PEDIATRICS Vol. 110 No. 4 October 2002, pp. 729-736
Barriers to Booster Seat Use and Strategies to Increase Their Use
* Division of General Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Roper Starch Worldwide, Inc, Princeton, New Jersey
University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Objective. Children who have outgrown child safety seats and been placed in adult seat belts are at increased risk for injury. Pediatricians and other advocates have been called on to encourage booster seat use in these children. The objective of this study was to identify barriers to booster seat use and strategies to increase their use.
Methods. A qualitative study consisting of focus groups and follow-up in-depth discussions were conducted among parents and/or children to elicit barriers and strategies to appropriate/best practice child restraint system use. Phase I focus groups (parents and children) identified barriers to booster seat use along with children’s self-reported likes and dislikes about booster seats. Phase II focus groups (parents only) identified additional barriers to booster seat use and suggestions for strategies to increase the use of booster seats. In-depth telephone discussions (parents only) were conducted after each phase of focus groups to identify new themes and to explore further previously emerged topics that were not conducive to probing in focus group settings.
Results. This study demonstrated that although knowledge of the benefits and purpose of booster seats is an important issue in promoting booster seat use, it is not the only issue. In particular, differences in risk perception, awareness/knowledge, and parenting style were noted when comparing parents of children in booster seats with those whose children were in seat belts. Media campaigns, improved laws, parenting education, and extending the use of child restraints to older ages were among the strategies suggested by parents to increase booster seat use.
Conclusions. Anticipatory guidance regarding booster seats may be new for many pediatricians. This article arms pediatricians with insights from parents about their perceptions regarding booster seats and how parents think that the booster seat message can be most effectively delivered. Furthermore, it gives insight into how parents make safety decisions for their children and the important role of children in this decision-making process.
Key Words: motor vehicle safety • child safety seat • seat belt • booster seat • qualitative research • focus groups
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Motor vehicle crashes are the leading cause of death among children ages 4 to 14 years of age.1 Booster seats have been demonstrated to be an effective injury prevention strategy. Although advocates have promoted booster seat use to protect children who are involved in motor vehicle crashes,2 booster seat use remains low. In fact, 86% of children who should be restrained in car seats or belt-positioning booster seats are inappropriately placed in seat belts.3 This inappropriate restraint places children at a 3.5-fold increased risk for serious injuries when involved in a motor vehicle crash.3 An important step in reducing the risk of childhood injuries as a result of motor vehicle crashes involves encouraging parents to adhere to best practice child restraint system use. In particular, children who have outgrown their child safety seats (usually around 40 pounds and 4 years of age) should use belt-positioning booster seats until the adult seat belt fits appropriately across the shoulder and low across the hips (usually around 80 pounds, 4 feet 9 inches, and at least 8 years of age).
The first step in encouraging parents to use booster seats is to gain an understanding of their child restraint use behaviors and associated perceived barriers. Little is known regarding barriers that parents face when attempting to practice appropriate child restraint use behaviors, especially through the use of booster seats, and how this might contribute to the adoption of best practice. Given the magnitude and significance of this problem, the purpose of this qualitative research study was to identify barriers to booster seat use and to identify potential strategies to increase the use of booster seats among young preschool- and school-aged children.
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Design
This qualitative study consisted of 2 phases of focus groups and follow-up in-depth individual telephone discussions that were conducted among parents and/or children to elicit barriers and strategies to appropriate child restraint system use (applicable during the time of the study), as described in Table 1.4,5 The purpose of in-depth telephone discussions after each phase of focus groups was to identify new themes and to explain further previously emerged topics that were not conducive to probing in focus group settings. This study used qualitative methods to gain an understanding of the range of challenges that parents face when attempting to restrain their children appropriately. Focus groups and follow-up telephone discussions were held until data saturation occurred.
|
Focus groups were conducted among parents to identify barriers to booster seat use and to assess children’s self-reported likes and dislikes about booster seats. Phase 1 of the study consisted of 5 separate focus groups: 3 with parents and 2 with children. Focus group topics for parents included perceived risk of injury to children, safety in the motor vehicle, and barriers to appropriate child restraint use. Topics such as sibling effects/peer pressure and perceptions of booster seats were discussed in the children’s focus groups. The first phase of in-depth individual telephone discussions focused on the topic of barriers to booster seat use.
