Children Wearing Bicycle Helmets Influenced by Their Parents’ Safety Perception as Adults and Children

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The study tackles a significant public health concern: Saudi Arabian children's use of bicycle helmets. It offers useful information on the attitudes of parents, the frequency of helmet use, and the variables affecting parental choices. Despite the importance of the subject, the paper has a few shortcomings that should be removed to improve its scientific rigor and applicability.

Areas of improvement;

1. Convenience and snowball sampling, two non-probability sampling techniques, are used, which may add bias and restrict how broadly the results may be applied.

2. Social media and public spaces like toy stores may draw a disproportionate number of parents who are concerned about safety, which could inflate the stated helmet use rates.

3. Regression models ignore potential interactions between variables, such as socioeconomic or regional disparities, and instead concentrate on a small number of predictors.

4. There is insufficient discussion of certain findings that contradict the body of current knowledge, such as the absence of correlation between helmet use and socioeconomic position.

5. Although there are many tables, they don't provide readers with clear explanations or visual aids to assist them rapidly understand the main conclusions. Clarity and reader engagement would be improved by a condensed presentation backed by understandable graphics.

6. The conclusions are restated in the discussion section without critically addressing the limitations or conflicting findings from related studies conducted in different regions. To put the results in context, compare them more closely with research conducted globally.

7. The possible impact of Saudi Arabian-specific cultural and legal elements is not adequately discussed by the authors. In order to address potential cultural or contextual factors specific to Saudi Arabia, a more thorough investigation is necessary given the lack of significant relationships (e.g., socioeconomic level and helmet wearing).

8. The introduction section lacks statistics about the cycle usage in Saudi Arabia and cycle related injury statistics as well.

 

Author Response

1. Convenience and snowball sampling, two non-probability sampling techniques, are used, which may add bias and restrict how broadly the results may be applied.

Reply 1:

Thank you for your insightful comments regarding our methodological approach. We appreciate your recognition of the strengths of our study, as well as your constructive suggestions for improvement.

We would like to clarify that we have acknowledged the limitation related to our use of convenience sampling in our manuscript (page no. 24, lines 846-853). The reliance on convenience sampling may have introduced selection bias, potentially limiting the generalizability of the findings. We have expanded on this point further on page no. 25, lines 855-870, where we discuss how this sampling method may affect the representativeness of our findings and consider demographic and geographic factors that could influence helmet use. This expanded discussion aims to provide a clearer understanding of the potential biases associated with our sample and the implications for interpreting our results.

However, to mitigate this bias and enhance the robustness of our findings, we adjusted for potential confounding variables, including socioeconomic status and educational attainment, which are known to influence helmet use behaviors (table 10 and limitations on page no. 25, lines 872- 878).

2. Social media and public spaces like toy stores may draw a disproportionate number of parents who are concerned about safety, which could inflate the stated helmet use rates.

Reply 2:

Thank you for your insightful comment regarding the potential selection bias in our study due to recruiting participants from social media and public spaces like toy stores. We acknowledge that our recruitment strategy might have attracted a disproportionate number of parents particularly concerned about safety, which could indeed influence the reported rates of helmet use. This concern was addressed in our methodology section on page no. 5 and 6, lines 201- 203, where we highlighted the potential for selection bias inherent in our approach.

Given the constraints we faced in terms of resources and time, expanding the sample size by alternative means was not feasible for this study. However, we recognize the importance of ensuring representative sample groups and have addressed this limitation in limitations section no. 25, lines 855- 870. Additionally, to mitigate this bias and enhance the robustness of our findings, we made adjustments for potential confounding variables, including socioeconomic status and educational attainment, which are known to influence helmet use behavior (table 10 and limitations on page no. 25, lines 872- 878). Thus, we emphasized the need for future studies to include a more diverse range of recruitment strategies to capture a broader and more varied demographic profile.

 

3. Regression models ignore potential interactions between variables, such as socioeconomic or regional disparities, and instead concentrate on a small number of predictors.

Reply 3:

Thank you for your insightful feedback regarding the use of regression models in our analysis. We appreciate your suggestion, as it highlights an opportunity for expansion in our subsequent research endeavors.

