Bicycle helmet use by children. Evaluation of a community-wide helmet campaign. Does office-based counseling of adolescents and young adults improve self-reported safety habits? A randomized controlled effectiveness trial. Bicycle helmet promotion among low income preschool children. Cycle helmet ownership and use; a cluster randomised controlled trial in primary school children in deprived areas. Impact of a theory based intervention to increase bicycle helmet use in low income children. Helmet promotion in the emergency room following a bicycle injury: a randomized trial. Bicycle helmet use among Maryland children: effect of legislation and education. Physicians promoting bicycle helmets for children: a randomized trial. Evaluation of a bicycle skills training program for young children: a randomized controlled trial. The MORE HEALTH bicycle safety project. Correlates of children's bicycle helmet use and short-term failure of school-level interventions. Effect of a bicycle safety program and free bicycle helmet distribution on the use of bicycle helmets by elementary school children. Evaluation of a pilot program in rural schools to increase bicycle and motor vehicle safety. Persuading school-age cyclists to use safety helmets: Effectiveness of an intervention based on the Theory of Planned Behaviour. Promotion of bicycle helmet use among schoolchildren: a randomized clinical trial. Evaluation of a subsidy program to increase bicycle helmet use by children of low-income families. A randomized controlled trial of sport helmet interventions in a pediatric emergency department. Evaluation of a promotional strategy to increase bicycle helmet use by children. The effects of a 4-year program promoting bicycle helmet use among children in Quebec. A school-based intervention to increase the use of bicycle helmets. Does sharing the cost of a bicycle helmet help promote helmet use? Evaluation of the Think First head and spinal cord injury prevention program. Design and implementation of injury prevention curricula for elementary schools: lessons learned. A hospital led promotion campaign aimed to increase bicycle helmet wearing among children aged 11-15 living in West Berkshire 1992-98. Behavior change counseling in the emergency department to reduce injury risk: a randomized, controlled trial. Contracting with children and helmet distribution in the emergency department to improve bicycle helmet use. Evaluation of a school-based peer leader bicycle helmet intervention.
To assess the effect of a community-wide bicycle helmet campaign on helmet use, we observed 9827 children riding bicycles at sites in high-, middle-, and low-income census tracts in Seattle, Wash (intervention city), and Portland, Ore (control city); observations were made during 2-week intervals before and 4, 12, and 16 months after the campaign's start. Helmet use increased from 5.5% before the campaign to 15.7% afterward in Seattle and from 1.0% to 2.9% in Portland. Strong associations were found between helmet use and white compared with black or other race; riding geared vs nongeared bicycles; riding at playgrounds, in parks, or on bicycle paths vs on city streets; and riding with adults or other children compared with riding alone. The proportions of helmet wearers, adjusted for these variables, increased from 4.6% to 14.0% in Seattle and from 1.0% to 3.6% in Portland, a significantly greater increase in use in Seattle compared with Portland. We conclude that a community-wide bicycle helmet campaign can increase helmet use among children. 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. 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. 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. 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. 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. Although bicycle helmets are effective in preventing head injuries, use of helmets among children remains infrequent. In response to the bicycling deaths of two children, Howard County, Maryland, became the first US jurisdiction to mandate use of bicycle helmets for children. Schoolchildren were lectured by police about the law before its enactment. Prelaw and postlaw helmet use was observed in Howard County and two control counties: Montgomery (which sponsored a community education program) and Baltimore County (no helmet activities). Prelaw crude helmet use rates for children were 4% (95% confidence interval [CI] 0% to 10%) for Howard, 8% (95% CI 3% to 13%) for Montgomery, and 19% (95% CI 5% to 33%) for Baltimore. Postlaw rates were 47% (95% CI 32% to 62%), 19% (95% CI 11% to 27%), and 4% (95% CI 0 to 11%), respectively. The rate of bicycle helmet use by Howard County children is now the highest documented for US children. A similar increase in helmet use among children younger than 16 years nationwide could prevent about 100 deaths and 56,000 emergency-department-treated head injuries annually. Physicians and other health professionals should consider proposing and supporting the Howard County approach in their communities. 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. To evaluate the effectiveness of a skills training program in improving safe cycling behavior, knowledge, and attitudes in young children.
                Grade 4 children from six elementary schools in East York (a borough of Metropolitan Toronto) participated. The intervention--playground based instruction on bicycle handling skills by certified instructors--was randomly allocated to three schools. Altogether 141 children participated: 73 in the intervention group and 68 in the control group, with follow up evaluations available on 117 (83%). The primary outcome was safe cycling behavior (straight line riding, coming to a complete stop, and shoulder checking before a left turn). A self report questionnaire collected data on knowledge and attitudes. Baseline assessments were made in June, with follow up evaluations in September, 1995.
                The prevalence of safe cycling behaviors at follow up in the intervention and control groups respectively, were: straight line riding (90% v 88%; p = 0.782), coming to a complete stop (90% v 76%; p = 0.225), and shoulder checking (0% v 2%; p = 1.000). Over time (from baseline to follow up) children in both groups were more likely to maintain straight line riding, less likely to ride on the sidewalk, and less likely to consider that a car had more right to the road.
