Abstract
Objective:
To examine self-reported safety behaviours among 3828 Alaskan Native and American Indian people enrolled in the Alaska Education and Research Towards Health (EARTH) Study, 2004–2006.
Design:
A cross-sectional analysis of baseline data from a cohort study. A non-random sample of participants (2322 women and 1506 men) aged ⩾ 18 years from three regions of Alaska completed questions on safety behaviours as part of a comprehensive health and lifestyle computer-assisted self-administered questionnaire.
Results:
Most participants reported never driving after drinking (94.1%) or riding with a driver who had been drinking (91.3%). Fewer (74.1%) participants reported using a seatbelt always or almost always when riding in a vehicle. Only about half (55%) always kept to the speed limit when driving or used a personal flotation device when boating (51.5%). Even fewer (20.5%) reported using a helmet when riding on off-road vehicles, including four-wheelers and snowmobiles. Factors identified among those least likely to use safety devices and practise good safety behaviours are: younger age, lower household income and education, non-married, speaking only English at home, and a self-reported health status of poor to fair (p<0.05).
Conclusions:
Recommendations for future injury prevention efforts in this population are to increase use of personal flotation devices while boating and address the underuse of helmets with off-road vehicles. Limited prevention resources should be used to target those who engage in risky behaviours to maximise programme impact.
Injury disparities exist between indigenous and non-indigenous populations worldwide. Canadian Aboriginal injury rates are three to six times the national rate.1 2 Status Indians in Canada experience rates of years of potential life lost due to motor vehicle crashes that are almost two and a half times that of all other residents of British Columbia.3 A study of road injury in Western Australia found that road injury hospitalisation rates among Aboriginal people were also twice that of non-Aboriginal people.4
In Alaska, unintentional injuries are the third leading cause of death of Alaskan Native people, preceded by cancer and heart disease.5 6 They account for 14.7% of all deaths. Despite decreases in injury rates for some causes, disparities persist. The unintentional injury death rate for Alaskan Native people is currently twice that of all Alaskans and three times greater than the overall rate among the US population (101.8 vs 58.8 and 36.3 per 100 000, respectively).
A study of Alaskan Native deaths during 1999–2005 found that 682 Alaskan Native people died as a result of an unintentional injury. Alaskan Native people under the age of 40 were more likely to die from injuries than those over the age of 40 (228.2 vs 176.8 per 100 000).7 Alaskan Native men were 2.6 times more likely to die from an injury than Alaskan Native women. The leading causes of unintentional injury death were drowning (20%), motor vehicle crashes (19%) and off-road vehicle crashes (11%). The largest disparity found was for drowning death. Alaskan Native people were 5.5 times more likely to die from drowning than Alaskan White people and 10.3 times more likely to die from drowning than US all races.7
Alaskan Native people are two to three times more likely to be hospitalised for an unintentional injury than Alaskan White people.8 Hospitalisations due to injury are 1.5 times higher among men than women, and are greatest among younger Alaskan Native people. The leading causes of hospitalisation due to unintentional injury were falls and motor vehicle and snowmobile crashes.5 Data on all-terrain vehicle (ATV)-related and snowmobile-related injury hospitalisations in 1991–2003 among Alaskan Native people showed that these types of injuries were about three times higher among adult men than among adult women.5 Some of the injury disparity between sex and age groups may be explained by greater exposure to the mechanism of injury.
Economic changes in the past 50 years in rural communities have led to greater use of mechanised modes of transportation such as motor vehicles, ATVs, snowmobiles and motorised boats.9 10 However, the use of safety devices such as seatbelts, helmets and personal flotation devices (PFDs) is still not widespread in most of rural Alaska. An increase in the use of safety devices, such as helmets, PFDs and seatbelts, and in the prevalence of safety behaviours may help to reduce the rates of hospitalisation, severity of injury and deaths due to injury among Alaskan Native people. Even though almost 20% of traumatic brain injuries among Alaskan Native people are due to off-road vehicles (10% from ATVs and 9% from snowmobiles), snowmobile helmet usage rates were only 57% in Alaska in 2006.11 Studies have also found that lack of PFD use is associated with drowning-related mortality.12 13 Lastly, according to the National Highway Traffic and Safety Administration (NHTSA), seatbelts reduce the risk of death for a front seat car occupant by ~50%. Furthermore, NHTSA estimates that 5000 additional US car crash fatalities would have been avoided if the victims wore seatbelts.14
To date no information exists on multiple safety behaviours and practices across different groups of Alaskan Native people. We report on the rates of self-reported safety behaviours in a large cohort of Alaskan Native and American Indian (AN/AI) people living in three regions of Alaska and compare those rates with the limited data that exist in other surveys. We further describe the characteristics of people who were less likely to practise safety behaviours, which is an important prerequisite for the design of intervention programmes.
