A risky treat: exploring parental perceptions of the barriers to seating their children in the rear seats of passenger vehicles

Change in seating position of children in towaway crashes from 1989 to 2019

OBJECTIVE

The purpose of this study was to examine the impact of the nationwide response to passenger airbag (PA) related deaths of children. The response was implemented in 1996 and focused on moving children to rear seats. This study determined the change in seating position of children from 1989 to 2019.

METHODS

Field accident data on exposed occupants in towaway crashes was determined using 1989-2015 NASS-CDS in five groups (1989-1995, 1996-99, 2000-04, 2005-09 and 2010-15) and 2017-19 CISS in one group. Children were grouped as 0-2 yo (years old), 3-7 yo and 8-12 yo. Occupants 13 + were included for completeness. Seat position was defined as left-front (LF), right-front (RF), 2nd row and 3rd row. The weighted data provided an estimate for the change in seating position over time by occupant age with standard errors.

RESULTS

For 0-2 yo, 27.9% were in the RF seat in 1989-95. The fraction decreased to 0.40% in the 2017-19 (p < 0.001). For 3-7 yo, 32.1% were in the RF seat in 1989-95 and 3.2% in 2017-19 (p < 0.001). There has been a steady decrease in 0-7 yo using the RF seat. For 8-12 yo, there was a step decline in use of the RF seat from 39.5% in 1989-95 to 23.2% in the 2017-19 (p < 0.001).

CONCLUSIONS

The immediate reduction in front-seat use among younger children was associated with the nationwide public information efforts implemented in 1996 to move children to rear seats. Children up to 7 yo are no longer riding in the RF seat of vehicles in towaway crashes, unless there is no other option. Children 8-12 yo are still using the RF seat, but at a lower rate. The change in use of the RF seat for children 0-7 yo provides evidence that safety campaigns on placing young children in rear seats were successful in the US.

Child restraint system use and its associated factors in Shenzhen

Child restraint system (CRS) is effective to protect child passenger safety in a motor vehicle crash. However, research on CRS is limited and the use rate of CRS is not high in China. We carried out a cross-sectional study to examine the use of CRS and its associated factors in Shenzhen. Via the method of cluster random sampling, parents who had at least one child aged 0 to 6 and owned a car from nine community health service centers and eight kindergartens were invited to complete the self-administered questionnaire during April and May 2014, including their knowledge of, attitude toward, and use behavior of CRS and socio-demographics. Multivariable logistic regression was used to explore the factors associated with CRS use. A total of 3768 parents participated in the survey, with a mean age of 33.94. Parents' knowledge and attitude regarding CRS were fair, with the mean score of 3.07 and 3.33 out of 6, respectively, and only 22.8% of them used CRS for their child passengers. Children aged below 3 years, drivers owing expensive cars and wearing seatbelts, and parents with higher knowledge and attitude scores had greater likelihoods to use CRS. Moreover, trip frequency and distance were also significantly associated with CRS use. The findings indicate that the use rate of CRS is low in Shenzhen and parents have fair levels of knowledge and attitude regarding CRS use. Comprehensive public education programs and legislative interventions are urgently required to increase the use of CRS and ensure child passenger safety in Shenzhen.

An Adapted Child Safety Seat Hassles Score Is Associated With Suboptimal Child Passenger Safety Behaviors Among Parents

OBJECTIVE

We modified the Child Safety Seat (CSS) Hassles Scale to characterize CSS hassles in a diverse population and test for associations between hassles and caregiver-reported child passenger safety behaviors.

METHODS

Secondary analysis of a 2-site survey of caregivers seeking emergency care for their ≤10-year-old child in 2015. Caregivers answered questions regarding CSS hassles, child passenger safety behaviors, and demographics. Size-appropriate restraint use was defined by the American Academy of Pediatrics (AAP) 2011 Guidelines for Child Passenger Safety. We tested for associations between the number of hassles and adherence to AAP guidelines (including the consistent use of a size-appropriate CSS, travel in a back seat, and never traveling unrestrained).

RESULTS

There were 238 caregivers included in analyses. Overall, caregivers endorsed a median of 5 hassles (interquartile range 2, 8). Half (50.8%) of caregivers endorsed child passenger safety behaviors that were nonadherent to AAP guidelines. Compared with caregivers reporting no hassles, there was an increased odds of not adhering to AAP child passenger safety guidelines for each additional hassle reported (adjusted odds ratio [aOR] 1.11; 95% confidence interval [CI] 1.03, 1.19). In addition, a higher number of hassles was associated with the inconsistent use of a size-appropriate CSS (aOR 1.15; 95% CI 1.06, 1.25) and as sometimes traveling unrestrained (aOR 1.13; 95% CI 1.03, 1.23).

