Christmas 2016: Famous Figures
BMJ
2016;
355
doi: http://dx.doi.org/10.1136/bmj.i6355
(Published 14 December 2016)
Cite this as: BMJ 2016;355:i6355
- John J Park, Kennedy scholar1,
- Ben G T Coumbe, medical student2,
- Esther H G Park, medical student3,
- George Tse, academic clinical lecturer4,
- S V Subramanian, professor of population health and geography5,
- Jarvis T Chen, research scientist5
- Correspondence to: J J Park john.park@mail.harvard.edu
- Accepted 22 November 2016
Abstract
Objective To determine which factors influence whether Santa Claus will visit children in hospital on Christmas Day.
Design Retrospective observational study.
Setting Paediatric wards in England, Northern Ireland, Scotland, and Wales.
Participants 186 members of staff who worked on the paediatric wards (n=186) during Christmas 2015.
Main outcome measures Presence
or absence of Santa Claus on the paediatric ward during Christmas 2015.
This was correlated with rates of absenteeism from primary school,
conviction rates in young people (aged 10-17 years), distance from
hospital to North Pole (closest city or town to the hospital in
kilometres, as the reindeer flies), and contextual socioeconomic
deprivation (index of multiple deprivation).
Results Santa
Claus visited most of the paediatric wards in all four countries: 89%
in England, 100% in Northern Ireland, 93% in Scotland, and 92% in Wales.
The odds of him not visiting, however, were significantly higher for
paediatric wards in areas of higher socioeconomic deprivation in England
(odds ratio 1.31 (95% confidence interval 1.04 to 1.71) in England,
1.23 (1.00 to 1.54) in the UK). In contrast, there was no correlation
with school absenteeism, conviction rates, or distance to the North
Pole.
Conclusion The results of this
study dispel the traditional belief that Santa Claus rewards children
based on how nice or naughty they have been in the previous year. Santa
Claus is less likely to visit children in hospitals in the most deprived
areas. Potential solutions include a review of Santa’s contract or
employment of local Santas in poorly represented regions.
Introduction
Santa
Claus (also known as Saint Nicholas, St Nick, Father Christmas, Kris
Kringle, Santy, or simply Santa) is a popular Christmas figure
celebrated for travelling around the world to give children presents on
Christmas Day (25 December).
It has long been thought
that Santa Claus visits children depending on whether they have been
naughty or nice in the past year (fig 1⇓).
This belief finds textual support in the popular holiday song “Santa
Claus is coming to Town,” written by Fred Coots and Haven Gillespie and
published in 1934.1
The Christmas classic goes on: “he sees when you’re sleeping, he knows
when you’re awake, he knows if you’ve been bad or good, so be good for
goodness sake!” Yet no empirical evidence exists to support the
assertion that Santa Claus rewards children based on good behaviour or
to establish whether this is the only factor determining the likelihood
of a visit from him.2
We chose to study paediatric hospital wards because sick children are
the most deserving of a visit from Santa Claus at Christmas. We
evaluated the relative importance of children’s behaviour, distance to
the North Pole, and contextual socioeconomic deprivation on the
likelihood of a visit from Santa Claus.
Fig 1 Many children believe that Santa Claus rewards good behaviour. Written by Fred, aged 7
Methods
Outcomes
Because
auditing departments close over Christmas, hospitals hold no records on
visits by Santa Claus. Therefore we telephoned every UK hospital with a
paediatric ward (obtained from the Royal College of Paediatrics and
Child Health) and asked the ward staff to identify someone who worked on
Christmas Day 2015 and could attest to a visit by Santa Claus. We
recorded the name and position of the witness and whether or not Santa
Claus had visited. We also collected additional information about other
superheroes who visited the ward on this festive occasion. Data
collection occurred in July and August 2016.