METHODS
Study population
The study population, data collection methods and measurement instruments for the Education and Research Towards Health (EARTH) Study have been described in detail elsewhere.15 Participants were recruited from 26 Alaskan communities in three regions of the state. The southcentral Alaska region included AN/AI people from many different ethnic groups living in or around Alaska’s largest city (population 350 000). The southeast Alaska region included mostly Tlingit, Haida and Tsimshian Indian people living in smaller communities (population 500–30 000). The southwest Alaska region included mostly Yup’ik people and was the most rural and remote of the three regions, with communities ranging in population size from 200 to 5500. All of the southeast and southwest communities were located off the road system and were accessible only by airplane, with seasonal access by snow machine or boat. Methods of recruitment included presentations to tribal groups and healthcare providers, informational tables staffed by study personnel at community events, house-to-house recruiting, brochures and flyers in public locations, and public service announcements on local radio and in newspapers. In each community, attempts were made to enrol all residents of the community who met the following inclusion criteria: AN/AI eligible for healthcare through the Alaska Tribal Health System; age ⩾ 18 years; able to give informed consent. Those who were pregnant and/or receiving chemotherapy were asked to participate at a later date because of changes in health measurements caused by these two factors. This report summarises data collected from 3828 participants enrolled in the study from March 2004 through August 2006.
Data collection
EARTH participants completed self-administered and interviewer-administered questionnaires on demographics, diet, physical activity, lifestyle and cultural practices, environmental exposures, cancer-screening practices, personal medical and reproductive history, and family history of chronic diseases. In addition, height, weight, waist and hip circumference, blood pressure, fasting glucose and a lipid panel were recorded. Questions on safety were adapted from the Behavioral Risk Factor Surveillance System (BRFSS).16 Participants were queried about seatbelt use when riding in a car or truck (always, almost always, about half the time, never/rarely) in the manner of the 2006 BRFSS questionnaire. Participants were also asked how close to the speed limit they usually drove (always kept to the speed limit, 5–10 miles over the limit, more than 10 miles over the limit), which was not a BRFSS question and was not validated in other populations. The BRFSS question about the number of times a participant drove vehicles in the past month “after having perhaps too much to drink,” was modified as the result of tribal input to read “after having more than one alcoholic beverage.” Participants were asked about: the number of times they had ridden in vehicles after the driver had consumed more than one alcoholic drink; helmet use (always, almost always, about half the time, never/rarely); PFD use (always, about half the time, never/rarely). All three of these questions were last asked by BRFSS in 1993.
Participants were asked if they wore a helmet when riding a bicycle, motorcycle, snowmobile, four-wheeler or ATV. In Alaska, the off-road vehicles most commonly used are four-wheelers in the summer and snowmobiles in the winter. Type of use also varies by region. In more urban areas, off-road vehicles are generally used for leisure-time recreation. In rural areas, off-road vehicles are the main transportation method, and are used for everyday transport to schools or workplaces, or for traditional hunting and fishing activities.
Participants completed the safety practices questionnaire by using computer-assisted self-interview on touch-screen panels while listening to an audio version of the questionnaire by headphones in English or Yupik.17 The study protocol was approved by the Alaska Area Institutional Review Board, the research and ethics committees and governing boards of each of the participating regional tribal health corporations, and the tribal councils of each participating community. All participants signed an informed consent form before participating in the study.
