Overall, 18% of parents reported that their child walked to school on most days of the week. For traffic safety, students were more likely to walk to school if their parent reported favorable perceptions about the following items in the home neighborhood environment: higher sidewalk availability, well maintained sidewalks and safe road crossings. For the route to school, the odds of WTS were higher for those who reported "no problem" with each one of the following: traffic speed, amount of traffic, sidewalks/pathways, intersection/crossing safety, and crossing guards, when compared to those that reported "always a problem". For personal safety in the en-route to school environment, the odds of WTS were lower when parents reported concerns about: stray or dangerous animals and availability of others with whom to walk.
While safety concerns are hypothesized barriers to WTS, there is clearly the need for more focused empirical inquiries into the potential relationship between these two phenomena because current research offers little in terms of exploring/explaining the mechanisms through which safety concerns might impact active transport [23, 24]. Generally, safety concerns have been investigated in terms of road safety (traffic- or pedestrian-related safety concerns) and personal safety (crime- or predator-related safety concerns). Better understanding of the relationships between multiple domains of safety concerns and WTS can contribute to the development of practical intervention strategies to reduce barriers to WTS, which may lead to increases in physical activity and long-term health benefits to school-aged children.
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To contribute to the growing yet limited body of literature on safety and WTS, we examined the relationships between WTS and specific measures of road and personal safety measures in a sample of U.S. schoolchildren who were selected from elementary schools across Texas. We also examined the relationships between selected covariates and walking, in order to obtain insights into the relations between these covariates in our population, as well as to adjust for the effects of the socio-demographic covariates in the potential relationships between safety concerns and WTS.
In the home neighborhood environment, bivariate analysis showed that one out of the four items in this domain was associated with WTS; parents who reported that it was safe for their child to walk or bike in the neighborhood also reported higher WTS when compared to their counterparts. In the en-route environment, children were less likely to report WTS if their parents reported some measure of concern on the following issues: having other adults or children to walk with; violence or crime problems; and stray or dangerous animals. None of the constituent variables for personal safety in the school environment showed significant association with WTS. More details are given in Table 4.
Our findings suggest that the en-route environment may be the most critical environment to parents for both traffic safety and personal safety. All but one of the 8 items that were assessed in the en-route environment maintained significant relationships with walking to school in the expected direction, i.e. more safety concern associated with less walking to school. Comparatively, 4 of 8 and 3 of 13 items remained significant in adjusted models at the home neighborhood and school environment respectively. Further, the largest measures of effect were seen in the en-route domain. These findings suggest that parents may weigh the safety of the specific route a child will travel over the safety of the neighborhood or school environment when deciding whether to allow their child to walk to school. This finding lends further support to the call for specificity when defining the spatial domain of a behavior of interest [49].
Despite the acknowledged limitations, our findings have relevance to the behavioral medicine field in a variety of ways. First of all, the current study asked participants about specific safety concerns, rather than using general safety questions, which provides evidence that road safety may be more relevant than personal safety to parents, as far as walking to school is concerned. However, despite this more robust assessment, the full range of parental perceptions around safety for their child may not be fully captured. Future research would benefit from the use of qualitative data gathering in communities (e.g. focus group discussions and interviews) to improve the operationalization of safety concern constructs. Secondly, a major contribution to existing knowledge is the level of spatial specificity offered by T-COPPE data that previous studies have lacked. This study provides the ability to examine relevant safety concerns across different spatial domains (i.e., home neighborhood, en-route, and school environments) going beyond previous single domain studies. Consequently, we were able to examine the differential effects in the exposure-outcome relationships across these spatially-distinct domains.
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While the positive association between education and health has been established, the explanations for this association are not [31]. People who are well educated experience better health as reflected in the high levels of self-reported health and low levels of morbidity, mortality, and disability. By extension, low educational attainment is associated with self-reported poor health, shorter life expectancy, and shorter survival when sick. Prior research has suggested that the association between education and health is a complicated one, with a range of potential indicators that include (but are not limited to) interrelationships between demographic and family background indicators [8] - effects of poor health in childhood, greater resources associated with higher levels of education, appreciation of good health behaviors, and access to social networks. Some evidence suggests that education is strongly linked to health determinants such as preventative care [9]. Education helps promote and sustain healthy lifestyles and positive choices, nurture relationships, and enhance personal, family, and community well-being. However, there are some adverse effects of education too [9]. Education may result in increased attention to preventive care, which, though beneficial in the long term, raises healthcare costs in the short term. Some studies have found a positive association between education and some forms of illicit drug and alcohol use. Finally, although education is said to be effective for depression, it has been found to have much less substantial impact in general happiness or well-being [9].
For both types of interviews, the questions asked about problems affecting children and adolescents in general and we did not seek information about the specific problems of individual respondents. Interviewers were trained to redirect any discussion about personal experience or problems to focus back on the problems of children and adolescents in the community in general. Interviewers were also trained to stop an interview and contact his or her supervisor if a respondent became upset; however, during data collection there were not instances of a respondent becoming upset and a supervisor needing to be contacted. The supervisors were program coordinators from each of the organizations and were present and available on site during both data collection activities. Both the JHU Institutional Review Board (IRB: 6933) and the Department of Medical Research Ethical Review Board in Yangon, Myanmar (IRB: 001116) reviewed and approved this study protocol.
Among our representative sample, 26% reported having experienced an injury since the pandemic started. By comparison, in 2017, 14.3% of respondents to the NHIS survey reported an injury to someone in their household in the 3 months prior to the survey (Michael E. Martinez, National Center for Health Statistics, personal communication, 9/1/2020). The time periods covered by these two surveys are comparable, given that our survey was fielded (i.e., mid to late June) about 3 months after states started issuing stay at home orders and people began working from home (i.e., mid to late March). Considering ingestions as well as injuries, we found that 28% of households experienced either and 13% experienced both. Falls were the most common cause of injury, which is consistent with other studies of home injuries (Chen et al. 2009; Mack et al. 2013; Gielen et al. 2015; McDonald et al. 2016). Having children living in the home was significantly associated with a higher likelihood of households reporting an injury and/or ingestion, and having more adults in the home was not. Families in urban areas and with higher annual incomes were more likely to report an injury and/or ingestion.
Also important to note is the absence of a conceptually sound and psychometrically robust measure of resilience for children aged under 12. Only one of the measures, the Resilience Scale of the California Healthy Kids Survey applied this to primary school children (mean ages 8.9, 10.05, 12.02), however this measure scored poorly according to our quality assessment. Resilience research with children has tended to operationalise resilience by looking at ratings of adaptive behaviour by other people, such as teachers, parents, etc. A common strategy is to use task measures which reflect developmental stages [6]. For example Cichetti and Rosgoch [51] examined resilience in abused children and used a composite measure of adaptive functioning to indicate resilience which consists of 7 indicators; different aspects of interpersonal behaviour important for peer relations, indicators of psychopathology and an index of risk for school difficulties. 2ff7e9595c
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