We would like to emphasize that the analytical approach utilized in this study has been carefully selected to effectively address the primary research questions set forth in the paper. By concentrating on a limited number of predictors, we aimed to present the central findings in a clear and concise manner, avoiding the introduction of unnecessary complexity that could detract from our main objectives.

While we acknowledge the importance of examining interactions among variables, we note that such analyses can certainly be performed in a cross-sectional study, albeit with limitations regarding causal inference. Compared to cohort studies, which provide a more robust framework for exploring these interactions over time, cross-sectional studies allow for the investigation of relationships at a single point in time. Nonetheless, we will consider incorporating a thorough examination of interactions in our future cohort study, where a more in-depth understanding can be achieved.

 

4. There is insufficient discussion of certain findings that contradict the body of current knowledge, such as the absence of correlation between helmet use and socioeconomic position.

Reply 4:

Thank you for highlighting this important aspect. We have added a discussion on the relationship between socioeconomic status and helmet use on page no. 18-19, lines 534- 551. Additionally, we have linked our findings to broader public health policy implications in Saudi Arabia, as detailed on page no. 22, lines 715- 727.

 

5. Although there are many tables, they don't provide readers with clear explanations or visual aids to assist them rapidly understand the main conclusions. Clarity and reader engagement would be improved by a condensed presentation backed by understandable graphics.

Reply 5:

Thank you for your valuable feedback regarding the presentation of our data. We appreciate your suggestion to enhance clarity and reader engagement through the use of visual aids.

While we acknowledge that the tables contain complex information, we believe they serve an essential role in conveying the detailed findings that are critical to understanding our study. The intricacies of the data require a level of detail that may not be easily translated into simplified graphics without losing important contextual information. However, we do present the methodology in a flowchart (Figure 1. on page no. 5, lines181-182), which visually summarizes the process and enhances understanding.

Nevertheless, we recognize the importance of making our findings more accessible to readers. Therefore, we replace table 6 with a bar chart (Figure 2. on page no.13, lines 396- 399) as a visual aid that highlights the most significant trends and outcomes from the tables. We aim to strike a balance between maintaining the necessary detail and enhancing overall readability and engagement.

 

6. The conclusions are restated in the discussion section without critically addressing the limitations or conflicting findings from related studies conducted in different regions. To put the results in context, compare them more closely with research conducted globally.

Reply 6:

Thank you for your insightful feedback regarding the conclusions presented in the discussion section. We have revised the discussion section to provide a more nuanced examination of the limitations inherent in our study (page no. 25, lines 882- 905), as well as a comprehensive comparison with relevant research conducted globally. This includes addressing discrepancies in findings from studies in different contexts and regions, which allows for a more thorough framing of our results (page no. 25, lines 882- 895).

Thank you for your insightful comments. We have substantially revised the discussion section to directly address your concerns.  Specifically, we now:

 

Explicitly address the study's limitations: The revised discussion now explicitly acknowledges the limitations of our cross-sectional design and convenience sampling, acknowledging the potential for selection bias and the consequent impact on generalizability (as detailed on pages no. 25-26, lines 837- 881).  We explain how these limitations might affect the interpretation of our findings and their applicability to other populations.

Integrate a comprehensive comparison with global research:  We have expanded the discussion to incorporate a more detailed comparison of our findings on helmet use prevalence (approximately 60% in our study) with those reported in other studies from various regions (e.g., the United States, where rates are much lower). This comparison is now included page no. 25, lines 882- 905, highlighting both similarities and discrepancies, and exploring potential underlying reasons for differences, such as cultural norms and public health policies page no. 25, lines 882- 895.

Move beyond simple restatement of conclusions:  The revised discussion no longer simply restates the conclusions but critically analyzes the results within the context of the broader literature, acknowledging any conflicting findings and offering potential explanations.  This enhanced analysis is specifically on page no. 25, lines 882- 895.

 

7. The possible impact of Saudi Arabian-specific cultural and legal elements is not adequately discussed by the authors. In order to address potential cultural or contextual factors specific to Saudi Arabia, a more thorough investigation is necessary given the lack of significant relationships (e.g., socioeconomic level and helmet wearing).