Statistical analysis
Summary statistics provide an overview of the demographic characteristics of EARTH study participants. Responses to safety questions were analysed by EARTH Study region, age, sex, marital status, education, employment, income, language spoken at home and self-reported health status. Analysis of variance and χ2 tests for proportion differences were used for univariate analyses. Multiple linear regression was used to determine demographic factors associated with greater prevalence of safety behaviours among study participants. The safety behaviour variable was defined as answering yes to any of the following: always wearing a seatbelt; always adhering to the speed limit; always wearing a helmet; always wearing a PFD; never driving while drinking alcohol; and never riding in a vehicle with a driver who was drinking alcohol. All demographic characteristics that were significant in the univariate analyses were retained in the multiple linear regression model. All analyses were conducted with the SPSS V15; p ⩽ 0.05 was considered to be significant.
RESULTS
Table 1 shows demographic descriptions of the Alaska (n = 3828) study population in comparison with US census data. Most participants came from the southwest region (40%). Participant age at recruitment ranged from age 18 to 94 (median 40.0). More women than men were enrolled in the study (61% vs 39%). About a quarter of participants (23%) had not completed high school, 55% were not currently employed, and 41% had a reported annual household income up to US$15 000. One-third of participants spoke their native language at home, and most participants (74%) reported “good to excellent” health.
Table 1.
Demographic and socioeconomic characteristics for Alaskan Native and American Indian adult participants of the Education and Research Toward Health (EARTH) Study compared with all Alaskan Native people in Alaska (US census 2000 data)
| EARTH Study (n) |
EARTH Study (%) |
Census* (%) |
|
|---|---|---|---|
| Total | 3828 | 100.0 | – |
| Region† | |||
| Southcentral | 1396 | 36.5 | 6.3 |
| Southeast | 887 | 23.2 | 9.4 |
| Southwest | 1545 | 40.4 | 13.7 |
| Age (years)‡ | |||
| 18–29 | 1086 | 28.4 | 27.9 |
| 30–39 | 792 | 20.7 | 24.6 |
| 40–49 | 272 | 24.8 | 22.4 |
| 50–59 | 569 | 14.9 | 12.6 |
| 60–69 | 275 | 7.2 | 6.9 |
| ⩾70 | 157 | 4.1 | 5.6 |
| Sex‡ | |||
| Male | 1506 | 39.3 | 49.2 |
| Female | 2322 | 60.7 | 50.8 |
| Marital status¶ | |||
| Married/living as married | 1632 | 42.8 | 39.0 |
| Separated/divorced/never married | 2181 | 57.2 | 61.0 |
| Education‡ | |||
| High school or higher | 2936 | 76.8 | 72.8 |
| Employment status§ | |||
| Employed or self-employed | 1719 | 45.1 | 48.8 |
| Annual household income (US$)** | |||
| ⩽22 15000 | 1343 | 41.1 | 20.4 |
| 15 001–25 000 | 526 | 16.1 | 16.1 |
| 25 001–35 000 | 449 | 13.7 | 13.7 |
| 35 001–50 000 | 444 | 13.6 | 15.8 |
| ⩾50 001 | 505 | 15.5 | 34.0 |
| Language spoken at home†† | |||
| Non-English/both | 1265 | 33.2 | 18.0 |
| English only | 2545 | 66.8 | 82.0 |
| Self-reported health status‡‡ | |||
| Excellent/very good/good | 2868 | 75.0 | 87.2 |
| Fair/poor | 956 | 25.0 | 12.8 |
Dataset: Census 2000 American Indian and Alaskan Native summary file—sample data; geographic area: Alaska; tribes alone or in any combination: American Indian and Alaskan Native alone or in any combination.
Census 2000 data for the corresponding Alaskan Native Regional Corporations (ANRC) southcentral: Cook Inlet ANRC; southeast: Sealaska ANRC; southwest: Calista ANRC.
Census 2000 data for population 18 years and over.
Census 2000 data for population 15 years and over.
Census 2000 data for population 16 years and over.
Census 2000 data for households. EARTH data 555 missing values.
Census 2000: language use and English-speaking ability, US all races.
Behavioral Risk Factor Surveillance System 2005, Alaska all races.
