|CJEB||Neighbourhood Sociocultural Demographics and their Association with Helmet Use in Children|
Neighbourhood Sociocultural Demographics and their
Heather L. White BHSc1, Harvey Low BAA2 &
Alison K. Macpherson PhD1, 3
1. School of Kinesiology and Health Science, York University
2. City of Toronto, Social Development Finance & Administration Division
3. The Institute for Clinical Evaluative Sciences, Toronto
Dr. Alison K. Macpherson
School of Kinesiology and Health Science
337 Bethune College
4700 Keele Street
Tel: (416) 736-2100 x 77216
Fax: (416) 736-5774
Heather White and Alison Macpherson were the recipients of an Ontario Neurotrauma Foundation mentor/student award. This paper was partially supported by a Junior Faculty Research Award from York University. The authors have no conflict of interest to report.
Background - Wheeled sport (bicycle, scooter, and in-line skate) head and facial injuries can be prevented through use of a properly worn helmet. Given the evidence for the effectiveness of bicycle helmets, it is important to examine factors related to their use among children. The objective of this study was to examine neighbourhood sociocultural demographics and their association with observed helmet use among school-aged children riding in defined urban communities.
Methods - Children were observed at fifty-five pre-selected sites in twenty defined neighbourhoods in Toronto, Ontario between June and September of 2005. Trained volunteer observers recorded information on helmet use. Neighbourhood level data was adapted from Statistics Canada, and socio-economic and demographic variables for the year 2000-2001 were obtained for each of the twenty neighbourhoods included in the study. Logistic regression was preformed to examine the relationship between neighbourhood sociocultural demographics and helmet use.
Results - Of the 306 riders, 174 children were observed riding without a helmet. Neighbourhood socio economic and demographic variables were significantly associated with observed helmet use. Helmet use was lowest among children observed riding in neighbourhoods with a high percent of families with an incidence of low income; a high percent of the population aged fifteen and over with less than high school education; high percent of the population with no knowledge of English or French; and low childhood immunization rates.
Conclusion - Results from this study indicate that neighbourhood sociocultural demographics are significantly associated with observed helmet use among children. These results offer a unique opportunity to target specific neighbourhoods according to their sociocultural demographics for helmet-promotion programs and interventions.
MeSH Terms: Injuries; Socioeconomic Factors; Accident Prevention; Public Health;
Cycling is a popular recreational activity enjoyed by children and adolescents. Despite the potential health benefits from being physically active, participation in any recreational activity comes with an inherent risk of injury. The popularity of cycling has resulted in correspondingly high rates of injuries, with school-aged children being at greatest risk for bicycle-related morbidity and mortality(1-9)[IC1] .
The majority of bicycle-related deaths and disability are the result of sustained head injuries (10, 11). While these are among the most serious and life-threatening which can be sustained by cyclists, they are also among the most preventable. Several studies indicate bicycle helmets to be highly effective in preventing injuries to the head, brain and face in the event of a crash when worn correctly (10-15). Bicycle helmet legislation has shown to be effective in increasing rates of helmet use, however rates remain low with less than 50% of riders reporting regular helmet use (16-19).
Given the effectiveness of helmets in preventing head injuries, research aimed at identifying factors influencing their use have been popular in identifying children at highest risk for non-use. While the majority of studies involved self-report methods (1, 20-25). observational studies have been conducted to determine the influence of individual rider characteristics on helmet use (26-31). One factor that has been identified as related to helmet use is socio-economic status of the child or neighbourhood. (32-35) Aside from income, research has yet to investigate the relationship of neighbourhood demographics and their potential association with helmet use. Therefore, the purpose of the current study was to examine neighbourhood sociocultural demographics and their association with observed helmet use among school-aged children participating in wheeled sports in defined urban communities.
This study was conducted in the City of Toronto, Ontario; with an estimated population of 2,500,000 and a school aged population of 460,000(36). Toronto has been previously divided into 140 distinct neighbourhoods by the City of Toronto’s Social Development, Finance & Administration Division (SDFA) (37). Sociodemographic profiles for each of the 140 neighbourhoods were prepared by SDFA based on census data available through Statistics Canada (37). Neighbourhoods were ranked according to average family income, with those ranked in the top and bottom 20% excluded from the study. Previous research has shown that children living in wealthier neighbourhoods are more likely to wear a bicycle helmet while riding; hence the highest income quintiles were excluded. Neighbourhoods in the lowest quintiles were excluded out of concern for observers, who may not have felt safe in some of the poorest areas.Of the remaining communities, twenty neighbourhoods were selected at random for observation. Sociocultural demographics for the year 2000-2001 were obtained for each of the neighbourhoods included in the study.
