Barriers to Children Walking and Biking to School—United States, 1999

Physical activity is an important part of a healthy lifestyle; however, many children in the United States do not meet recommended levels of physical activity. Although walking and biking to school can increase physical activity among children, motor-vehicle traffic and other factors can make these activities difficult. The majority of U.S. children do not walk or bike to school, approximately one third ride a school bus, and half are driven in a private vehicle. Less than one trip in seven is made by walking or biking. To examine why the majority of children do not walk or bike to school, CDC analyzed data from the national HealthStyles Survey. This report summarizes the results of that analysis, which indicate that long distances and dangerous motor-vehicle traffic pose the most common barriers to children walking and biking to school. Public health and community-based efforts that encourage walking and biking to school should address these barriers.

PHYSICAL ACTIVITY IS AN IMPORTANT PART of a healthy lifestyle; however, many children in the United States do not meet recommended levels of physical activity. 1 Although walking and biking to school can increase physical activity among children, motor-vehicle traffic and other factors can make these activities difficult. The majority of U.S. children do not walk or bike to school, approximately one third ride a school bus, and half are driven in a private vehicle. Less than one trip in seven is made by walking or biking. 2 To examine why the majority of children do not walk or bike to school, CDC analyzed data from the national HealthStyles Survey. This report summarizes the results of that analysis, which indicate that long distances and dangerous motor-vehicle traffic pose the most common barriers to children walking and biking to school. Public health and community-based efforts that encourage walking and biking to school should address these barriers.
CDC provides technical assistance to Porter/Novelli (Washington, D.C.) in conducting the HealthStyles Survey, an annual mail survey of health-related attitudes and behaviors in the United States. In 1999, investigators solicited 3,550 households that had previously indicated a willingness to respond to survey questions. This sample was selected as representative of the U.S. population on the basis of eight demographic variables: age, sex, marital status, race/ethnicity, income, region, household size, and population density. A total of 2,636 (74%) house-holds responded; the 749 (28%) households with children aged 5-18 years were asked (1) if their youngest child walked or biked to school at least once a week during the preceding month, and (2) whether any of six specified conditions made it difficult to do so: traffic danger, crime danger, long distances, weather, opposing school policy, or other reasons. Respondents also had the option of stating that their children had no barriers to walking or biking to school. Results were weighted to match population distribution in the United States by using the eight demographic variables.
Of the 611 respondents, 19% reported children walking and 6% reported children biking to or from school at least once a week during the preceding month. Frequency of walking and biking trips ranged from zero to Ͼ10 times a week (mean frequency: six oneway trips a week). These trips represented 14% of all school trips (11% walking and 3% biking). The proportions of primary school-aged children walking (18.6%) and biking (5.7%) to school were similar to those of secondary school-aged children walking (19.6%) and biking (5.7%) to school.
Of the 16% of respondents who reported no barriers, 64% reported children walking, and 21% reported children biking to or from school at least once a week during the preceding month. Children with no barriers were six times more likely to walk or bike to school than the rest of their peers aged 5-18 years with one or more barriers.
A total of 66% of the children were primary school-aged (aged 5-11 years); 34% were secondary school-aged (aged 12-18 years). Reported barriers for primary school-aged children were compared with those for secondary schoolaged children. Proportions were similar for distance, weather, opposing school policy, and other reasons. The proportion of respondents reporting no barriers to their children walking or biking to school was the same for both age groups. However, primary schoolaged children reportedly faced barriers of traffic danger and crime danger significantly more than their older peers.

CDC Editorial Note:
To increase physical activity among children, two of the national health objectives for 2010 are to increase the proportion of trips to school made by walking and biking (objectives 22-14,15). 3 The median distance to school from a child's residence is relatively long (2 miles for children aged 5-15 years); however, many children do not walk or bike to school even when distances are short. For children living Յ1 mile from school, only 31% of trips are made by walking, and for children living Յ2 miles from school, only 2% of trips are made by biking. 3 Results from the HealthStyles Survey indicate that approximately two thirds of children walk or bike to school when barriers are not present; however, the majority of parents report that their children face barriers to walking and biking to school. Substantial resources, diverse expertise, and ongoing political commitment are required to address the two most important barriers: long distances and traffic danger.