Of the EARTH Study participants surveyed, in the past year 3.4% (131) had not ridden in a car or truck, 33% (1260) did not drive a car or truck, 38.1% (1454) did not use an off-road vehicle, and 24.8% (948) did not use a boat (data not shown). Women and those over the age of 65 were the least likely to operate motor vehicles, off-road vehicles and boats. Those in the southwest region were the least likely to ride in a car or truck, those in the southeast region were least likely to ride off-road vehicles (snowmobile or ATV), and those in the southcentral region were least likely to ride in a boat (p<0.05 for all associations except sex and motor vehicle use, data not shown).
Table 2 shows the number and percentage of participants reporting safety behaviours practised by those who reported using motor vehicles, off-road vehicles and boats. Almost three-quarters (74.1%) of participants reported using a seatbelt always or almost always when riding in a vehicle. Approximately half (55%) reported that they adhered to the speed limit. Most participants reported never driving after drinking (94.1%) or riding with a driver who had been drinking (91.3%). Use of PFDs and helmets were the least reported safety behaviours. About half (51.5%) always used a PFD when boating. In contrast, only 20.5% reported always or almost always using a helmet when riding on an off-road vehicle.
Table 2.
Number and percentage of participants reporting safety behaviours by sex, age and Alaska Education and Research Towards Health (EARTH) Study region*
| Sex | Age | Region | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Behaviour | Total | Men | Women | 18–29 | 30–39 | 40–59 | 60+ | Southcentral | Southeast | Southwest |
| Seatbelt use | ||||||||||
| Always/almost always | 2733 (74.1) | 1004 (69.5) | 1729 (77.2) | 705 (67.0 | 568 (73.7) | 1155 (78.9) | 305 (76.2) | 1304 (94.2) | 635 (72.2) | 794 (55.9) |
| About half the time/rarely/never | 953 (25.9) | 441 (30.5) | 512 (22.8) | 347 (33.0) | 203 (26.3) | 308 (21.1) | 95 (23.8) | 81 (5.8) | 245 (27.8) | 627 (44.1) |
| Adhere to the speed limit | ||||||||||
| Always | 1405 (55.0) | 559 (54.6) | 846 (55.2) | 319 (43.9) | 313 (53.2) | 628 (60.8) | 145 (69.7) | 499 (49.4) | 418 (62.1) | 488 (56.0) |
| 5+ mph over | 1150 (45.0) | 464 (45.4) | 686 (44.8) | 407 (56.1) | 275 (46.8) | 405 (39.2) | 63 (30.3) | 512 (50.6) | 255 (37.9) | 383 (44.0) |
| Drive after drinking 1+ alcoholic beverages | ||||||||||
| Never | 3398 (94.1) | 1271 (91.2) | 2127 (95.9) | 925 (92.2) | 684 (92.6) | 1381 (95.2) | 408 (97.8) | 1271 (95.3) | 819 (94.9) | 1308 (92.5) |
| 1+ times | 212 (5.9) | 122 (8.8) | 90 (4.1) | 78 (7.8) | 55 (7.4) | 70 (4.8) | 9 (2.2) | 62 (4.7) | 44 (5.1) | 106 (7.5) |
| Ride after driver drinking 1 + alcoholic beverages | ||||||||||
| Never | 3270 (91.3) | 1249 (89.4) | 2021 (92.5) | 870 (87.9) | 663 (90.5) | 1333 (92.2) | 404 (97.8) | 1200 (90.9) | 773 (92.4) | 1297 (91.1) |
| 1+ times | 311 (8.7) | 148 (10.6) | 163 (7.5) | 120 (12.1) | 70 (9.5) | 112 (7.8) | 9 (2.2) | 120 (9.1) | 64 (7.6) | 127 (8.9) |
| Helmet use | ||||||||||
| Always/almost always | 485 (20.5) | 209 (19.0) | 276 (21.8) | 120 (14.9) | 130 (24.3) | 198 (23.5) | 37 (20.6) | 273 (37.9) | 142 (44.5) | 70 (5.3) |
| About half the time/rarely/never | 1879 (79.5) | 891 (81.0) | 988 (78.2) | 686 (85.1) | 404 (75.7) | 646 (76.5) | 143 (79.4) | 447 (62.1) | 177 (55.5) | 1255 (94.7) |
| PFD use | ||||||||||
| Always | 1476 (51.5) | 576 (45.2) | 900 (56.5) | 373 (42.0) | 290 (48.1) | 646 (58.6) | 167 (60.9) | 524 (64.0) | 323 (51.9) | 629 (44.1) |
| About half the time/rarely/never | 1392 (48.5) | 699 (54.8) | 693 (43.5) | 516 (58.0) | 313 (51.9) | 456 (41.4) | 107 (39.1) | 295 (36.0) | 299 (48.1) | 798 (55.9) |
Values are number (%).