Observation sites were pre-selected, including public and private elementary and secondary schools and local parks. Observations took place from June to September 2005. Observers were trained to collect reliable observational data using a standardized data collection form. Children were included if they were between the ages of five and sixteen (as judged by the development of secondary sexual characteristics) and were riding wheeled equipment (bicycle, self-powered scooter, skateboard or rollerblades). Data were collected for each observed rider on helmet use, correct use, gender, riding status, and the helmet status of any riding companions. Day of week, time of day, neighbourhood and weather conditions were also recorded.
Descriptive statistics were run to describe the observation sample, and cluster analysis was performed by neighbourhood. Bivariate statistical significance was determined using Pearson’s chi square, with statistical significance set to an alpha of 0.05. Multivariate logistic regression was used to model the odds of helmet use taking into account the effects of neighbourhood sociocultural factors while adjusting for neighbourhood clustering. Variables were retained in the regression model if they were statistically significant at the bivariate level, even if the significance was not sustained in the multivariate model, except in cases where the exposure variables were highly correlated (percent of single parent families, and percent of families residing in a rented dwelling). The primary outcome variable for the regression analysis was helmet use (yes/no). Adjusted odds ratios with 95% confidence intervals are provided. Analysis was conducted using SPSS statistical software, version 13.0 and SAS version 9.0.
Over the four month study period, a total of 306 observations were made. Of these, 69.8% of riders were male (206 of 306) and 21.2% were female (66 of 306). Gender could not accurately be identified in 8% of riders (33 of 306). Overall, 45.9% (132 of 306) of children were observed wearing a helmet, of which 89.4% (118 of 132) were worn correctly. Descriptive statistics and bivariate results can be found in Table 1.
Table 2 provides a summary of results for the logistic regression model, including crude and adjusted odds ratios with 95% confidence intervals between the exposure variables and helmet use. Of those neighbourhoods where more than 20% of the population was composed of single parent families, children were 1.7 times more likely to be observed without a helmet (Crude OR 1.7; 95% CI: 1.0 to 3.4). Neighbourhoods in which more than 40% of families resided in rented dwelling were also associated with increased odds of non-helmet use (Crude OR: 2.3; 95% CI: 1.3 to 4.2). While these variables were significantly associated with helmet use at the bivariate level of analysis, both were both significantly correlated with percent of low income families and were subsequently omitted from the regression model (Correlation = p < 0.01).
Results from this study indicate neighbourhood sociocultural demographics are significantly associated with observed helmet use among children riding in these communities. Helmet use was lowest among children observed participating in wheeled sports in neighbourhoods: with a high percent of families with an incidence of low income; a high percent of the population aged fifteen and over with less than high school education; a high percent of the population with no knowledge of English or French; and low childhood immunization rates. This study suggests that the social determinants of health, particularly poverty, are barriers to helmet use.
The finding that 46% of children were observed wearing a helmet is similar to findings reported in comparable studies (5, 21, 22, 24, 25, 33). Populations from which these study samples were drawn have all been exposed to extensive helmet promotion campaigns and introduced legislated helmet laws over similar time frames. The consistency between rates across these studies highlight that helmet use remains low despite the legislation and promotion programs actively in place within these communities. While females were more likely to be observed wearing a helmet, gender was not significantly associated with helmet use after adjusting for other variables. Results from this study fit with recent literature, suggesting a slight gender difference in helmet use since the introduction of legislation, but not enough to reach statistical significance (20, 22, 24, 26, 27, 30, 32, 34).
Children who rode in neighbourhoods comprised of a high percent of families with an incidence of low income were significantly more likely to be observed riding without a helmet. Children from low income families and those residing in low-income neighbourhoods are consistently associated with lower rates of helmet use than children from middle-to-high income families living in higher average income communities (29, 34). Low income communities have been targeted extensively for helmet education and promotion programs and are often linked with helmet subsidies and give-a-ways aimed at providing helmets to those who cannot afford to purchase them. While these programs are effective in raising awareness and initial levels of helmet use, use rates remain well below those of their higher income neighbours (29, 32, 34). This suggests that ongoing efforts that address not only helmet use, but the social and cultural diversity of neighbourhoods, may be a more promising approach.