CONCLUSIONS

Caregivers who reported more CSS hassles were more likely to report behaviors that were not adherent to AAP guidelines. Addressing CSS hassles may provide solutions for nonadherence of AAP child passenger safety guidelines.

Facilitators and barriers to child restraint use in motor vehicles: a qualitative evidence synthesis

BACKGROUND

Road traffic collisions contribute a significant burden of mortality and morbidity to children globally. The improper or non-use of child restraints can result in children sustaining significant injuries in the event of a collision. Systematic reviews on the effectiveness of various interventions to increase the use of child restraints already exist but to the best of our knowledge, there has been no qualitative evidence syntheses on the facilitators and barriers to child restraint usage. This review aims to fill that gap.

METHODS

We searched for qualitative studies, which focused on perceptions, values and experiences of children, parents/caregivers or any other relevant stakeholders on the use of restraints for children travelling in motor vehicles in PubMed, EMBASE and Global Health and screened reference lists of all included studies. We assessed the quality of included studies with the Critical Appraisal Skills Programme (CASP) checklist and used the PROGRESS Plus lens for an equity focused analysis.

RESULTS

We identified a total of 335 records from searching the databases and five records from other sources. After screening, we identified 17 studies that met our inclusion criteria. All but one study (which had children as participants) focused on the perceptions, attitudes and barriers of parents or caregivers. The included studies were from three high-income (n=14) and one upper-middle income (n=3) country. In addition, although many focused exclusively on participants from culturally and linguistically diverse minorities, the issue of equity was not well addressed. Five major themes emerged from the analysis. (1) perceived risk for injuries and perceived safety benefits of child restraint usage varies in different settings and between different types of caregivers; (2) practical issues around the use of child restraints is a major barrier to its uptake as a child safety measure; (3) restraint use is considered as a mechanism to discipline children rather than as a safety device by parents and as children became older they actively seek opportunities to negotiate the non-usage of restraints; (4) adoption and enforcement of laws shape perceptions and usage in all settings and (5) perceptions and norms of child safety differ among culturally and linguistically diverse groups.

CONCLUSION

The results of this systematic review should be considered when designing interventions to promote the uptake of child restraints. However, there is a need to conduct qualitative research around the facilitators and barriers to child restraint usage in low-income and middle-income countries. Furthermore, there is a need for more evidence conducted in semiurban and rural areas and to involve fathers, policy-makers, implementers and enforcement agencies in such studies.

A comparative analysis of child passenger restraint use in China and the United States

BACKGROUND

Few published studies have examined child passenger safety practices across countries. This study compared the prevalence and associated factors of child passenger restraint use among children, aged 0 to 17 in the state of Iowa in the United States, and the city of Shantou in China.

METHODS

Child restraint use observations were conducted in Iowa and in Shantou in 2012, respectively, among child passengers. Observations in Iowa were conducted at randomly selected gas stations, while in Shantou observations were completed at randomly selected schools or medical clinics. Research observers approached the driver, observed restraint use, and collected brief survey data.

RESULTS

A total of 3049 children from Iowa and 3333 children aged 0 to 17 years from Shantou were observed. For children aged 0 to 3 years, only 0.1% were compliantly restrained in Shantou as compared to 95.9% in Iowa. The proportion of children who were compliantly restrained in Shantou increased with age, but generally decreased with age in Iowa. In Shantou, 36.0% of children aged 0 to 3 were sitting in the front seat as compared to only 1.7% of children of the same age in Iowa. Driver seat belt use was significantly associated with child restraint in both Iowa and Shantou; the association was stronger in Iowa than Shantou for all age groups.

CONCLUSIONS

A significantly higher prevalence of children who were not appropriately restrained was observed in Shantou than in Iowa. Our findings support the need of mandatory child safety restraint use legislation in China.