P<0.05 for all comparisons except sex and adhering to the speed limit, and region and riding after driver drinking.
Of those participants who drive or ride in a vehicle, or use a boat.
Women were more likely than men to report engaging in all safety behaviours surveyed. Practice of all safety behaviours was lowest among the 18–29 year age group, and particularly low for adhering to the speed limit (43.9%) and helmet (14.9%) and PFD (42.0%) use. The most noticeable regional difference was in the use of helmets when riding off-road vehicles: in the southeast region, reported helmet use was 44.5%, in the southcentral region, it was 37.9%, but in the southwest region, which has the highest use of off-road vehicles, reported helmet use was only 5%.
Most participants reported engaging in multiple safety practices. The percentage reporting one or more safety behaviours was as follows: one (5.9%); two (23.6%); three (30.3%); four (23.9%); five (11.4%); and 2.7% reported all six safety behaviours. In univariate analyses, sex, age, region, education, marital status, employment status, income, language spoken at home and self-reported health status were all significantly associated with greater number of safety behaviours reported and were retained in the multivariate model. Except for sex and employment, the following factors were significant predictors of higher reporting of safety behaviours, after adjustment for all other factors: older age, greater educational attainment, married, higher household income, living in the southcentral region, speaking a Native language in the home, and self-reported health status of good to excellent (p<0.01) (table 3).
Table 3.
Multiple regression of demographic characteristics on reported safety behaviours among Alaskan Native and American Indian people living in Alaska
| Non-STD β |
SE | STD β |
95% CI | p Value | |
|---|---|---|---|---|---|
| Sex | |||||
| Male | −0.061 | 0.044 | −0.024 | −0.147 to 0.026 | 0.168 |
| Age (years) | 0.011 | 0.001 | 0.127 | 0.008 to 0.014 | <0.001 |
| Region (reference Southcentral) | |||||
| Southeast | −0.257 | 0.056 | −0.086 | −0.367 to −0.147 | <0.001 |
| Southwest | −0.659 | 0.053 | −0.256 | −0.764 to −0.555 | <0.001 |
| Education | 0.030 | 0.009 | 0.062 | 0.012 to 0.048 | 0.001 |
| Marital status | |||||
| Married/living as married | 0.163 | 0.046 | 0.064 | 0.072 to 0.253 | <0.001 |
| Employment status | |||||
| Employed or self-employed | 0.079 | 0.047 | 0.031 | −0.012 to 0.171 | 0.089 |
| Household income | 0.032 | 0.007 | 0.085 | 0.017 to 0.046 | <0.001 |
| Language spoken at home | |||||
| English only | −0.129 | 0.051 | −0.048 | −0.229 to −0.030 | 0.011 |
| Self-reported health status | |||||
| Excellent/very good/good | 0.159 | 0.049 | 0.054 | 0.062 to 0.255 | 0.001 |
Non-STD β, non-standardised regression coefficient; STD β, standardised regression coefficient; p value for linear trend, probability that the estimated coefficient of safety behaviours is different from zero.
Table 4 shows a comparison of EARTH Study self-reported data with BRFSS data obtained by phone survey. Comparison data were available for all safety behaviours queried except for adhering to the speed limit. The EARTH Study found lower self-reported rates than either Alaskan Native or non-Native respondents to the Alaska BRFSS. The sole exception was PFD use, for which EARTH respondents were more likely to report always or almost always using a PFD than BRFSS survey respondents. Questions about riding in a vehicle after the driver was drinking, helmet use and PFD use had not been asked in the BRFSS since 1993.
