title: Influence of socioeconomic status on the effectiveness of bicycle helmet legislation for children: a prospective observational study.
abstract: OBJECTIVE
  To evaluate the influence of average family income in a geographic area on the effectiveness of helmet legislation on observed helmet use by children (5-14 years).
  
  
  METHODS
  The study was conducted in East York, a health district of Metropolitan Toronto, in collaboration with the East York Health Unit. In 1996, the total population was 107 822, 11 340 of which were children 5 to 14 years. Census data were used to group the 21 census tracts in East York into 7 geographically distinct areas. The boundaries of these areas are natural barriers to travel, such as expressways, ravines, railway tracks, and hydroelectric power lines. The areas were also ranked according to average family income (based on Statistics Canada data). For analytical purposes, areas were defined as low-, mid-, and high-income areas. Census data profiles of the areas have been previously described. For each consecutive year from 1990 to 1997 inclusive, direct observations of children riding bicycles in East York during the months of April through October were made. In 1995, observations were completed before the introduction of the law on October 1, 1995. Only children who were between 5 and 14 years of age and riding a 2-wheeled bicycle were included in the study. In total, 111 sites across all 7 areas were selected for observation. Observational sites included school yards of all elementary and middle schools (kindergarten to grade 8) and all parks in East York. In addition, 5 major intersections and 5 residential streets from each area were randomly selected. Observers were trained and used a standardized data collection form. A pilot study showed that the data collected by observers were reliable and valid. Observers remained at each site for 1 hour and collected data on helmet use and sex. Ethical approval for the study was obtained from the Hospital for Sick Children Research Ethics Board, the East York Board of Education, and the Metropolitan Separate School Board. The proportion of children who were wearing a bicycle helmet was estimated by year (1990-1997, inclusive), sex (male, female), location (school, park, major intersection, residential street), and income area (low, mid, high). For estimating the effect of legislation on helmet use, data from the year immediately after legislation (1996) were compared with data from the year preceding legislation (1995). The relative risk (RR) of helmet use (after vs before legislation) was calculated along with a 95% confidence interval (CI). Logistic regression analysis was used to adjust for potential confounding variables (sex and location).
  
  
  RESULTS
  During the 8-year study period, 9768 observations were made (range: 914-1879 observations per year). The proportion of child cyclists who wore a bicycle helmet increased steadily during the first 4 years of the study period, from 4% in 1990 (34 of 914), to 16% in 1991 (303 of 1879), to 25% in 1992 (383 of 1563), and to 45% in 1993 (438 of 984). During 1994 (460 of 1083) and 1995 (568 of 1227), helmet use remained relatively stable at approximately 44%. Helmet use rose markedly in 1996 (the first year after helmet legislation was introduced) to 68% (818 of 1202) and remained stable at 66% (609 of 916) in 1997. Throughout the study period, girls were consistently more likely to wear helmets than were boys. In total, 47% (1420 of 3047) of girls wore helmets, compared with 33% (2193 of 6721) of boys (RR: 1.43; 95% CI: 1.36-1.50). In addition, children who were riding to school were more likely to use helmets, compared with children who were riding on residential streets, major intersections, and parks. Overall, 48% (1497 of 3129) of children who were riding to school wore bicycle helmets, compared with 32% (2116 of 6639) of children who were riding at other locations (RR: 1.50; 95% CI: 1.43-1.58). Children in the high-income areas were consistently more likely to wear helmets, compared with children in the mid- and low-income areas. Helmet legislation was associated with a significant increase in helmet use by children in East York. In 1995, 46% (ast York. In 1995, 46% (568 of 1227) of children wore bicycle helmets, compared with 68% (818 of 1202) of children in 1996 (RR: 1.47; 95% CI: 1.37-1.58). The effect of legislation, however, varied by income area. In low-income areas, helmet use increased by 28% after legislation, from 33% (213 of 646) in 1995 to 61% (442 of 721) in 1996 (RR: 1.86; 95% CI: 1.64-2.11). In mid-income areas, helmet use increased by 29% after legislation, from 50% (150 of 300) in 1995 to 79% (185 of 234) in 1996 (RR: 1.58; 95% CI: 1.39-1.80). In high-income areas, helmet use increased by only 4%, from 73% (205 of 281) in 1995 to 77% (191 of 247) in 1996 (RR: 1.06; 95% CI: 0.96-1.17). This finding of a significant increase in helmet use after legislation in low- and mid-income areas but not in high-income areas remained even after logistic regression analysis adjusted for sex and location.
  
  
  CONCLUSIONS
  This study showed that bicycle helmet use by children increased significantly after helmet legislation. In this urban area with socioeconomic diversity and in the context of prelegislation promotion and educational activities, the legislative effect was most powerful among children who resided in low-income areas.
authors.affiliation: Department of Paediatrics, University of Toronto Faculty of Medicine, Ontario, Canada. patricia.parkin@sickkids.ca
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Parkin
authors.forename: Amina
authors.initials: A
authors.lastname: Khambalia
authors.forename: Leanne
authors.initials: L
authors.lastname: Kmet
authors.forename: Colin
authors.initials: C
authors.lastname: Macarthur
mesh_terms: D000063:Accidents, Traffic / Q000191:economics / Q000517:prevention & control; D000293:Adolescent; D001265:Athletic Injuries / Q000191:economics / Q000517:prevention & control; D001642:Bicycling / Q000191:economics / Q000293:injuries / Q000331:legislation & jurisprudence* / Q000639:trends*; D002170:Canada; D002648:Child; D002675:Child, Preschool; D005260:Female; D006260:Head Protective Devices / Q000191:economics / Q000639:trends*; D006801:Humans; D008297:Male; D019370:Observation / Q000379:methods; D011446:Prospective Studies; D012737:Sex Factors; D012959:Socioeconomic Factors