In phase II, focus groups were conducted to identify further the barriers to booster seat use among parents and to elicit their suggestions for strategies to increase the use of booster seats. Phase II of the study focused on the parent’s experience of the transition stage, a period of time when a child who is usually between the ages of 2 and 4 years might be moved out of a forward-facing convertible child safety seat to either a seat belt or a belt-positioning booster seat. Four parent focus groups were conducted during this phase of the study. The second phase of in-depth individual telephone discussions also focused on the transition stage.
Sample
Participant eligibility and parent and child groupings were determined according to the age of the child, method of restraint (Table 2), and previously described goals specific to each study phase. Potential candidates were excluded from participating in this study when they 1) failed to meet the inclusion criteria as set forth; 2) were known to have participated in a focus group within 3 months before the start of this study; or 3) were employees of 1 of the market research firms, as described below, that was used to recruit participants for this study. In addition, eligible candidates were excluded from participating in more than 1 focus group and/or telephone discussion.
|
Participants for phase I and phase II focus groups were recruited by 1 of 2 local market research firms located in New Jersey and Pennsylvania. Study candidates were randomly chosen from databases maintained by each firm. An effort was made to include both male and female parents and to have a mix of racial/ethnic groups and educational levels. The goal of recruiting from large databases and including a mix of demographic characteristics was to include participants with a variety of attitudes and behaviors.6
Eligibility to participate in this study, as previously described, was determined via telephone. Eligible candidates were invited to participate after hearing an overview of the focus group goals or objectives and information regarding the scheduled date, time, and location. Eligible candidates were told that they would receive an honorarium for participation. A similar method of introduction to the study was provided to eligible phase I and phase II telephone discussion participants, and an interview time was scheduled. Market research firm employees as well as previous discussion participants referred participants for these phases of the study.
Instruments
A topic guide was developed for the phase I focus groups of the study. The development of this guide was based on a comprehensive review of the literature and existing education programs as well as incorporating results from brainstorming sessions that were held with experts in the fields of medicine, psychology, child passenger safety, and qualitative research. On the basis of a review of the transcribed focus group data from phase I of the study, a topic guide for the phase II focus groups was then drafted; reviewed; and modified by the experts, the professional moderator, and a research assistant. In-depth discussion guides, used for telephone discussions in phase I and phase II of the study, were developed after both phases of transcribed focus group data were evaluated by the same reviewers.
Data Collection Procedures
An exempt institutional review board status was granted in this study for the purposes of preliminary data collection.
Focus Groups
Data were collected from phase I and phase II focus group participants at either the New Jersey- or the Pennsylvania-based market research firm. The same professional focus group moderator facilitated each adult focus group, which lasted approximately 2 hours. A different professional focus group moderator, who was experienced in family relations, human development, and leading children’s play groups, facilitated each child focus group, which lasted approximately 45 to 50 minutes.
At the beginning of each focus group, the moderator provided an introduction to the focus group process and the specific topic for the group. As part of the introduction, participants agreed to participate and were informed that the session was being audiotaped and videotaped and that the group was being observed through the use of a 1-way mirror. Two physicians, a psychologist and a qualitative research specialist, were among those observing the focus groups sessions to ensure adequate discussion of all topics and to aid in the interpretation of the results. Throughout this research, attempts were made to minimize biases by involving experts, as previously described, to monitor the study as it progressed.
Telephone Discussions
The same moderator for the adult focus groups in phases I and II of the study was used to conduct all follow-up in-depth telephone discussions. Supplemental in-depth discussions were conducted by telephoning each participant at his or her home. The participant’s agreement to participate was obtained before the discussion. In addition, permission to audiotape the discussion was granted by the participants to allow the moderator to review the tapes, prepare an interpretive report, and allow members of the research team to review the tapes for quality assurance and insight.