Table 4.
Self-reported safety behaviour of Alaska EARTH Study participants compared with Alaska BRFSS respondents
| Alaska EARTH Study data | Alaskan Native unweighted BRFSS data | Alaskan non-Native unweighted BRFSS data | |
|---|---|---|---|
| Seatbelt use | |||
| Always/almost always | 2733 (74.1) | 272 (79.6, 73.8 to 84.3)† | 1521 (91.9, 89.9 to 93.6)† |
| About half the time/rarely/never | 953 (25.9) | 83 (20.4, 15.7 to 26.2)† | 146 (8.1, 6.4 to 10.1)† |
| Adhere to the speed limit | |||
| Always | 1405 (55.0) | Not Available | Not Available |
| 5+ mph over | 1150 (45.0) | ||
| Drive after drinking | |||
| Never | 3398 (94.1) | 138 (96.8, 91.6 to 98.9)† | 970 (95.0, 92.4 to 96.8.2)† |
| 1+ times | 212 (5.9) | 5 (3.2, 1.1 to 8.4)† | 34 (5.0, 3.2 to 7.6)† |
| Ride after driver drinking | |||
| Never | 3270 (91.3) | 308 (95.6, 92.2 to 97.6)* | 1148 (95.2, 93.0 to 96.7)* |
| 1+ times | 311 (8.7) | 15 (4.4, 2.4 to 7.8)* | 40 (4.8, 3.3 to 7.0)* |
| Helmet use | |||
| Always/almost always | 485 (20.5) | 25 (41.4, 26.4 to 58.2)* | 192 (68.1, 61.1 to 74.3)* |
| About half the time/rarely/never | 1879 (79.5) | 51 (58.6, 41.8 to 73.6)* | 140 (31.9, 25.7 to 38.9)* |
| PFD use | |||
| Always/almost always | 1476 (51.5) | 73 (40.6, 31.4 to 50.6)* | 539 (66.8, 62.0 to 71.2)* |
| About half the time/rarely/never | 1392 (48.5) | 136 (59.4, 49.4 to 68.6)* | 311 (33.2, 28.8 to 38.0)* |
Values are number (%) or number (%, 95% CI).
1993 BRFSS Survey.
2006 BRFSS Survey.
BRFSS, Behavioral Risk Factor Surveillance System; EARTH, Education and Research Towards Health; PFD, personal flotation device.
DISCUSSION
The EARTH Study is the largest exploration of safety behaviours associated with unintentional injuries among Alaskan Native people to date. The only other large-scale dataset available on this topic comes from the BRFSS, which only queries a small percentage of Alaskan Native respondents each year. The speed limit adherence question has never been asked before, and riding in a vehicle after the driver has been drinking and PFD and helmet use have not been queried on the Alaska BRFSS since 1993. These study data also offer a new way to identify at-risk groups. Current health promotion efforts use injury hospitalisation data as a resource to design injury prevention efforts. The EARTH Study provides direct data on safety behaviours instead of relying on death and hospitalisation outcomes.
The major strengths of this study are the size of the cohort and geographical diversity, comprising three regions of Alaska. A limitation of this study is the non-random sampling design. Although the cohort was not randomly selected, the distribution of the study population closely resembled the demographic distributions (except for sex) reported by the 2000 US census for AN/AI in the respective regions.18 A potential source of measurement error is that all data were collected by self-report versus direct observation. However, data were collected in a highly confidential manner by computer-assisted self-interview, which make the responses less likely to be subject to social desirability bias. Lastly, we report here cross-sectional data from an initial study visit. These data allow descriptive reporting but not evaluation of causal relationships between variables. These data on safety behaviours provide a baseline, and it is hoped that longitudinal follow-up of this cohort will help to provide more information on the predictors of safety behaviours, as well as associations with health outcomes in the future.
