Psychosocial factors related to parental restraint of pre-school children in motor vehicles

While the use of safety restraints effectively reduces the risk of death or injury in accidents, many children still travel unrestrained in motor vehicles. Compulsory seat belt legislation in Australia increased rates of adult use dramatically, but did not have the same impact with children. In order to understand why levels of children's restraint use remain low, it is necessary to investigate parental factors related to use and non-use of restraints. This study assessed the rates of safety restraint use of parents and their pre-school children, and the sociodemographic, attitudinal and belief characteristics of parents which relate to children's restraint use, using the Health Belief Model as a basis for investigation. Restraint use for adults was substantially higher than for pre-school children. Children were more likely to be restrained if their parents were wearing seat belts, were married, were of high socioeconomic status, did not smoke, engaged in certain other preventive health behaviors on their children's behalf, traveled longer distances to pre-school and provided child seats for their children. In terms of the Health Belief Model, parents of restrained and unrestrained children differed in their evaluation of the "costs" and "benefits" of using restraints for their children, and in health locus of control. Parents of unrestrained children perceived the "costs" of restraint use, in terms of nuisance value, installation difficulty and financial cost, to be high. They were also less likely to believe that they could play a significant role in preventing injury to their children. Implications of these findings for safety restraint campaigns are discussed.     

Children at risk: predictors of car safety seat misuse in Ontario

When used correctly, child safety seats can reduce the risk of death and serious injury by 54% in toddlers and 71% in infants [National Highway Traffic Safety Administration (NHTSA), 2001. Traffic Safety Facts 2001. Children (DOT HS 809 471), U.S. Department of Transportation, Washington, DC]. The purpose of this study was to identify factors that predict correct use of car safety seats. The study was conducted in a large urban area in Southwestern Ontario and a small urban and rural area in Northern Ontario. Participants were 1263 caregivers who completed a self-report survey on their knowledge and use of car safety seats for their children (N=2199). Logistic regression analysis revealed that female caregivers, caregivers with higher levels of education, and caregivers who reported that finding information about the correct use of child safety seats was "difficult" were more likely to report correctly using car safety seats. The results also showed that children aged 7 months to 8 years old had substantially lower odds of being in the correct car safety seat compared to children aged 6 months or younger, or children aged 9 years or older. The high risk nature of misuse of child seats for infants and younger children may be an important cue to action for health professionals to develop comprehensive prevention strategies.     

Factors influencing the use of booster seats: a state-wide survey of parents

This study used telephone interview data on booster seat use from a state-wide probability sample of parents with children ages 4-8-years-old who were living in Michigan. Interviews were completed with parents of children in 350 households. Analyses examined the entire sample, and three sub-groups: always users, part-time booster seat users, and booster seat non-users. Results indicated that booster seat legislation was a key determinant of the level of use and the motivation to use booster seats. Nearly 70% of part-time users said that they used booster seats because they believed it was the law. Similarly, 60% of part-time and non-booster seat users said that they would be more likely to use booster seats if use were mandated by law, with non-users being 3.5 times more likely than part-time users to agree that a law would increase their booster seat use. Finally, over 90% of part-time and non-booster seat users said it would be easier for them to use booster seats if a law required it, and non-users were almost six times more likely than part-time users to agree that a law would make use easier. The need for booster seat laws, issues of social equity, and implications for intervention were discussed.     

A longitudinal study of the effectiveness of a multi-media intervention on parents’ knowledge and use of vehicle safety systems for children

Motor-vehicle crashes are the leading cause of death and serious injury for children under the age of 14 in Canada and in the United States despite mandatory use of vehicle restraints since 1977. Using a pre- and post-test design, the present study tests the effectiveness of a multi-media intervention study on parents’ knowledge of car safety seat use for children (0-12 years). The sample included 201 parents from four Ontario cities. Results indicate that parents’ knowledge of when to accurately and safely transition a child to the appropriate car safety seat based on child's age, weight and height was retained at the 1 year post-test for children 4-8 years of age. The rates of correct use of safety seats significantly increased 1 year following the intervention program. Other factors that influenced parent's knowledge included being a parent versus non-parents, gender, income, education, sources of information, and regional location. The results of this study can help guide the development and implementation of future intervention programs and injury prevention policy.     