Reply 7:

Thank you for highlighting this important aspect. Various statistical tools were used to evaluate associations between parental attitudes, sociodemographic characteristics, and helmet use.

Nevertheless, we have added a discussion on the relationship between socioeconomic status and helmet use on page no. 18-19, lines 516- 551 and on page no. 21, lines 658- 663. Additionally, we have linked our findings to broader public health policy implications in Saudi Arabia, as detailed on page 21-22, lines 669- 727.

 

8. The introduction section lacks statistics about the cycle usage in Saudi Arabia and cycle related injury statistics as well.

Reply 8:

Thank you for your valuable feedback concerning the introduction section of our manuscript.

We understand the importance of providing a strong statistical basis for the context of our study. Prior to writing this manuscript, we conducted a thorough search of readily available official websites for statistics on bicycle use and cycling-related injuries in Saudi Arabia, including those maintained by relevant government ministries and health organizations. Unfortunately, despite our diligent efforts, we were unable to locate such comprehensive data. This absence of readily accessible, publicly available statistics highlights a significant gap in data collection concerning cycling safety in the country, which emphasizes the importance of our study.

To address this, we have added a revised statement in the introduction (page no. 2, lines 55- 61) to reflect the challenges encountered in accessing these statistics and to further emphasize the critical need for more comprehensive data collection in this area to inform future policy development and interventions.

 

Reviewer 2 Report

Comments and Suggestions for Authors

This study is about assessing the prevalence of bicycle helmet use among children between 5 to 17 years in Saudi Arabia, parents’ attitudes and safety perception toward children’s bicycle helmets, and factors that influence parents’ decisions regarding their children’s bicycle helmets. The authors used an analytical cross-sectional design via a validated questionnaire. The study from September 2023 to September 2024, involved 492 participants recruited from all regions of Saudi Arabia. A validated, translated questionnaire assessed helmet usage attitudes, considering demographic factors, and potential confounders. The paper is written with care and the structure seems nice. However, there are some issues that need to be thoroughly addressed to for the paper clarity and improvement.

1.      Authors should consider clearly stated the main motivations and contributions in the introduction section and emphasized it throughout the manuscript.

2.      Authors should consider presenting the flowchart of their methodology.

3.      Adding a sperate section related to the literature section by adding more studies.

4.      The discussion section is presented with care. However, I advised authors to add the managerial implications related to their study.

5.      Authors should consider move the limitations of their study from discussions to the conclusion part.

6.      Authors should consider presenting more key points related to future studies in the conclusion part.

7.      Check and correct the grammatical errors and typo throughout the manuscript.

8.      Also, check the English writing style through the manuscript and correct it accordingly.

Comments on the Quality of English Language

The English should be checked and improved

Author Response

 

1. Authors should consider clearly stated the main motivations and contributions in the introduction section and emphasized it throughout the manuscript. 

Reply 1:

Thank you for your comment. We revised the manuscript to clearly state the main motivations and contributions in the introduction section (page no. 2, lines 55-61 and page no. 4, lines 147- 172), and ensured these elements were emphasized throughout the manuscript.

 

2. Authors should consider presenting the flowchart of their methodology.

Reply 2:

Thank you for your comment. We present the methodology in flowchart (Figure 1, page no.5, lines 181-182).

 

3. Adding a separate section related to the literature section by adding more studies.

Reply 3:

Thank you for your insightful feedback on our manuscript. We appreciate your suggestion to better articulate the uniqueness of the context regarding helmet use in children within Saudi Arabia.

 

It is important to note that there is a significant gap in the literature concerning helmet use among children in Saudi Arabia. While helmet use has been widely studied in various contexts globally, research specifically addressing this issue within the Saudi Arabian population remains limited (this information was added on page no. 2, lines 55- 61). This lack of data hinders our understanding of the prevalence, attitudes, and behavioral factors influencing helmet use among children in the region.

 

By adding a comparative dimension, we aim to highlight the differences in helmet use practices and policies between Saudi Arabia and other countries where helmet use among children is more established and documented. This will further elucidate the cultural, environmental, and policy-related factors that may contribute to the observed gaps in helmet use, emphasizing the necessity for targeted interventions in this context.