EARTH Study self-reported safety behaviour data were generally lower than those reported by Alaskan Native people in the Alaska BRFSS. These variations may suggest some regional disparity in these safety practices or a difference in responses based on interviewer-administered phone survey (BRFSS) as compared with a computer-assisted self-interview. Alaskan Native people also tend to be under-represented in the BRFSS (n = 464 in 2006), whereas the EARTH Study surveyed almost 4000 Alaskan Native adults. The BRFSS also included Alaskan Native people from all regions of Alaska, whereas the EARTH Study only surveyed Alaskan Native people in three regions of the state. In both surveys, more women than men participated.
Although this study found a high frequency of use of off-road vehicles, helmet use while riding off-road vehicles was the least commonly practised safety behaviour in all three regions. In the southwest, where these vehicles are most commonly used, only one in 20 participants reported always/almost always wearing a helmet. A 2006 State of Alaska observational study of snowmobile riders showed that helmet usage rates for those riding a snowmobile in a southwest Alaskan town was similar to that found in this analysis; only 3% of adults observed were wearing a helmet.19 Encouragingly, teen helmet usage rates were much higher; 40% of teens observed riding a snowmobile were wearing a helmet.
Regression analyses of EARTH study data show that multiple factors are associated with the likelihood of practising safety behaviours including older age and greater educational attainment. A lower income level was also associated with practising fewer safety behaviours. Safety products such as PFDs and snowmobile helmets can be costly and may not be viewed as a priority. Some tribal health organisations with injury prevention programmes make these products available to their regional residents, at cost, to encourage their purchase and use. Further expansion of these programmes may help to increase the number of Alaskan Native people practising safe behaviours. One study conducted in predominantly Alaskan Native communities in northwest Alaska showed that increased availability and education was successful in increasing helmet use.20
As recommended by the Australian Injury Prevention Network for work within indigenous communities, any injury prevention strategy to address safer behaviours will need to be built on partnerships and collaborations at the local level.21 Some Alaskan Native villages have local safety ordinances, such as adult PFD laws and curfews for minors driving off-road vehicles. There is currently no state-wide off-road vehicle helmet law in Alaska, although the law requires that all children under the age of 13 wear a PFD while boating. The enactment and diligent enforcement of helmet and PFD laws, along with subsidising helmets and educational campaigns to change social norms, may lead to increased use of these safety devices and reduced injury rates among Alaskan Native people. Our data show that the youngest age group analysed, 18–29 year olds, were the least likely of any age group to practise safety behaviours. Injury prevention efforts for this age group may need to take into consideration that safe practices in general are less likely to be used. A culturally appropriate educational campaign focusing on the lack of use of safety behaviours and how injuries affect families and the community may lead to safer behaviours. Focus group discussions in communities may also lead to a better understanding of the motivations for safety behaviours. Limited prevention resources should be used to target those who engage in risky behaviours to maximise programme impact.
Key points.
Unintentional injuries are the third leading cause of death of Alaskan Native (AN) people, and the unintentional injury rate for AN people is currently twice that of all Alaskans and three times greater than the overall rate among the US population.
The leading causes of AN unintentional injury death were drowning (20%) and motor vehicle (19%) and off-road vehicle (11%) use.
The use of safety devices, such as personal flotation devices (PFDs), seatbelts and helmets, may help to reduce the rates of hospitalisation, severity of injury and deaths due to injury among AN people.
This study is the largest exploration to date of safety behaviours (PFD use, seatbelt use, helmet use and motor vehicle safety behaviours) among AN and American Indian people living in urban and rural regions of Alaska.
Factors identified among those least likely to use safety devices and practise good safety behaviours are: younger age, lower household income and education, speaking only English at home, and a self-reported health status of poor to fair (p<0.05).
Acknowledgements:
This study was funded by grants CA88958 and CA96095 from the National Cancer Institute. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the National Cancer Institute or the Indian Health Service. We acknowledge the contributions and support of the Indian Health Service, the Alaskan Native Tribal Health Consortium Board of Directors, Southcentral Foundation (SCF), Southeast Alaska Regional Health Consortium (SEARHC), the Yukon-Kuskokwim Health Corporation (YKHC), and Tribal Advisory Board Members.
Footnotes
Competing interests: None.
Ethics approval: Obtained.
Patient consent: Obtained.
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