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.
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.
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.