Seat belt misuse among children transported in belt-positioning booster seats

Objective

Observe and report seat belt use among children transported in belt-positioning booster seats.

Design

We conducted a cross-sectional, observational survey of children transported in motor vehicles between 2006 and 2007. While drivers completed a survey reporting the child's age, weight and gender, and the driver's age, gender, race, income, education, and relationship to the child; a child passenger safety technician recorded vehicle seating location, restraint type, and use of the car safety seat harness or seat belt as appropriate for the child.

Setting

Twenty-five fast food restaurants and discount department stores throughout Indiana.

Participants

A convenience sample of drivers transporting children younger than 16 years.

Main exposure

Seat belt use among children transported in belt-positioning booster seats.

Outcome measure

Seat belt misuse.

Results

Overall, 1446 drivers participated, 2287 children were observed with 564 children in belt-positioning booster seats. At least one seat belt misuse was observed for 64.8% of the children transported. Common misuses were the shoulder belt being placed over the booster seat armrest (35.8%); shoulder belt not at mid-shoulder position (28.5%), seat belt was too loose (24.5%), and the shoulder belt was either behind the child's back (9.1%) or under their arm (10.0%).

Conclusion

There is a high frequency of seat belt misuses among children transported in booster seats. Advice to parents on appropriate car seat selection, and encouragement to parents to supervise seat belt use may decrease misuse.     

Use of booster seats by Michigan children 4-8 years of age

This study reports the results of a statewide survey of restraint use by 4–8-year-old children in Michigan conducted between July 13 and 29, 2004. In this study, 3420 4–8-year-old children were observed traveling in passenger cars, vans/minivans, sport-utility vehicles, and pickup trucks. Restraint use was estimated for children traveling in all vehicles combined, as well as for each vehicle type separately. Children's restraint use was also calculated by the sex, age, and belt use of the driver. Separate estimates were also made of the restraint use of 4–8-year-old children by the combination of sex and belt use of the driver. Overall, 8.6 ± 5.9% of 4–8-year-old children were seated in a booster seat, 48.8 ± 10.3% were wearing a safety belt, 5.1 ± 3.4% were seated in a child safety seat, and the remaining 37.5 ± 11.5% were traveling completely unrestrained. When examining the rates by vehicle type, booster seat use was highest among children riding in sport-utility vehicles and lowest for those in pickup trucks. Surprisingly, children riding in passenger cars were more likely to be completely unrestrained than those in any other type of vehicle. While the sex of the driver did not seem to influence the restraint use of target-aged children, the driver's age did seem to have an effect. Booster seat use was quite low (0.6%) for children traveling with a driver over the age of 60, compared to 7.0 and 9.1% for those riding with drivers 16–29 and 30–59 years of age, respectively. The safety belt use of the driver also had a substantial influence on children's restraint use. Irrespective of driver sex, children riding with belted drivers were traveling in booster seats about 10% of the time, while those riding with unbelted drivers were only in booster seats 1–2% of the time.     

Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia—A population-based study

Objectives

To determine discrepancies between knowledge and practice of childhood motor vehicle restraints (CMVRs) and vehicle seating position amongst parents within the province of Nova Scotia.

Design

Random telephone survey.

Setting

The Canadian province of Nova Scotia.

Subjects

Four hundred and twenty-six households with at least one child under the age of 12 years, totaling 723 children.

Main outcome measures

The proportion of parents whose children who should be in a specific stage of CMVR and sitting in the rear seat of the vehicle, and who demonstrate correct knowledge of that restraint system and seating position, yet do not use that restraint system/seating position for their child (demonstrate practice discrepant from their knowledge).