Traffic danger inhibited approximately 40% of children from walking or biking to school. When extrapo-lated to the U.S. population, these findings indicate that perceived traffic danger prevents approximately 20 million children from walking or biking to school. 4 Additional data indicate that perceived traffic danger is an understandable concern. Although U.S. children aged 5-18 years walk relatively little and bike even less, approximately 550 pedestrian deaths and 250 cyclist deaths occur annually among this population, 5 and approximately 100 nonfatal injuries occur for each death. 6 The findings in this report are subject to at least two limitations. First, the HealthStyles Survey solicits a population identified by its willingness to participate in survey research. Second, approximately 18% of respondents with children did not respond to questions about walking and biking to school. This pool of respondents might not represent the overall attitudes and behaviors of U.S. households.
Improving traffic safety is crucial for programs that encourage children to walk or bike to school. To advance local pedestrian and cyclist safety initiatives, CDC research and surveillance data have been used to (1) formulate guidelines for age-appropriate childpedestrian supervision, 7 (2) support bicycle-helmet promotion, and (3) outline national strategies for advancing both child-pedestrian and bicycle safety. 8,9 Many U.S. communities are facilitating walking and biking to school by addressing traffic safety concerns, mapping safe routes to local schools, building new schools in residential neighborhoods, and involving parents in programs such as Walking School Bus, Bike Trains, and Walk to School Day. The Marin County Safe Routes to School program in California is an ongoing effort developed by the Marin County Bicycle Coalition, funded by the National Highway Traffic Safety Administration and other state and local sources, and assisted by numerous parent volunteers. The Marin County program reported a 57% increase in walking and biking to school in its first year. 10 Efforts focused on creating safe and accessible routes for children walking and biking to school promise the additional benefit of producing neighborhoods that ensure safer walking and biking for all ages.
Additional information about programs and resources for promoting safe walking and biking to school is available at the following websites:  [1][2][3] Two important strategies to reduce HIV transmission among young BMSM are to increase the proportion of men who are aware of their HIV infection and to increase the consistent use of condoms among sexually active men. 4,5 However, limited information is available to help develop HIV-testing and condompromotion programs for young BMSM. To address this need, data from CDC's Young Men's Survey (YMS) were used to evaluate the prevalence of unrecognized HIV infection, barriers to testing, and reasons for nonuse of condoms among BMSM aged 15-22 years. This report summarizes the results of the survey, which indicated that of the 16% of young BMSM participants who were infected with HIV, nearly all were unaware of their infection. Few young BMSM reported testing frequently for HIV, and many reported engaging in behaviors that could transmit HIV because they perceived themselves or their partners to be at low risk for infection. These findings underscore the urgency of expanding and improving prevention efforts for young BMSM by increasing the demand for and availability of HIV-testing services and by providing high-quality prevention counseling that includes assessment and clarification of perceived risks for infection.

FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION
YMS was a cross-sectional survey conducted during 1994-1998 of males aged 15-22 years who attended MSMidentified venues (e.g., shopping areas, dance clubs, bars, and organizations) in Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida; New York, New York; the San Francisco Bay Area, California; and Seattle, Washington. 1 Extensive formative research was conducted to construct monthly sampling frames of the days, times, and venues attended by young BMSM. Each month, 12-16 venues and their associated day/time periods were selected randomly and scheduled for sampling. During sampling events, men were approached consecutively to assess their survey eligibility. BMSM eligible for the survey were aged 15-22 years and residents in one or more local counties. Participants were interviewed by using a standard questionnaire, had blood drawn for HIV testing, were given appointments to obtain test results, and were provided HIV-prevention counseling and referral for care when needed.
Specimens were tested for HIV at local laboratories with standard assays. Analyses were restricted to men who reported ever having sex with men and who described their racial background as either being only black or having a mixed background that included being black. Analyses excluded records of duplicate participants, who were identified by using the Miragen antibody profile assay. 6 Records also were excluded from Seattle because few BMSM had participated in that city.
During the 6 months preceding the survey, the 920 BMSM reported a median of two male sex partners (interquartile range: one to three), 712 (77%) reported having anal intercourse with another man, and 342 (37%) reported having unprotected anal intercourse (UAI). Of the 79 BMSM with unrecognized HIV infection who had UAI, 41 (52%) reported not using condoms for one or more of the following reasons: they "knew" they were HIV-negative (24%), they "knew" their partners were HIVnegative (20%), or they thought their partners were at low risk for infection (35%); 34 (43%) also reported not using condoms because none were available.