An ecological model to factors associated with booster seat use: A population based study

Belt-positioning booster seat use (BPB) is an effective technology to prevent severe child injury in cases of car crash. However, in many countries, age-appropriate car restraint use for children aged 4-7 years old remains the lowest among all age groups. The aim of this study was to identify the main determinants of BPB use through a comprehensive approach. An ecological model was used to analyze individual, parent-child relationships, and neighborhood characteristics. Parents of children enrolled in the first and second grades completed a self-reported questionnaire (n=745). The data were subjected to multilevel modeling. The first level examined individual and parent-child relationship variables; in addition the second level tested between neighborhood variance. According to parental self- reports, 56.6% of their children had used a BPB on each car trip during the previous month. The results indicated that the determinants positively related to BPB use were individual and parental; namely, the number of children in the family, the parents' car seat belt use, parental knowledge of children's car safety principles, and a highly authoritative parenting style. Children's temperaments and parental supervision were not associated with BPB use. At the neighborhood level, a small difference was found between neighborhoods for BPB users compared to non-users.

Do parental decision-making patterns predict compliance with use of child booster seats?

Booster seat use for 4-9 year olds remains the lowest of all age groups in many countries. The objective of this study is to examine whether parents' decision-making patterns, as measured by the Melbourne Decision Making Questionnaire, relate to car booster seat use. Israeli parents of 4-7 years old children (n = 398) answered a questionnaire about car safety and decision-making habits. Ninety per cent of parents reported having a booster seat; 70.5% reported consistent booster seat use in general and on short drives during the last month (booster seat use compliance index). Greater compliance index was positively related to a vigilant decision-making pattern, passenger compliance with rear seat belts and families with fewer children. Lower booster seat use compliance index was associated with buck-passing decision-making pattern. Health professionals and policy-makers should take into account parents' habitual decision-making patterns when designing interventions for car booster seat compliance.

Parents' knowledge, attitude, and use of child restraints, Shantou, China

BACKGROUND

China has not adopted national policies for child safety restraints in cars, although children are increasingly traveling in cars.

OBJECTIVE

To describe child restraint use, and parents' knowledge of and attitude toward child restraint in Shantou, China.

METHODS

An observational study and driver survey on child restraint use was conducted in the Southeast China city of Shantou in 2012. Observational sites included 22 middle schools, 31 primary schools, 24 kindergartens, and 4 hospitals. Drivers were asked about their knowledge of and attitude toward the use of child restraints. In September 2012, multivariate regression was used to evaluate the factors associated with increased child restraint use.

RESULTS

Of 3333 children observed in vehicles, only 22 (0.6%) children were secured in child safety seats or booster seats and 292 (8.7%) children were wearing seatbelts. More than half (n=508, 56.1%) of the infants or toddlers were riding on the laps of adults. Of 1069 drivers who responded to the survey, more than 62% thought it was necessary to use child restraint while traveling in a car. The drivers' higher education status (OR=1.56, 95% CI=1.07, 2.27) and seatbelt use (OR=4.00, 95% CI=2.56, 6.25) were associated with increased child restraint use. Parents (OR=0.55, 95% CI=0.34, 0.88) and male drivers (OR=0.61, 95% CI=0.46, 0.81) had reduced odds of children properly rear-seated.

CONCLUSIONS

Child restraint use is very low in China, although the majority of drivers had positive attitudes about child restraint. These findings indicate that child restraint policies and educational approaches are urgently needed in China.

Social prejudice hindering proper use of car safety seats

The compliance of parents with child passenger safety (CPS) has been mainly explained by their level of knowledge. Social, ethnic and cultural factors have not been investigated in detail. This study investigated the rate of compliance of parents with CPS guidelines, as well as the factors hindering it. Parents of infants aged 2-10 days were enrolled. The proportions of families obtaining a car safety seat (CSS; 57%) and complying with CPS recommendations (2%) were very low. Most of the parents thought CSS were harmful for infants (mother, 57%; father, 63%), despite having already purchased one. Parents believed their children to be too small to use CSS and cannot sit in CSS because they should lie flat on their backs at all times. These prejudices may be due to the social and cultural circumstances specific to Turkey, or corresponding findings may be found in countries with similar socioeconomic status.

Front versus rear seat placement of children aged 12 or younger within vehicles: a rural/urban comparison in North Dakota

OBJECTIVE

Research has shown that rear-seated children are 36 to 40 percent safer than front-seated children. Because of the substantial differences in traffic safety culture that appear to exist in rural areas and the limited research regarding seat placement and rurality, this study seeks to contribute to the safety literature by determining at what rate children are riding in the front seat and whether differences exist between rural and urban areas in regards to child front seat placement.

METHODS

Current child placement frequencies within vehicles were ascertained through direct observations of morning child drop-offs at randomly selected urban and rural elementary schools in eastern North Dakota during November and December of 2009, with a focus on children aged 12 or younger. Two observers wearing orange safety vests and carrying observation sheets were stationed at each elementary school a minimum of 45 min prior to each school's designated start time. Based on the vehicles that entered the school's parking lot/drop-off circle and from which a minimum of one child exited, observers were instructed to record vehicle type, presence of children in the front seat appearing to be younger than 13 years old, availability of room in the back seat, and placement of other children in the vehicle.