Results

Awareness of what restraint system to use is good (>80%). However, knowledge of when it is safe to graduate to the next stage is low (30–55%), most marked for when to use a seatbelt alone. Awareness of the importance of sitting in the rear seat of a vehicle was universal. Discrepancies between knowledge and practice were most marked with booster seats and rear-seating of older children. Factors influencing incorrect practice (prematurely graduated to a higher-level restraint system than what is appropriate for age and weight) included lower household income, caregiver education level, and knowledge of when to graduate from forward-facing car seats and booster seats. Incorrect practice was also more commonly observed amongst children of weight and/or age approaching (but not yet reaching) recommended graduation parameters of the appropriate CMVR.

Conclusions

Discrepancies between knowledge and practice are evident through all stages of CMVRs, but most marked with booster seats. The roles of lower socioeconomic status and gaps in CMVR legislation, in influencing discrepant practice, must be acknowledged and suggest the need for targeted education concurrent with development of comprehensive all-stages CMVR policies.     

Parental survey of beliefs and practices about bathing and water safety and their children: guidance for drowning prevention

Drowning represents the second leading cause of unintentional injury death in children less than 19 years. In children less than 5 years, many of these deaths occur in bathtubs. The objective of this study was to describe parental beliefs and practices regarding bathing their children and general water safety to aid in improving anticipatory guidance for drowning prevention. We distributed a written survey about parental beliefs and practices concerning their children's bathing and general water safety to a convenience sample of caregivers. One hundred and thirty-six caregivers participated in the survey providing data for a total of 209 children. Overall, 85% of respondents reported using baby bathtubs, and 46% reported using bath seats when bathing their children. Some caregivers reported leaving a 6-12 months old child unsupervised in the tub, either alone or with a sibling. About half of respondents (52%) indicated that pediatricians discussed water safety and supervision with them, and 36% indicated discussing the proper use of bathing aids with their child's pediatrician. In conclusion, the survey found the majority of caregivers use bathing aids, and caregivers reported some risky behaviors of unsupervised bathing of infants, either alone or with siblings. Better water safety anticipatory guidance is needed for caregivers.     

Recognition of home injury risks by novice parents of toddlers

Objective

Unintentional injury in the home is a leading cause of death for toddlers. The majority of injuries occur at home; parents play a significant role in injury prevention. Health-related behavior change theory suggests that behavior change is only possible if individuals (a) recognize the problem, and (b) believe they are vulnerable. This study examined these characteristics among novice parents of toddlers by investigating how well parents recognize hazards in the home and whether they believe their toddlers are vulnerable to those hazards.

Methods

Three types of participants were recruited: novice parents of toddlers ages 12-36 months, daycare employees, and pediatric healthcare workers. All participants were examined three rooms simulating a typical toddler's bedroom, a living room, and a bathroom. Participants marked any hazards they recognized with stickers. Parents completed the hazard identification task twice, once identifying hazards for all toddlers and another time identifying hazards for their child.

Results

Participants identified less than half the hazards present in the simulated rooms; parents identified more hazards than comparison groups. Parents identified significantly fewer hazards for their own child than they identified for other children.

Discussion

Although parents identified more hazards than the professionals, they failed to identify a large portion of hazards and they perceived their own children to have less vulnerability than toddlers more broadly. Results indicate that education about toddler's vulnerability to injury in the home, as well as instructing parents about what situations are hazardous, might be considered during development of toddler home injury prevention programs.     

Accessory child safety harnesses: Do the risks outweigh the benefits?

Accessory child safety harnesses are available in some countries as alternative restraints for young children or as an accessory restraint used with booster seats. Their use, in Australia at least, is becoming more common. There have been concerns that the risk of misuse of these restraints outweighs any potential benefit this system might have over a retractable lap-shoulder belt system used with a booster seat. However to date there is no evidence to confirm or deny this. This study used laboratory simulated frontal crash tests to examine the performance of accessory child safety harness systems compared to the lap-shoulder belt when used alone and when used with two common designs of Australian booster seat. The performance of the child safety harness system when misused was also investigated. The results demonstrate that the correctly used child safety harness system performed no better than the lap-shoulder system, and in fact allows for a greater risk of submarining. Furthermore, one common form of child safety harness misuse, where the harness is over-tightened causing the lap belt to be positioned high over the abdomen, allowed extremely undesirable dummy motion. This involved gross submarining and direct contact between the harness system and the dummy's neck. These findings suggest that the risks associated with accessory child safety harness systems most likely outweigh any potential benefits, in frontal impacts at least.     