Data Analysis
Transcripts of phase I and phase II focus group and individual in-depth telephone discussion data were analyzed according to standard qualitative research methods.6 Data analysis was conducted by experts, the moderator, and a research assistant. Transcripts were reviewed for common themes and new ideas. After each phase of focus groups and in-depth discussions, the moderator drafted an initial summary of the focus groups and in-depth discussions for review among researchers. All researchers who observed the focus groups reviewed the summary and made comments. The researchers and the moderator discussed all comments to reach consensus. In situations in which consensus could not be reached, all possible interpretations were included in the summary document.
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Study Sample
A total of 111 eligible participants were included in this study (Table 2). Phase I of the study consisted of a total of 54 participants: 31 parents who participated in 3 parent focus groups (10–11 participants/group), 8 children who participated in 2 child focus groups (4 participants/group), and 15 parents who participated in telephone discussions. A total of 57 parents participated in phase II of the study: 36 parents who participated in 4 parent focus groups (7–11 participants/group) and 21 parents who participated in telephone discussions.
The majority of parents who participated in phase I and phase II focus groups of the study were white (77% and 83%, respectively), were female (71% and 69%, respectively), were ages 35 to 44 (phase I; 52%) and 25 to 34 years (phase II; 56%), and had at least some college education (81% and 78%, respectively). Children who participated in phase I focus groups were between the ages of 4 and 7 years. Similar demographic characteristics were found among the in-depth telephone discussion participants.
Overall Study Findings
Overall study findings were described according to emerging themes captured through the use of focus groups, in-depth discussions, and the method of restraint used by parents and children. Recurrent themes, such as perception of risk, booster seat awareness and knowledge, and parenting style, emerged throughout the study.
Parental Characteristics and Chosen Child Restraint Practice
Perception of Risk
Risk perception was explored in 2 ways: risk of being in a motor vehicle crash and risk of crash-related injury to children. Parents of seat belt users commented that they were safe drivers (or drove safe cars) and were not likely to be involved in a crash. In particular, parents of seat belt users demonstrated more concern about the possibility of injury if their child was not properly using a seat belt. However, they felt confident that using the seat belt was the step needed to reduce the risk of injury. One parent of a seat belt user commented, "Now that my daughter is in a seat belt, I feel safer about it. She’ll stay in a seat belt and she’ll control it and she’ll sit properly."
Parents of children using booster seats expressed more concern over the possibility of their child being injured in a crash. Overall, these parents seemed less confident that they could protect their child from injury even when using a booster seat. For example, one parent who used a booster seat commented, "I don’t feel very effective in protecting my child from injury in a motor vehicle accident. You can be as prepared as you can be, but there is nothing saying that you can keep your child safe every time you take him out in the car."
Awareness/Knowledge
Parents of children using booster seats demonstrated a greater overall awareness of the issues in child passenger safety, including design and installation of booster seats, child passenger safety laws, best practices for child restraint, and the risks associated with premature use of seat belts. Parents of booster seat users also seemed to be more proactive in seeking information related to child passenger safety. These parents commented that they had attended seminars on child safety, read magazine or newspaper articles about the topic, and used the Internet to get information. Parents of seat belt users tended to receive information more passively, primarily through television programs. Many of the seat belt users’ parents commented that they did not understand the purpose of a booster seat. One parent said, "To be honest, I never really got it. It just boosts them up—it’s not as good as a car seat."
Parenting Style
One key difference between parents who use booster seats and parents who use seat belts for their children seems to be "negotiability." Parents who used booster seats for their children commented that they insist that their children use the booster seat every time they are in the vehicle, with no exceptions. It is nonnegotiable. One parent of a booster seat user commented, "It’s the routine that makes it work. It’s just a ritual so no one questions it. It’s just the way it’s done. We required it from the start."
Another parent who used a booster seat for his child commented, "Those kinds of strategies [for convincing a child to comply] aren’t used when it comes to booster seats. Maybe because you know they can’t win that argument. You can actually put off bedtime another 10 minutes—they have ways of winning that argument. But when it comes to driving in the car, they have to be in the booster seat."
Another parent of a booster seat user commented that "it could be their life. Getting a bath or not is not going to hurt them."
However, parents of seat belt users commented that they had trouble getting their child into the booster seat or child safety seat. These parents ensured that their children were restrained in a seat belt but did not argue with their children for booster seat use. One parent of a child using a seat belt commented, "I think it would be a constant struggle with my daughter. She is finally at the point of accepting being in a seat belt instead of the [shield] booster. I can’t picture going back to the battle."