The introduction was revised to include these points, thereby strengthening the rationale behind our study (page no. 2-4). (this information was added on page no. 2, lines 55- 61).

 

4. The discussion section is presented with care. However, I advised authors to add the managerial implications related to their study.

Reply 4:

Thank you for your comment. We expand on managerial implications and actionable recommendations based on the findings (page no. 21- 22, lines 669- 727).

 

5. Authors should consider move the limitations of their study from discussions to the conclusion part.

Reply 5:

Thank you for your comment. We moved the limitations to the conclusion section (page no. 24-25, lines 837- 881).

 

6. Authors should consider presenting more key points related to future studies in the conclusion part.

Reply 6:

Thank you for your comment. The conclusion part was updated with the key points related to future studies on page no. 25- 26, lines 890- 918.

 

7. Check and correct the grammatical errors and typo throughout the manuscript.

Reply 7:

Thank you for your comment. The manuscript was revised and edited by MDPI Author Services (please find attached editing certificate).

 

8. Also, check the English writing style through the manuscript and correct it accordingly.

Reply 8:

Thank you for your comment. The manuscript was revised and edited by MDPI Author Services (please find attached editing certificate).

Reviewer 3 Report

Comments and Suggestions for Authors

1. The introduction part could be helpful to articulate what is uniquely lacking in the context of Saudi Arabia. Adding a comparative dimension could strengthen the rationale for conducting this research.

2. The methodological approach is good; however, the use of convenience sampling raises concerns about representativeness. While the justification for this method is given, consider discussing how the potential bias could affect the generalizability of findings. Additionally, the questionnaire validation process is rigorous but could be expanded with more details on how cultural nuances were integrated into the adaptation of the survey instrument.

3. The results are comprehensive, but some sections lack clarity in connecting findings to the study objectives. For example, the relationship between socioeconomic status and helmet use contradicts previous research. Expanding on possible reasons for this disparity and its implications for public health policy in Saudi Arabia would add depth.

4. The discussion effectively interprets results but occasionally lacks depth in linking findings to broader implications. For instance, the study emphasizes parental modeling as a strong predictor of helmet use but does not explore specific interventions or campaigns that could leverage this insight. Expanding on actionable recommendations would enhance the practical value of the study.

Comments on the Quality of English Language

The quality of English is generally good, with clear and precise language used throughout the manuscript. However, there are occasional issues with sentence structure and redundancy that could benefit from revision to improve readability and flow. Minor grammatical errors and overly complex sentences in the discussion section should also be addressed for better clarity.

Author Response

1. The introduction part could be helpful to articulate what is uniquely lacking in the context of Saudi Arabia. Adding a comparative dimension could strengthen the rationale for conducting this research.

Reply 1:

Thank you for your insightful feedback on our manuscript. We appreciate your suggestion to better articulate the uniqueness of the context regarding helmet use in children within Saudi Arabia.

It is important to note that there is a significant gap in the literature concerning helmet use among children in Saudi Arabia. While helmet use has been widely studied in various contexts globally, research specifically addressing this issue within the Saudi Arabian population remains limited. This lack of data hinders our understanding of the prevalence, attitudes, and behavioral factors influencing helmet use among children in the region (this information was added on page no. 2, lines 55- 61).

 

By adding a comparative dimension, we aim to highlight the differences in helmet use practices and policies between Saudi Arabia and other countries where helmet use among children is more established and documented. This will further elucidate the cultural, environmental, and policy-related factors that may contribute to the observed gaps in helmet use, emphasizing the necessity for targeted interventions in this context. The introduction was revised to include these points, thereby strengthening the rationale behind our study (page no. 2-4).

 

2. The methodological approach is good; however, the use of convenience sampling raises concerns about representativeness. While the justification for this method is given, consider discussing how the potential bias could affect the generalizability of findings. Additionally, the questionnaire validation process is rigorous but could be expanded with more details on how cultural nuances were integrated into the adaptation of the survey instrument.

Reply 2:

Thank you for your insightful comments regarding our methodological approach. We appreciate your recognition of the strengths of our study, as well as your constructive suggestions for improvement.