Determinants
We used the website FreeMapTools (www.freemaptools.com)
to record the distance (km) between the hospital (closest city or town
to the hospital) and North Pole, as the reindeer flies. We considered
two sources of data as potential indicators of naughtiness. Firstly,
rates of absenteeism from primary school as a proxy for child behaviour
were obtained from national government databases in 2015, available
online for each respective country (England,3 Scotland,4 Northern Ireland,5 and Wales6)
and regions within England. School absenteeism was defined by the total
number of authorised and unauthorised absences, counted in sessions
where each session is equivalent to half a day. Secondly, we obtained
data from the Ministry of Justice on the conviction rate for crimes by
young people per 1000 of the 10-17 year old population.7
Data were unavailable for Kent, Surrey, Sussex, Thames Valley, Wessex,
Northern Ireland, and Scotland. For regions within London we assigned
values based on the conviction rate for ages 10-17 years in all of
London. Contextual socioeconomic deprivation was characterised by the
index of multiple deprivation, which combines data on seven domains of
deprivation: income, employment, health deprivation and disability,
education skills and training, barriers to housing and services, crime,
and living environment, as calculated by each of the four countries.8 9 10 11
Each hospital was assigned a score based on the decile ranking of the
area in which it is located. Since publically available index of
multiple deprivation deciles in Wales are classed into broader
categories (deciles 1, 2, 3-5, 6-10), paediatric wards in Wales were
assigned to the midpoint of their deprivation category. We carried out
subanalyses restricted to regions within England, and for analyses
involving conviction data to selected regions within England as well as
Wales. Table 1⇓ presents the summary statistics for the determinants.
Table 1
Distribution of covariates across 186 paediatric hospital wards in the UK, 2015
For
modeling purposes we reversed the coding of the deprivation variable
(making 10 most deprived and 1 least deprived) so that our odds ratios
could be interpreted in relation to the effect of increased deprivation
on the odds of Santa’s visit.
Statistical analyses
We
calculated the proportions of paediatric wards visited by Santa Claus
for each of the four countries and for regions within England (table 2⇓). Fisher’s exact test was used to detect differences between areas in the likelihood of visits.
Table 2
Regional and national patterns of visits by Santa Claus to 186 paediatric hospital wards in the UK, 2015
To
explore associations between school absenteeism, conviction rates in
young people, distance to North Pole, and contextual socioeconomic
deprivation, we fit logistic regression models for the odds of no visit
by Santa Claus, with each predictor modeled linearly. To evaluate
potential regional clustering, we fit logistic mixed effect models with
random regional effects but found no evidence of a statistically
significant component for regional variance. Accordingly, the results of
the models are reported based on traditional logistic regression models
(table 3⇓). All analyses were conducted in R.12
Table 3
Logistic
regression models: association of school absenteeism, conviction rates,
distance from hospital to North Pole, and socioeconomic deprivation
with odds of no visits to 186 paediatric hospital wards in the UK by
Santa Claus, 2015
Patient involvement
No
patients were involved in setting the research question or the outcome
measures, nor were they involved in developing plans for recruitment,
design, or implementation of the study. No patients were asked to advise
on interpretation or writing up of results. There are no plans to
disseminate the results of the research to study participants or the
relevant patient community.
Results
Santa
Claus visited 168 (90%) of the 186 paediatric hospital wards in the UK.
Of the original 191 paediatric wards obtained from the Royal College of
Paediatrics and Child Health, we excluded five. Of those five (all in
England), staff of one ward declined to answer and four wards had closed
or been transferred to another hospital.
All eight of
the paediatric wards in Northern Ireland were visited by Santa Claus,
representing the most successful coverage of visits by Santa. Scotland
achieved second place, with 93% coverage (14/15 wards), and Wales came
third with 92% coverage (11/12 wards). Notably, the proportion of wards
visited in Northern Ireland, Scotland, and Wales was higher than the 89%
(135/151 wards) visited in England (although relatively smaller numbers
of paediatric wards led to Fisher’s exact P values of 0.42 for Northern
Ireland, 0.53 for Scotland, and 0.64 for Wales compared with England)
(table 2⇑).