Grandparents and child passenger safety

Purpose

This study compares child passenger safety (CPS) practices of grandparents versus parents and determines grandparents’ opinions on car safety seats (CSS), barriers to use, and ways to transport grandchildren safely.

Methods

Observational surveys were conducted on a convenience sample of drivers transporting children younger than sixteen years at 25 locations by certified child passenger safety technicians observing children in motor vehicles and recorded use of child passenger restraints. The drivers were surveyed on their knowledge, attitudes, beliefs, and practices regarding CPS. Data from drivers identifying themselves as grandparents were analyzed; also, three grandparent focus groups provided opinions on CPS practices.

Results

During the study 1758 parents transporting 2713 children and 284 grandparents transporting 391 grandchildren were included. While most drivers were restrained and used child occupant restraints, almost 25% of parents and grandparents chose the incorrect seat to transport the child, and greater than 68% had at least one harness error. Grandparents were more likely to have looser lower anchor straps or seat belts and have children younger than thirteen years in the front seat.The focus group-grandparents had a favorable attitude toward CSS. Grandparents acknowledged the need for CSS but opined that CSS were difficult to use. Physical barriers included arthritis, back pain, mobility, decreased strength, and vision problems.

Conclusions

Grandparents and parents were equally likely to use CSS and choose correct seats. Compared to parents, grandparents were more likely to travel with their grandchildren with CSS installed with looser harnesses or an installed CSS with looser seat belt or lower anchors. Additionally, grandparents were more likely to have a child younger than thirteen years in the front seat. The use of community resources such as permanent fitting stations could help grandparents improve a grandchild's travel safety.     

Vehicle child restraint usage for Pacific children aged 6 weeks to 4 years: Findings from the Pacific Islands Families study

Child restraint systems (CRSs) for vehicles are designed to provide protection and prevent or reduce child mortality and morbidity in road traffic accidents. Overall, 90% of children under 5 years of age in New Zealand currently use CRSs. There is considerable regional variability in CRS usage, but little information exists on its ethnic variations or determinants. “Increasing the level of restraint use” is explicitly stated as one of the 13 priorities within the New Zealand Ministry of Transport's new road safety strategy. As such, understanding CRS prevalence, patterns and associates within different communities is essential in realising this priority. Utilising a large birth cohort of Pacific children (n = 1376 mothers), this study aimed to report the prevalence of maternal self-reported car seat usage at the 6 weeks, 1-year, and 2 years postpartum measurement waves; car/booster seat usage at the 4 years postpartum measurement wave; and to identify important associates using generalised estimating equation (GEE) models. Car seats were not used by 161 (11.8%) Pacific children at the 6 weeks measurement wave, 71 (5.8%) at 1-year, and 44 (3.8%) at 2 years, while car/booster seats were not used by 139 (13.3%) at the 4 years wave. Multivariable GEE model results revealed that mothers with no formal education, high parity, who smoked tobacco, lower household income, who lacked English language proficiency, and had multiple births were all at higher odds of failing to use car seat/booster seats. Despite differential attrition being noted in mothers over time, a sensitivity analysis using multiple imputation methods yielded similar findings. Targeted initiatives and education programs focusing on these higher risk groups, in particular, is needed to increase uptake and use of CRS thereby decreasing Pacific children's exposure to injury risk. As New Zealand has a large and increasing proportion of Pacific, Maori and Asian people, there is a continuing need to understand cultural factors in traffic safety. Only when culturally appropriate initiatives and education programs have been developed and disseminated that meet the needs of New Zealand's different communities is the national priority likely to be realised.     

Knowledge and practice of childhood motor vehicle restraint use in Nova Scotia: Phase II

Objective

To examine changes to knowledge and practice of childhood motor vehicle restraint (CMVR) use in Nova Scotia after the implementation of stricter car seat and new booster seat (BS) legislation in 2007.