Of the 920 BMSM, 585 (64%) had ever tested previously for HIV, but few had tested frequently (median number of tests: one; interquartile range: zero to two). Of those who had tested previously, 536 (92%) reported last testing HIV-negative, and of these, 87 (16%) were found to be infected with HIV. The 332 (36%) men who had not tested previously gave the following reasons for not testing (more than one reason could be given): low risk for infection (45%), fear of learning their results (41%), and fear of needles (21%). Of those who had not tested previously, 42 (13%) were HIV-infected. Of the 148 men who had not tested previously because of perceived low risk, 122 (82%) ever had anal intercourse with a man, 99 (67%) had at least three lifetime male partners, and 11 (7%) were HIV-infected.
Compared with their noninfected peers, young BMSM with unrecognized infection were more likely to report engaging in UAI and not testing previously because of fear about learning their results. Noninfected young BMSM were more likely to perceive themselves at low risk for infection and not to have tested previously because of this perception. CDC Editorial Note: The findings in this report are consistent with previous studies suggesting that in several U.S. cities, the majority of young HIVinfected MSM, particularly BMSM, were unaware of their infection. 1,7 In a preliminary analysis of 573 HIV-infected MSM aged 16-29 years sampled in six U.S. cities, proportionally more BMSM were unaware of their infection than were white MSM (91% versus 60%). 7 However, among all young MSM with unrecognized HIV infection, no racial or ethnic differences were observed among those perceiving themselves at low risk for being infected (66%), engaging in UAI (54%), or not using condoms during anal intercourse because of perceived low personal or partner risks for HIV infection (46%). 7 These findings underscore the urgency of improving HIV-prevention efforts for all young MSM by (1) increasing the demand for and availability of HIVtesting services and (2) providing young MSM with high-quality HIV-and STDprevention services that include assessment and clarification of personal risks for infection.
In accordance with recently revised guidelines, health-care providers should assess the HIV risks of their patients routinely and encourage all MSM at risk for HIV to test at least annually. 8,9 Findings from this report indicate that demand for testing by young BMSM might be increased by implementing efforts that increase personal risk perceptions; addressing concerns about testing positive by conveying the benefits of early diagnosis and HIV care; and marketing the availability of oral fluid, urine-based, or finger-stick HIV tests that do not require venipuncture. 9 Use of testing services also might be increased by offering testing in nonclini- cal settings that serve or are attended by young BMSM and by providing highquality partner referral services for all those who test positive. 5,9 HIV testing should be accompanied by high-quality prevention counseling that includes an in-depth personalized risk assessment, clarification of risk perceptions, and negotiation of steps to reduce risks. 9 Because 16% of young BMSM who reported being HIV-negative were found to be HIVinfected, providers should encourage young BMSM to use condoms consistently with all partners, including those who have tested negative previously. In negotiating risk reduction with young BMSM, providers should be prepared to address alcohol, drug, and partner influences on condom use and to help young BMSM cope with emotional responses in high-risk situations. Providers should refer clients who have difficulty in initiating or sustaining safer behavior for more intensive individualized prevention counseling and support services. 9,10 Finally, managers of prevention programs should consider increasing the availability of condoms in settings where young BMSM are likely to encounter sex partners.
The findings in this report are subject to at least three limitations. First, findings might not be applicable to young BMSM who do not attend MSMidentified venues or reside in the six participating cities. Second, because approximately 39% of eligible young BMSM chose not to participate, selective nonparticipation could have biased reported findings. Finally, data were collected during face-to-face interviews and are subject to disclosure biases. The finding that nearly all HIVinfected young BMSM in this survey were unaware of their infection might be attributed, in part, to one or more of these biases. However, a high proportion of young BMSM who are unaware of their infection is likely given the high HIV incidence and low frequency of testing among young BMSM. 2 In partnership with state and local health departments, nongovernment organizations, community stakehold-ers, and other federal agencies, CDC is taking steps to reduce HIV transmission and unrecognized infection among young MSM, particularly BMSM. Since September 2001, five national consultations have helped identify current prevention needs of MSM, including young minority MSM. In 2001, additional resources were made available to expand HIV counseling and testing, outreach services, and behavioral riskreduction interventions for young minority MSM. Ongoing prevention efforts also are being strengthened through capacity development for minority community-based organizations serving young MSM, and through recently released guidelines calling for expanded risk assessment and HIV testing for homosexual and bisexual men. 8,9 Finally, new research efforts, including rapid ethnographic assessments, have been initiated to identify additional factors that influence HIVacquisition risks among young minority MSM. These and similar efforts signal the increased priority at national, state, and local levels to reduce the considerable racial disparities in HIV morbidity and unrecognized infection among young MSM.