Within England, regional variation was observed in the proportion of
paediatric wards visited (from a minimum of 50% in the north east to
100% in south London, Thames Valley, and Wessex, fig 2⇓).
The low proportions of paediatric wards visited in the north east (50%)
and in north west London (71%) point to the need for urgent corrective
action by Santa Claus.
Fig 2 Regional variations in visits by Santa Clause in England, 2015
Naughty or nice?
Based on the results of logistic regression models summarised in table 3⇑,
regional rates of school absenteeism were not statistically
significantly associated with the odds of no visit by Santa Claus in
either the full UK analysis or the England subanalysis, although the
point estimate in the England subanalysis was substantially higher than
in the UK analysis. Furthermore, we found no association between
conviction rates in young people and visits from Santa Claus in the
subanalysis of English regions and Wales.
Distance between hospital and North Pole
In
neither the UK analysis nor England subanalysis did distance (km) of
hospital to the North Pole have a statistically significant effect on
whether Santa Claus would or would not visit a paediatric ward (table 3⇑).
Contextual socioeconomic deprivation
In
the UK analysis, the index of multiple deprivation was marginally
associated with the odds of not being visited by Santa Claus: a 1 unit
change in the index of multiple deprivation decile from least deprived
to most deprived was associated with a 1.23 times increase in the odds
of not being visited by Santa Claus (95% confidence interval 1.00 to
1.54, P=0.06). In the England subanalysis, the odds ratio for a 1 unit
change in the index of multiple deprivation decile was 1.31 (1.04 to
1.71, P=0.03). We also explored the relation between index of multiple
deprivation decile and proportion of visits (fig 3⇓).
A generally decreasing pattern of visits was observed with increasing
deprivation across the top five deciles (1-5) of deprivation, with only
79% of paediatric wards in the fifth decile reporting visits. The
pattern of visits varied across the bottom five deciles (6-10), with all
showing fewer visits than the top four deciles (1-4).
Fig 3 Proportion
of paediatric hospital wards visited by Santa Claus according to
deprivation, 2015. Deprivation deciles from 1 (least deprived) to 10
(most deprived)
Local superheroes
Santa
Claus was not the only non-clinical visitor to the paediatric wards on
Christmas Day. Twenty three different fictional and non-fictional
characters also brought festive cheer. Of those, the most popular were
elves, followed by footballers, pantomime characters, and clowns. Elsa
(from the animated movie, Frozen) was joint fifth with firemen (fig 4⇓).
Fig 4 Local superheroes who also spread festive cheer on paediatric wards, 2015
Discussion
Our findings do not support the widely accepted belief that Santa Claus only visits children who are nice.13
Dispelling the “naughty or nice” myth has important implications,
including a possible increase in outbursts of bad behaviour by children
over Christmas if they find out. This raises the important ethical
question: should children be told about this?
Our most
important finding is that Santa Claus is less likely to visit hospitals
in deprived areas. Of note was the significant association of visits
with index of multiple deprivation decile in England (P=0.03). One
possible reason for the weaker association observed in the UK analysis
(P=0.056) is that the index of multiple deprivation is calculated and
summarised differently in each of the four countries. A nation specific
index of multiple deprivation is preferred for policy, planning, and
resource allocation as it is sensitive to each nation’s unique patterns
of deprivation, but future analyses of Santa’s visitation patterns in
relation to contextual deprivation across the UK would benefit from a
consistent and comparable deprivation metric.14
A
surprising finding was that Santa Claus does not discriminate against
children based on country or region (for example, we hypothesised that
he would prefer to visit Wales and Scotland owing to these countries
seemingly more habitable climates for reindeers). Indeed this study
shows that distance from the North Pole was not a factor that influenced
whether Santa Claus visited a hospital and confirms the widely held
belief that he is not limited by distance or time and is capable of
delivering gifts across the globe within a 24 hour period.15
It
is the authors’ anecdotal experience that children rarely voluntarily
admit to being naughty. Our study therefore included two potential
indicators of child naughtiness: regional primary school absenteeism and
conviction rates in young people. Neither is ideal as they are measured
at a relatively coarse level of geographical aggregation, and in the
case of conviction rates are subject to uneven reporting across the
regions. The fact that we found no significant associations with either
indicator suggests that the “nice or naughty” myth can be dispelled, but
future research should attempt to obtain better individual level
estimates of naughtiness in children to confirm this finding. We must
also acknowledge the limitations of these ecological variables: we would
hope that Santa Claus makes his decisions to visit sick children in
hospital independent of the naughtiness of other children in the region.