Methods

A random telephone survey of households (at least one child <12 years) was performed in 2004 and 2010. Logistic regression determined variables independently associated with correct knowledge and/or practice of CMVR use.

Results

Families were surveyed in the pre- (N = 426 families, 728 children) and post- (N = 453 families, 723 children) legislative periods. Reported appropriate use of forward-facing car seats (FFCSs) and BSs increased significantly (74–92% and 58–95%, respectively). After adjusting for covariates, the post-law period remained a significant predictor of increased knowledge of when to graduate to a BS or a seat belt alone (SB) (OR:1.4(95% CI:1.0–2.0) and 1.9(1.4–2.7), respectively), which was significantly associated with correct use. The strongest independent predictor of the correct use of FFCSs and BSs was the post-law period (OR:14(3.0–68) and 43(17–114), respectively). With regards to rear-facing car seats (RFCSs), new legislation and associated social marketing on graduating from a rear-facing car seat was not associated with increases in correct practice.

Conclusions

Legislation, combined with social marketing at the time of introduction, is an effective means to educate parents on when to graduate from a FFCS and the importance of BSs while also influencing parents to use them, though not for RFCS graduation. The known protective effect of BSs dictates the need for all regions in Canada to adopt comprehensive BS legislation.     

Evaluation of a child passenger safety class in increasing parental knowledge

Background

Child passenger restraint systems have been found to greatly reduce the risk of injury and death among child passengers. However, nearly half of the children who died in 2009 as a result of motor vehicle crashes were completely unrestrained. Our global hypothesis is that parents and other caregivers failed to restrain children due to a lack of child passenger seat education and practice. In this report, we postulate that a car seat class will improve the basic understanding of child passenger safety. The objective of the study was to evaluate the effectiveness of a car seat class in increasing parental knowledge about child passenger safety.

Methods

Car seat classes were held at a Level 1 pediatric trauma center every other Tuesday for ten months. The curriculum consisted of: child passenger safety laws discussion, a 21-min video on the use of child safety seats followed by a 15-min discussion about the video, 15 min of discussing the different types of car seats, and hands-on training on how to properly install and use child restraints. Free car seats were provided to eligible parents. The pre-test was administered at the beginning of class and the post-test at the end of the class. McNemar's test and a paired t-test were used to compare pre- and post-test scores. Test scores were also stratified by language spoken.

Results

Forty-four classes were held and a total of 491 parents/caregivers attended the classes. An increase in knowledge was found for all survey questions. Mean knowledge score for the post-test was 3.10 points higher compared to the mean knowledge score from the pre-test. Mean difference in knowledge scores for English-speaking participants were higher than Spanish-speaking participants.

Conclusion

Lack of knowledge and low risk perception have frequently been cited as barriers for the use of child passenger restraints. Our intervention attempted to eliminate these barriers. We found that this intervention was effective at increasing parental knowledge about child passenger safety. The results of this study may be used to design and implement future interventions in multicultural settings.     

Rear seat safer: seating position, restraint use and injuries in children in traffic crashes in Victoria, Australia

Car crashes are a major cause of death and serious injury to children but most analyses of risk are based on US data. The Australian context is different in at least three ways: (1) the proportion of passenger-side airbags, a potential risk to children in front seats, is much lower; (2) unlike in the US, Australian airbags are designed to work with restrained passengers; (3) restraint use for children 0-12 years is high (>90%). Official data drawn from Victorian crash records (n=30,631) were used to calculate relative risks of death or serious injury for children (0-3 years, 4-7 years; 8-12 years) traveling in passenger cars during 1993-1998 and 1999-2004. Over 90% were reportedly wearing a restraint, and 20% were traveling in the front seat. For children under 4 years traveling in the front seat, the relative risk of death was twice as great as when traveling in the rear, and that of serious injury was 60% greater. The relative risk of death whilst traveling in the front seat was almost four times greater for children aged under 1 year. We suggest that serious consideration should be given to mandating rear seating for children, particularly those aged 4 and under.     