                This brief skills training program was not effective in improving safe cycling behavior, knowledge, or attitudes among grade 4 children. A K-2 MORE HEALTH bicycle safety education program was provided in nine elementary schools in Hillsborough County, Florida. This innovative community program consisted of interactive education sessions and reduced-cost bicycle helmet sales. Evaluation of the pilot program showed that it affected helmet use in the intervention schools compared to nine other schools that served as controls. More than 1,000 helmets were distributed through the bicycle helmet sales. Approximately 3,500 children participated in the education sessions. The preprogram helmet use rate among all schools was 8.5%. Postprogram results showed that the helmet use rate among intervention schools was significantly greater than among control schools (p < .01). This report describes the MORE HEALTH bicycle helmet promotion program. To test the utility of school-level interventions for child bicycle safety and to identify social and behavioral factors associated with children's bicycle helmet use, a two-level intervention was conducted in two suburban elementary schools. Children (N = 209) and parents (N = 125) in school 1 and in school 2 (children, N = 470; parents, N = 364) were surveyed regarding bicycle injuries and helmet use. Children and parents in schools 1 and 2 received literature about bicycle safety and discount coupons for helmet purchase. School 1 was then the target of an intensive safety campaign, including meetings with the school safety committee and the PTA and a classroom presentation to children emphasizing helmet use. Ten months later the same survey was again administered. Children in school 1 were more likely at posttest to believe that helmets were protective (P = .003) but did not differ on other variables. Logistic regression showed that sibling helmet ownership, parental helmet use, and lower parental perceived social barriers to helmet use were independently associated with children's reported helmet use and with parental intent for the child to use a helmet at posttest. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Project objectives were to: (1) design and produce an easy-to-use, replicable comprehensive injury prevention curriculum for elementary schools; (2) pilot the program to determine instructors' ease in teaching the material and its usefulness in enhancing student knowledge and behavior change; (3) present material in subject-integrated, grade-specific lessons that would meet state and national student learning objectives; and (4) submit and obtain adoption of the curriculum by the State Department of Education.
                A pilot program was developed, implemented, and evaluated in six intervention and six control schools. The curriculum was revised and implemented in five other schools and finalized according to evaluation results and teachers' and parents' suggestions. Community resources such as police, fire, and county health departments participated in program implementation.
                The program showed a significant increase from 21% to 36% in seatbelt use during the school year in program schools compared with a 1% decrease in control schools. Bicycle helmet use increased from 0% to 10% in the program schools. Pre-test and post-test results showed significant differences in student knowledge, attitudes, and behaviors within the program schools, and in comparing the program and control schools. On a Likert scale of 1 (poor) to 7 (excellent), teachers rated lesson content, exercises, and the usefulness of materials and resources as 5.8, 5.5, and 5.4, respectively. Evaluations for the revised curricula ranged from 5.7 to 6.2.
                The favorable evaluation results resulted in the adoption of the curriculum as a state textbook, and widespread teaching of the curriculum. The product is appropriate and efficacious in these elementary schools and their communities. 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. To determine whether a brief session of behavior change counseling (BCC), offered to injured adolescents in the emergency department (ED) as a therapeutic intervention, could be used to change injury-related risk behaviors and the risk of reinjury.
                A randomized, controlled trial.
                Adolescents between 12 and 20 years old who were undergoing treatment for an injury in the ED and who were cognitively able to participate in the intervention.
                An urban ED at a level 1 pediatric trauma center.
                Study participants completed a baseline risk behavior prevalence assessment. Participants were then randomly assigned to receive BCC or routine ED care. Those in the treatment group underwent a brief session of BCC with a study social worker focused on changing an identified injury-related risk behavior (seatbelt use, bicycle helmet use, driving after drinking, riding with an impaired driver, binge drinking, or carrying a weapon). Participants were recontacted 3 months and 6 months after enrollment to assess the prevalence of positive behavior change and the interim occurrence of medically treated injuries.
                We enrolled 631 participants (78% of those eligible) and obtained follow-up for 76% at 3 months and 75% at 6 months. The relative risk of a positive behavior change with respect to seatbelt use was 1.34 (95% confidence interval [CI]: 1.00, 1.79) at 3 months, favoring the intervention group. The relative risk for the same outcome was 1.47 (95% CI: 1.09, 1.96) at 6 months. A positive change in bicycle helmet use was 1.81 (95% CI: 1.02, 3.18) times more likely at 3 months and 2.00 (95% CI: 1.00, 4.00) times more likely at 6 months in the intervention group. There was no effect of the intervention on changes in other target behaviors. Over the 6-month follow-up period, the risk of reinjury requiring medical attention did not differ between treatment groups.
                Brief BCC can be delivered to adolescents undergoing treatment for injury in the ED and can be used to address injury-related risk behaviors. The intervention was associated with a greater likelihood of positive behavior change in seatbelt and bicycle helmet use. This effect lasted over 6 months of follow-up. BCC was not associated with changes in other risk behaviors and could not be shown to significantly reduce the risk of reinjury. 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. 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.
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.