There are also other potential predictors of his visits that could not
be included in our analysis. For example, despite the authors’ best
efforts, information on the size and characteristics of paediatric wards
was not available for further analysis of the data. A response to the
authors’ freedom of information request to NHS England was that this
information was not available. We also caution that although our study
shows that Santa Claus is less likely to visit paediatric wards in more
deprived areas, we cannot conclude from our correlational study why this
association exists. Finally, other variables such as the quality of
whisky left for him in hospitals, availability of Christmas dinners,16
availability of chimneys, and free NHS parking spaces for reindeers may
need to be explored. Whether Santa Claus actively discriminates or
whether deeper structural factors are at play needs to be examined
through further studies.
Why do children in the most
deprived areas have it worse? One possible theory is that Santa Claus is
forced to sustain existing inequality, as he is contractually not
allowed to change anyone’s socioeconomic status.17
Giving children presents beyond their economic means might result in
Santa Claus gaining political power and thereby causing widespread
discontent. This would run directly contrary to the primary mission
statement of the North Pole: the deliverance of cheer.
Finally,
the authors (and the hospital staff who participated in the survey)
salute the local heroes and visitors who devote their time to visiting
sick children in hospital over Christmas. Even if Santa Claus does not
reach all areas equally, this is counterbalanced by the work of these
local heroes, who do a wonderful job spreading good cheer to sick
children, naughty or nice. Surprisingly, the most popular visitors apart
from Santa Claus were elves and not Elsa!
Conclusion
It
has long been thought that Santa Claus gives presents to nice but not
naughty children. This is the first study, to our knowledge, to dispel
the myth that Santa visits children based on behaviour and suggests
socioeconomic deprivation plays a greater role in determining a visit.
It raises important ethical dilemmas, such as whether children should be
told and what should be done about Santa.
Santa Claus
has an incredibly tough job to ensure that all the nice children receive
presents. Undoubtedly deeper socioeconomic factors are at play, even
impacting Santa Claus’s abilities to reach out to every child. Whether
his contract needs to be reviewed or local Santas employed in “hard to
reach” areas, all we want is for every child to be happy this Christmas.
What is already known on this topic
- It has long been believed that Santa Claus visits children who have been well behaved
What this study adds
- This study dispels the myth that Santa Claus visits children based on behaviour in the previous year
- Socioeconomic deprivation seems to play a greater role in determining a visit by Santa Claus, with children in hospitals in the most deprived areas less likely to receive a visit
Footnotes
- Contributors: JP conceived the study. JP and GT designed the study. BC, EP, and JP collected the data. JP, SVS, and JTC analysed the data. All authors contributed to the drafting and editing of the manuscript. JP is the guarantor.
- Funding: This study was not funded or sponsored by industry and follows guidelines on good publication practice.
- Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
- Ethical approval: A full submission for ethical approval using the integrated research application system was not required since the study did not involve “any modification of investigation, treatment or other aspects of clinical practice,” or involve “potentially physically or mentally invasive procedures on volunteers.” All participants gave informed consent before taking part in the questionnaire study.
- Data sharing: No additional data available.
- Transparency: The guarantor (JP) affirms that the manuscript is a honest, accurate, and transparent account of the study bring reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
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