Children observed participating in wheeled sports in neighbourhoods with a high percent of the population with less than high school education were significantly associated with non-helmet use. Studies have shown that parental insistence, encouragement and role modeling correlate highly with helmet use in their children (20-22, 24, 28). Given the magnitude of parental influence, information regarding the importance of helmet use should be targeted not only to children, but also to parents who are primarily responsible for enforcing helmet wearing behaviours. Results from this study can be used to guide programming for parents and families living in these neighbourhoods aimed at helmet education and promotion using material which is appropriate and engaging for adults with lower levels of education.
The importance of equipment is worth further research. Children participating in other wheeled sports were more likely to be unhelmeted that children riding bicycles. There is currently no legislation in Ontario requiring children to wear helmets when using scooters, skateboards, or in-line skates. Efforts to promote helmet use in these sports are clearly necessary.
Prior to, during, and immediately following the introduction of bike helmet legislation, communities across North America introduced extensive promotional programs regarding the risk of bicycling without a helmet and the importance of wearing an approved helmet while riding. With passing time and decreased public visibility, neighbourhoods comprised of a high percent of recent immigrants may be at increased risk for non-helmet use, as families may not be aware of the existence of mandatory helmet legislation. Throughout North America, an overwhelming majority of promotional material regarding helmet use is published in English, with limited availability in French. This poses as a barrier for individuals with little or no comfort or familiarity communicating in these languages. Results from this study indicate that neighbourhoods containing a high percent of the population with no knowledge of these languages are at increased likelihood for non-helmet use while riding. This research offers a unique opportunity to target at risk communities containing a high percent of non-English/French speaking populations for helmet promotion programs. Programs should be developed according to the needs of the community, appropriate to their culturally and linguistically diverse populations. The potential association between immigration, spoken language, and helmet use should be investigated further to determine the unique needs of recent immigrants and the extent of bicycle helmet knowledge in these populations.
This study produced novel results regarding the association between childhood immunization rates and helmet use. Higher immunization rates are typically seen among individuals and communities with higher income and education levels, and lower rates seen in low income brackets with lower levels of education. It is possible that parents who choose to immunize their children are often aware of the importance of other factors affecting their children’s health; as such, they may be more likely to insist on helmet use by their children. Helmet use could potentially be associated with other child health behaviours and is a new area to be investigated for future research.
In comparison to self-reported measures which may be subject to recall or social desirability bias (2), observational studies are known to be an accurate and preferred method of assessing helmet use. Observational strengths of this study include direct observation of helmet use and accurate representation of neighbourhoods through random sampling. Furthermore, neighbourhood demographics are population based and known to be accurate according to Statistics Canada (Toronto, 2006). Despite the strengths of the observational design, neighbourhoods with extreme high and low average family incomes were excluded from the study. This likely limits the variation in neighbourhood demographics.
Studies suggest children of this age range tend to ride in their own neighbourhoods close to home, partly enforced by the natural barriers in which these neighbourhoods were designed around. Despite this, we cannot be certain that the observed children were riding in the neighbourhoods in which he or she resides. Finally, this study had a relatively low number of observations, with volunteers frequently noting sites as not having bike racks available or undergoing construction in or around the play areas. These factors pose as barriers for children who could potentially bike to school and limit ridership at the observation sites.
Results of this study suggest neighbourhood socio-economic and demographic variables are significantly associated with helmet use among school-aged children observed participating in wheeled sports. In particular, there appears to be an association between helmet use and the percent of low income families; percent of the population with less than high school education; percent of the population with no knowledge of English or French; and childhood immunization rate within these neighbourhoods. This suggests that knowledge of the helmet law and the importance of helmets, and ability to purchase helmets may be important barriers to overcome.
There is an ongoing need to understand the multifaceted factors which influence helmet use and non-use among children. This study adds to the body of evidence of known factors associated with helmet use by looking at the influence of the neighbourhoods in which these children live and ride. This offers an opportunity to target neighbourhoods according to their socio-economic and demographic profiles for helmet-promotion programs and interventions which may be at increased risk for non-helmet use and subsequent related bicycle injuries.