particular are subject to a wide range of influences. Children and
adolescents have been found to be more likely to wear helmets
when accompanied by a parent or companion wearing a helmet
[21–23]. Various strategies including school or community-based
educational programs, free or subsidized helmet distributions, and
legislative action and enforcement of active laws have been studied
[24–26]. While outcomes have been mixed, one study found that of
the non-legislative programs, community-based and free helmet
distribution programs were most effective in increasing observed
helmet use while school-based programs were effective, but slightly
less [27]. Legislative action has been taken in parts of Canada and the
US. A Toronto-based observational study found that increases in
bike helmet use were greatest among middle- and low-income
areas after legislation, though over time helmet use returned to prelegislative
levels among the same socioeconomic groups [28,29]. A
multi-faceted, long term strategy will be necessary to increase
bicycle helmet use among children. Our study supports specifically
targeting low income and minority communities and middle and
high school children for implementation of bicycle helmet education
and injury prevention programs.