We would like to clarify that we have acknowledged the limitation related to our use of convenience sampling in our manuscript (page no. 24, lines 846-853). The reliance on convenience sampling may have introduced selection bias, potentially limiting the generalizability of the findings. We have expanded on this point further on page no. 25, lines 855-87, where we discuss how this sampling method may affect the representativeness of our findings and consider demographic and geographic factors that could influence helmet use. This expanded discussion aims to provide a clearer understanding of the potential biases associated with our sample and the implications for interpreting our results.

However, to mitigate this bias and enhance the robustness of our findings, we adjusted for potential confounding variables, including socioeconomic status and educational attainment, which are known to influence helmet use behaviors (table 10 and limitations on page no. 25, lines 872- 878).

Additionally, we recognize the importance of integrating cultural nuances into our questionnaire validation process. We have taken specific steps to ensure that the survey instrument is culturally relevant and appropriate for our target population, as explained in the figure 1 and methodology section on page 5, lines 182- 195. In this section, we detail our adaptation and validation process, which included a thorough translation of the questionnaire into Arabic, taking care to maintain the meaning of the questions while ensuring cultural sensitivity.

Furthermore, we consulted with local experts and stakeholders to incorporate cultural differences that may impact on the understanding and interpretation of the survey items. Their insights were invaluable in refining the questionnaire to reflect the unique perspectives and experiences of families in Saudi Arabia (page no. 6, lines 223- 227). The discussion of these cultural factors and their implications for helmet use is elaborated in detail on page no. 21-22, lines 662-727. By emphasizing these efforts, we aimed to enhance the instrument's reliability and relevance, ensuring that it captures the specific context of helmet use among children in our study population effectively. We highlighted these aspects in our revised manuscript to address your concerns comprehensively.

More importantly, to mitigate this bias and enhance the robustness of our findings, we adjusted for potential confounding variables, including socioeconomic status and educational attainment, which are known to influence helmet use behaviors (Table 10).

 

3. The results are comprehensive, but some sections lack clarity in connecting findings to the study objectives. For example, the relationship between socioeconomic status and helmet use contradicts previous research. Expanding on possible reasons for this disparity and its implications for public health policy in Saudi Arabia would add depth.

Reply 3:

 

Thank you for highlighting this important aspect. We have added a discussion on the relationship between socioeconomic status and helmet use on page no. 18-19, lines 534- 551. Additionally, we have linked our findings to broader public health policy implications in Saudi Arabia, as detailed on page no. 22, lines 715- 727.

 

4. The discussion effectively interprets results but occasionally lacks depth in linking findings to broader implications. For instance, the study emphasizes parental modeling as a strong predictor of helmet use but does not explore specific interventions or campaigns that could leverage this insight. Expanding on actionable recommendations would enhance the practical value of the study.

Reply 4:

Thank you for your valuable feedback regarding the depth of our discussion and the link between our findings and broader implications. We appreciate your suggestion to expand on actionable recommendations, particularly concerning parental modeling as a predictor of helmet use.

 

We would like to highlight that studies focusing on helmet use among children in Saudi Arabia are limited, which emphasizes the need for targeted research in this area (page no. 2, lines 55- 61). By establishing a clear connection between our findings and the existing gaps in literature, we can present a compelling case for the importance of parental influence on helmet-wearing behaviors.

 

In response to your comment, we enhanced our discussion by exploring specific interventions and campaigns that could effectively leverage parental modeling to promote helmet use. On page no. 21- 22, lines 669- 727, we discussed the findings related to public safety campaigns, noting that public safety campaigns positively influence behavior. Specifically, we found that 72.1% of parents who remember helmet safety promotions actively enforce helmet use, compared to only 54.7% of parents who do not recall such campaigns but still enforce helmet use. This highlights the importance of community and public awareness efforts in fostering safer behaviors. Furthermore, when looking at helmet use among children, we observed that while previous studies indicated that 51% of children consistently wore helmets while cycling, our study showed an improvement, with approximately 60% of children using helmets.

 

These findings highlight the effectiveness of safety campaigns and the potential for even greater improvements in helmet use when leveraging parental modeling and community awareness. Therefore, we provided actionable recommendations that build on these insights and suggest further research into targeted interventions that engage parents and communities effectively (page no. 26, lines 906- 911).

