, compared with 7.0% of the control group (chi 2 = 0.0056, P = .94). During the latter half of the study, bicycle safety received considerable media attention in Ottawa, and the provincial medical society sponsored a $5 discount campaign. Therefore both groups were subject to community "co-intervention." Nonetheless, we were surprised that physician counseling made no additional impact. Our results and the success of certain community programs suggest that physicians interested in helmet promotion would do better to participate in the design and implementation of multidisciplinary campaigns. Concerned with high bicycle-and motor vehicle-related mortality rates among children, Idaho's South Central District Health Department provided a competition to increase use of 1) seat belts, 2) motor vehicle rear seating, and 3) bicycle helmets among children attending elementary schools in the eight rural counties it serves. Nine of the 44 elementary schools in the health district chose to participate in the contest. Eight schools addressed increasing helmet use, four schools also addressed increasing seat belt use and rear seating, and one school addressed safety in general. A $1,000 prize was awarded to each of four schools judged to have the highest levels of student and community involvement, outreach, creativity, and changes in safety behavior (based on perceptions of outside judges). In 1997, baseline observations were collected for 1) seat belt use and rear seating for children in 28 schools, and for 2) bicycle helmet use among children in 25 schools. In 1998, follow up data were collected for 1) seat belt and rear seating in 42 schools, and 2) bicycle helmet use in 35 schools. Data were analyzed using SAS. Adjusting for differences in baseline rates, regression analysis was used to compare 1997 and 1998 rates for seat belt use, rear seating, and bicycle helmet use for those schools having baseline data. Results showed that although there was no significant difference between participating and non-participating schools in rear-seating behaviors, there was an increase in seat belt and bicycle helmet use for participating schools. Since schools self-selected participation, it is unknown whether those schools were fundamentally different from nonparticipating schools.
Non-legislative interventions appear to be effective in increasing observed helmet use, particularly community-based interventions and those providing free helmets. Those set in schools appear to be effective but possibly less so than community-based interventions. Interventions providing education only are less effective than those providing free helmets. There is insufficient evidence to recommend providing subsidised helmets at present. Interventions may be more effective if provided to younger rather than older children. There is evidence that interventions offered in healthcare settings can increase self reported helmet wearing.
Further high-quality studies are needed to explore whether non-legislative interventions increase helmet wearing, and particularly the effect of providing subsided as opposed to free helmets, and of providing interventions in healthcare settings as opposed to in schools or communities. Alternative interventions (e.g. those including peer educators, those aimed at developing safety skills including skills in decision making and resisting peer pressure or those aimed at improving self esteem or self efficacy) need developing and testing, particularly for 11 to 18 year olds. The effect of interventions in countries with existing cycle helmet legislation and in low and middle-income countries also requires investigation.