Individual factors affecting the risk of death for rear-seated passengers in road crashes

We studied the effect of age, gender, use of restraint systems and seat position on the risk of death for rear-seated passengers of cars involved in road crashes. The data source was the Spanish register of traffic crashes with victims compiled by the Government's General Traffic Directorate. Data for crashes recorded from 1993 to 2002, inclusive, were studied. We used a matched cohort design to analyze all 5260 rear-seated passengers in vehicles occupied by two or three rear-seated passengers for accidents in which at least one of these passengers was killed. Conditional Poisson regression with death as the dependent variable was used. An increased risk of death was observed for females and children aged <3 years. For passengers aged 25 years and older, the risk increased with age. The use of restraint systems and central and right-side seats was associated with a lower risk. These results should be considered in research focused on passenger fragility and strategies to prevent injury and death.     

Controlling factors of the parental safety perception on children's travel mode choice

The travel mode of children changed significantly over the last 20 years, with a decrease of children travelling as pedestrians or cyclists. This study focuses on six to twelve year old children. Parents determine to a large extent the mode choice of children in this age category. Based on the analysis of an extensive survey, the research shows that traffic infrastructure has a significant impact on parental decision making concerning children's travel mode choice, by affecting both the real and the perceived traffic safety. Real traffic safety is quantified in terms of numbers of accidents and road infrastructure. For the perceived traffic safety a parental allowance probability is calculated per road type to show that infrastructure characteristics influence parental decision making on the children's mode choice. A binary logistic model shows that this allowance is determined by age, gender and traffic infrastructure near the child's home or near destinations frequently visited by children. Since both real and perceived traffic safety are influenced by infrastructure characteristics, a spatial analysis of parental perception and accident statistics can be used to indicate the locations where infrastructure improvements will be most effective to increase the number of children travelling – safely – as pedestrians or cyclists.     

Community-based programs to promote car seat restraints in children 0-16 years -- a systematic review

STUDY OBJECTIVE: Community-based models for injury prevention have become an accepted part of the overall injury control strategy. This systematic review of the scientific literature examines the evidence for their effectiveness in reducing injury due to inadequate car seat restraint use in children 0-16 years of age. METHODS: A comprehensive search of the literature was performed using the following study selection criteria: community-based intervention study; target population was children aged 0-16 years of age; outcome measure was either injury rates due to motor vehicle crashes or observed changes in child restraint use; and use of community control or historical control in the study design. Quality assessment and data abstraction was guided by a standardized procedure and performed independently by two authors. Data synthesis was in tabular and text form with meta-analysis not being possible due to the discrepancy in methods and measures between the studies. RESULTS: This review found eight studies, that met all the inclusion criteria. In the studies that measured injury outcomes, significant reductions in risk of motor vehicle occupant injury (33-55%) were reported in the study communities. For those studies reporting observed car seat restraint use the community-based programs were successful in increasing toddler restraint use in 1-5 year aged children by up to 11%; child booster seat use in 4-8 year aged children by up to 13%; rear restraint use in children aged 0-15 years by 8%; a 50% increase in restraint use in pre-school aged children in a high-risk community; and a 44% increase in children aged 5-11 years. CONCLUSION: While this review highlights that there is some evidence to support the effectiveness of community-based programs to promote car restraint use and/or motor vehicle occupant injury, limitations in the evaluation methodologies of the studies requires the results to be interpreted with caution. There is clearly a need for further high quality program evaluation research to develop an evidence base.     

Child passenger safety and the immunity fallacy: Why what we are doing is not working

Motivating parents to take certain safety precautions when traveling with their children remains an elusive challenge for advocates, as caregiver naiveté contributes to poor parental participation in safety-seat checks, low booster-seat use, poor adherence to rear-seat positioning, and intermittent safety-belt use. Because of inherent human biases and unfortunate characteristics of vehicle travel, it is argued that most caregivers possess an immunity fallacy, or a reduced perception of risk for motor vehicle injury to their children. Consequently, traditionally designed child passenger safety campaigns, which are primarily informational, fail to have an impact on most parents. Rather, for maximum behavioral success, injury prevention messages must shock and surprise parents into paying attention to something they would normally dismiss as unimportant.