 

5. Comments on the Quality of English Language

The quality of English is generally good, with clear and precise language used throughout the manuscript. However, there are occasional issues with sentence structure and redundancy that could benefit from revision to improve readability and flow. Minor grammatical errors and overly complex sentences in the discussion section should also be addressed for better clarity.

Reply 5:

Thank you for your comment. The manuscript was revised and edited by MDPI Author Services (please find attached editing certificate).

Reviewer 4 Report

Comments and Suggestions for Authors

The paper explores factors influencing children's use of bicycle helmets in Saudi Arabia, with a particular focus on parental perceptions and habits. Here are the key observations and suggestions for review:

The introduction should be divided into sections for better clarity.

Expand the paper with more recent references.

Expand the introduction by exploring the topic, then narrow it down to your topic. This will allow you to use more recent references and will give you a broader perspective on the topic.

Clearly define the objectives of your research.

The analytical cross-sectional study and use of a validated questionnaire provide a solid basis for obtaining relevant results.

The inclusion of all regions of Saudi Arabia contributes to the diversity of the sample.

Various statistical tools were used to evaluate associations between parental attitudes, sociodemographic characteristics, and helmet use.

The study uses a non-probabilistic sampling method (snowball), which may limit the generalizability of the results. Future studies should focus on a more representative sample.

Although parents have positive attitudes toward helmets, their behavior does not align with these attitudes. The reasons for this gap should be explored in greater depth and solutions proposed.

While the study indicates that helmet affordability is not a significant factor in Saudi Arabia, further research is needed to confirm this finding, particularly for families of lower socioeconomic status and whether state subsidies for helmets are available.

Differences in approach between mothers and fathers were observed. A deeper analysis of the reasons for these differences would be beneficial.

While the inclusion of open-ended questions is a good idea, the results are insufficiently analyzed and not well-connected with the quantitative data.

The English language in the paper is generally precise and formally adequate, but certain sections could be improved for clearer communication and stylistic consistency.

The conclusion could emphasize the need for a combination of educational campaigns, legislative regulations, and initiatives to increase helmet accessibility to bridge the gap between parental awareness and behavior.

Author Response

The paper explores factors influencing children's use of bicycle helmets in Saudi Arabia, with a particular focus on parental perceptions and habits. Here are the key observations and suggestions for review:

1. The introduction should be divided into sections for better clarity.

Reply 1:

Thank you for your comment. The sequence in the introduction has already been taken into consideration; however, we added subheadings for more clarity.

2. Expand the paper with more recent references.

Reply 2:

Thank you for your valuable comment. The introduction has been updated with recent references as recommended (page no. 2-4, lines 66- 72, 77- 80,100-102 and 129-146).

1. Expand the introduction by exploring the topic, then narrow it down to your topic. This will allow you to use more recent references and will give you a broader perspective on the topic.

Reply 3:

Thank you for your comment. The introduction was expanded as suggested on page no. 2-4, lines 66- 72, 77- 80,100-102 and 129-146.

2. Clearly define the objectives of your research.

Reply 4:

Thank you for your comment. The aim and objectives are updated on page no. 4, lines 147-172.

3. The analytical cross-sectional study and use of a validated questionnaire provide a solid basis for obtaining relevant results.

Reply 5:

Thank you for your positive comment.

4. The inclusion of all regions of Saudi Arabia contributes to the diversity of the sample.

Reply 6:

Thank you for your positive comment.

 

5. Various statistical tools were used to evaluate associations between parental attitudes, sociodemographic characteristics, and helmet use.

Reply 7:

Thank you for your positive comments.

6. The study uses a non-probabilistic sampling method (snowball), which may limit the generalizability of the results. Future studies should focus on a more representative sample.

Reply 8:

Thank you for your insightful comments regarding our methodological approach. We appreciate your recognition of the strengths of our study, as well as your constructive suggestions for improvement.