RESULTS

During November and December of 2009 a total of 537 vehicles were observed at urban schools and 150 vehicles were observed at rural schools. Of the 537 vehicles observed at urban schools, 28.7 percent had children seated in the front seat, whereas 41.3 percent of the 150 vehicles observed at rural schools had front-seated children. Significant urban/rural differences exist in child seat placement, with vehicles in rural areas much more likely to be carrying front-seated children than vehicles in urban areas.

CONCLUSIONS

Based on a sample of vehicles observed at urban and rural elementary schools in North Dakota, the results of this study indicate that there are significant rural/urban differences in child seat placement.

Grandparents driving grandchildren: an evaluation of child passenger safety and injuries

OBJECTIVES

To compare restraint-use practices and injuries among children in crashes with grandparent versus parent drivers.

METHODS

This was a cross-sectional study of motor vehicle crashes that occurred from January 15, 2003, to November 30, 2007, involving children aged 15 years or younger, with cases identified via insurance claims and data collected via follow-up telephone surveys. We calculated the relative risk of significant child-passenger injury for grandparent-driven versus parent-driven vehicles. Logistic regression modeling estimated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for several child occupant, driver, vehicle, and crash characteristics.

RESULTS

Children driven by grandparents comprised 9.5% of the sample but resulted in only 6.6% of the total injuries. Injuries were reported for 1302 children, for an overall injury rate of 1.02 (95% CI: 0.90-1.17) per 100 child occupants. These represented 161 weighted injuries (0.70% injury rate) with grandparent drivers and 2293 injuries (1.05% injury rate) with parent drivers. Although nearly all children were reported to have been restrained, children in crashes with grandparent drivers used optimal restraint slightly less often. Despite this, children in grandparent-driven crashes were at one-half the risk of injuries as those in parent-driven crashes (OR: 0.50 [95% CI: 0.33- 0.75]) after adjustment.

CONCLUSIONS

Grandchildren seem to be safer in crashes when driven by grandparents than by their parents, but safety could be enhanced if grandparents followed current child-restraint guidelines. Additional elucidation of safe grandparent driving practices when carrying their grandchildren may inform future child-occupant driving education guidelines for all drivers.

The social context of motorcycle riding and the key determinants influencing rider behavior: a qualitative investigation

OBJECTIVE

Given the increasing popularity of motorcycle riding and heightened risk of injury or death associated with being a rider, this study explored rider behavior as a determinant of rider safety and, in particular, key beliefs and motivations that influence such behavior. To enhance the effectiveness of future education and training interventions, it is important to understand riders' own views about what influences how they ride. Specifically, this study sought to identify key determinants of riders' behaviors in relation to the social context of riding, including social and identity-related influences relating to the group (group norms and group identity) as well as the self (moral/personal norm and self-identity).

METHOD

Qualitative research was undertaken via group discussions with motorcycle riders (n = 41).

RESULTS

The findings revealed that those in the group with which one rides represent an important source of social influence. Also, the motorcyclist (group) identity was associated with a range of beliefs, expectations, and behaviors considered to be normative. Exploration of the construct of personal norm revealed that riders were most cognizant of the "wrong things to do" when riding; among those issues raised was the importance of protective clothing (albeit for the protection of others and, in particular, pillion passengers). Finally, self-identity as a motorcyclist appeared to be important to a rider's self-concept and was likely to influence on-road behavior.

CONCLUSION

Overall, the insight provided by the current study may facilitate the development of interventions including rider training as well as public education and mass media messages. The findings suggest that these interventions should incorporate factors associated with the social nature of riding in order to best align it with some of the key beliefs and motivations underpinning riders' on-road behaviors.

Maternal rules, compliance, and injuries to preschool children

This study examined the relationships among maternal rules, child compliance, and the injury experience of preschool children. To do so, 278 mothers of 3-year-old children were interviewed, mothers and children were videotaped, and medical records were reviewed. Results indicated that mothers' observed rule enforcement and children's committed compliance were inversely related to injury experience. The authors concluded that it is not the number or self-reported insistence on rules that are associated with injuries. Rather, it is only the mother's follow-through even in situations in which there was no perceived risk of injury that has an impact. Rules must be enforced and compliance encouraged in a manner that supports the development of autonomously motivated behavior.