We would like to clarify that we have acknowledged the limitation related to our use of convenience sampling in our manuscript (page no. 24, lines 846-853). The reliance on convenience sampling may have introduced selection bias, potentially limiting the generalizability of the findings. We have expanded on this point further on page no. 25, lines 855-870, where we discuss how this sampling method may affect the representativeness of our findings and consider demographic and geographic factors that could influence helmet use. This expanded discussion aims to provide a clearer understanding of the potential biases associated with our sample and the implications for interpreting our results.

However, to mitigate this bias and enhance the robustness of our findings, we adjusted for potential confounding variables, including socioeconomic status and educational attainment, which are known to influence helmet use behaviors (table 10 and limitations on page no. 25, lines 872- 878).

7. Although parents have positive attitudes toward helmets, their behavior does not align with these attitudes. The reasons for this gap should be explored in greater depth and solutions proposed.

Reply 9:

Thank you for your comment. Discussion of this gap was added and public health solutions were in depth provided on page no. 21- 22, lines 669- 727.

8. While the study indicates that helmet affordability is not a significant factor in Saudi Arabia, further research is needed to confirm this finding, particularly for families of lower socioeconomic status and whether state subsidies for helmets are available.

Reply 10:

Thank you for highlighting this important aspect. Various statistical tools were used to evaluate associations between parental attitudes, sociodemographic characteristics, and helmet use.

Nevertheless, we have added a discussion on the relationship between socioeconomic status and helmet use on page no. 18-19, lines 516- 551 and on page no. 21, lines 658- 663. Additionally, we have linked our findings to broader public health policy implications in Saudi Arabia, as detailed on page 21-22, lines 669- 727.

 

9. Differences in approach between mothers and fathers were observed. A deeper analysis of the reasons for these differences would be beneficial.

Reply 11:

Thank you for your insightful comment regarding the observed differences in approach between mothers and fathers in our study. We updated the result section by adding additional findings on page no.17, lines 412- 419. Moreover, discussion about these differences was added on page no. 22, lines 708- 727.

We agree that understanding the underlying reasons for these differences is essential for developing more effective interventions to promote helmet use. To gain deeper insight into these dynamics, we recognize the need for further qualitative research that explores the perspectives and experiences of both mothers and fathers.

We acknowledge this limitation in our study and have included it in our recommendations for future research. This qualitative approach could uncover the factors influencing their attitudes and behaviors regarding helmet use, including social norms, internalized beliefs, and their roles within the family. By conducting interviews or focus groups, we would be able to gather rich, detailed information that could illuminate the motivations driving distinct approaches to helmet safety among parents (page no. 25, lines 897- 904).

10. While the inclusion of open-ended questions is a good idea, the results are insufficiently analyzed and not well-connected with the quantitative data.

Reply 12:

Thank you for your valuable feedback and we appreciate your recognition of the inclusion of open-ended questions as a positive aspect of our study.

We understand your concern regarding the analysis and integration of the qualitative and quantitative data. To address this, we have undertaken a deeper analysis of the open-ended responses, utilizing thematic coding to systematically categorize and identify key themes. This additional analysis allows us to draw clearer connections between the qualitative insights and the quantitative findings (details were given in page no. 12- 13, lines 368- 398).

Furthermore, the discussion section was revised to better articulate these connections. By aligning the themes from the open-ended responses with the statistical trends observed in the quantitative data, we can provide a more comprehensive understanding of the results. This enhanced integration not only strengthens our conclusions but also enriches the narrative by providing context and depth to the numerical data.

Additionally, we acknowledge the limitations of our current study in terms of fully capturing the depth of attitudes towards helmet use. We recommend that future research consider conducting in-depth qualitative studies to gain a more nuanced understanding of this issue (page no. 25, lines 897- 904). Such studies could provide richer insights into the complex attitudes and behaviors surrounding helmet use, which our initial exploration through open-ended questions only begins to uncover.

11. The English language in the paper is generally precise and formally adequate, but certain sections could be improved for clearer communication and stylistic consistency.

Reply 13:

Thank you for your comment. The manuscript was revised and edited by MDPI Author Services (please find attached editing certificate).

    

12. The conclusion could emphasize the need for a combination of educational campaigns, legislative regulations, and initiatives to increase helmet accessibility to bridge the gap between parental awareness and behavior.

Reply 14:

Thank you for your comment. We emphasized the implications of educational campaigns, legislative regulations, and initiatives on helmet use (page no. 21-22, line 669- 707).

Reviewer 5 Report

Comments and Suggestions for Authors

The study focuses on the safety issues of children riding bicycles, particularly helmet usage and parents' safety awareness, which holds significant practical importance. After carefully reviewing the paper, the following suggestions are proposed:

1. The literature review could be more comprehensive, encompassing studies on children's cycling safety, helmet usage rates, and parental awareness, particularly research from the past five years. Additionally, the review should highlight the novelty of this study and the research gaps it aims to address.

2. The study primarily relies on questionnaire surveys and statistical analysis, lacking an in-depth theoretical discussion on children’s cycling safety behaviors. It is recommended to incorporate more theoretical frameworks, such as Social Cognitive Theory or the Theory of Planned Behavior, to explain the behavioral motivations and patterns of children and parents from a theoretical perspective.

Author Response

The study focuses on the safety issues of children riding bicycles, particularly helmet usage and parents' safety awareness, which holds significant practical importance. After carefully reviewing the paper, the following suggestions are proposed:

1. The literature review could be more comprehensive, encompassing studies on children's cycling safety, helmet usage rates, and parental awareness, particularly research from the past five years. Additionally, the review should highlight the novelty of this study and the research gaps it aims to address.

Reply 1:

Thank you for your valuable feedback on our literature review.

We have thoroughly revised the literature review (pages no. 2-4, lines 62- 172) to incorporate a more extensive range of studies on children's cycling safety, helmet usage rates, and parental awareness, with a particular focus on research published within the past five years. 

As you noted, the introduction now also more clearly articulates the novelty of this study and addresses the data gaps it aims to fill. This includes explicitly acknowledging the lack of readily available, comprehensive data on bicycle usage and cycling-related injuries in Saudi Arabia (as discussed on page no. 2, lines 55- 61) and highlighting how our findings contribute significantly to filling this gap (as detailed on page no. 4, lines 147- 172). Our study represents the first comprehensive assessment of bicycle helmet use among children in Saudi Arabia, providing much-needed insights into prevalent usage rates and factors that influence parental decisions. The extended literature review now further contextualizes these findings and their significance.

 

2. The study primarily relies on questionnaire surveys and statistical analysis, lacking an in-depth theoretical discussion on children’s cycling safety behaviors. It is recommended to incorporate more theoretical frameworks, such as Social Cognitive Theory or the Theory of Planned Behavior, to explain the behavioral motivations and patterns of children and parents from a theoretical perspective.

Reply 2:

Thank you for your insightful comment regarding the theoretical underpinnings of our study on children's cycling safety behaviors. We appreciate your suggestion to incorporate established theoretical frameworks such as the Social Cognitive Theory or the Theory of Planned Behavior to enrich our analysis.

We acknowledge that a comprehensive exploration of these theories would indeed add valuable depth to our understanding of the behavioral motivations underlying parental decisions regarding helmet use for their children. However, a detailed examination of these theoretical frameworks is beyond the scope of this study, which primarily focuses on examining the prevalence of helmet use among children in Saudi Arabia and the factors influencing parental decisions concerning their children's helmet use (as clearly outlined in our Introduction, page no. 4, lines 147- 172). Our specific aim was to investigate the influence of parents' attitudes, behaviors, and perceptions on their children's helmet use, as this is a crucial aspect of promoting cycling safety. Our study design was primarily quantitative (as detailed in the Methods, page no. 4, lines 174- 177 and page no. 6, lines 213- 227), utilizing a validated questionnaire and statistical analysis to achieve this objective.

 

Nevertheless, we fully recognize the merit of your suggestion. Exploring the behavioral motivations of both parents and children from a theoretical perspective, using frameworks such as the ones you mention, will be a critical focus of our future qualitative research (in the stage of finalizing the proposal). This will provide crucial additional depth and insight, building on the findings of our current cross-sectional quantitative study that focused on the significant influence of parental attitudes and behaviors.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have answered all my comments and improve the manuscript, ready for publication

Reviewer 5 Report

Comments and Suggestions for Authors

My comments have been addressed and this paper is appropriate for publication.