This "negotiability" factor seems to play an important role in child restraint use. Parents who used booster seats for their children drew a distinction regarding negotiability between safety (nonnegotiable) and bath time and eating habits (negotiable), whereas parents who used seat belts alone for their children did not make this distinction but rather viewed safety as negotiable as other child actions.
Barriers to Booster Seat Use
Lack of Knowledge
All groups identified knowledge as an important factor in booster seat use. Many parents were surprised to learn that children should remain in booster seats until they are approximately 8 years of age, 4 feet 9 inches, and 80 pounds. Without this knowledge, parents prematurely graduate their children to vehicle seat belts without realizing the risk at which they place their children. This information was so powerful for some parents who were previously confident in the protection of seat belts for their children that they were visibly taken aback once information was given about the injuries that can occur to young children who use seat belts.
In addition to lack of knowledge regarding best practices, parents demonstrated a lack of knowledge regarding the purpose of both booster seats and seat belts. Many believed that boosters served no real safety purpose and simply boosted up the child. When the purpose and function of booster seats and seat belts were explained to parents, many parents who were already using booster seats discussed the possibility of using them longer than they had originally planned. The effect was not as dramatic on parents who were using seat belts for their children, and although many accepted the explanation of the purpose of booster seats, they did not necessarily intend to change their child’s restraint.
Parents in these focus groups also tended to group different booster seat designs (shield, high back belt-positioning, and low back belt-positioning booster seats) together into one general category instead of differentiating between the shield design and the belt-positioning designs. That differences between types of booster seats are not clear to parents may add to parents’ misunderstanding of the purpose of boosters.
Gaps in Child Passenger Safety and Seat Belt Laws
Many parents commented that they look to the law to guide them in their choice of child restraint. At the time of this study, most states’ child passenger safety laws required only that children up to 4 years of age be restrained in a child safety seat; parents believe that the seat belt is the appropriate next restraint to use. This reliance on the law was most prevalent in the groups of parents who restrained their children with seat belts. In particular, they justified their actions based on the law. One parent who used a seat belt for her child commented, "When we transitioned our child to a seat belt, we followed [state] law, which says the child must be in a car seat up to age 4 and 40 pounds. Then the child must be in a seat belt."
Situational Influences
Parents described many situations in which it is more challenging or "nearly impossible" to use the booster seat. Some situations mentioned include extra passengers in the vehicle, lack of availability of the booster seat, and vehicle design that is incompatible with booster seat design. Other parents mentioned characteristics of trips when they are more or less likely to use the booster seat. Some parents indicated that if they are going on a "short" trip, then they might choose to use the seat belt as opposed to the booster seat. Others identified bad weather or parental bad mood as prompts for booster seat use.
Attitudes About Booster Seats
Many parents indicated that they had difficulty installing or using booster seats. The instructions were unclear, and it was difficult to determine whether the seat was being used correctly. One parent said, "You could think you have it in right and the next thing you go around the corner and the seat swings out."
Other parents who used seat belts for their children indicated that they believed that booster seats were unsafe because they are not anchored to the vehicle in the same way as child safety seats. They expressed concern that the seat could slide around under the child and cause additional injury. One parent commented, "I wouldn’t give a booster seat a high rating for safety. I don’t see any need for it with a 5-year-old."
Some parents also mentioned that they graduated their children to seat belts because their children seemed uncomfortable. It is important to note, however, that most parents said that their child did not express any discomfort. One parent who used a seat belt for her child commented, "He really didn’t have a problem with the booster seat, but I thought it looked uncomfortable."
Some parents of seat belt users also indicated that they thought the seat belt adjusting devices (sleeves placed on the belt to draw together the shoulder and lap portions) seemed safer than belt-positioning booster seats. One parent who used the positioning device with the seat belt commented. "I thought the [name of device] compensated for the seat belt not fitting the child. I thought [name of device] was a safe alternative."
Child Behavior
Among parents who used a seat belt for their child, the child’s resistance reportedly played a major role in the decision to transition the child to a seat belt. In most cases, the transition was made from a booster seat. Both parents of booster seat users and parents of child safety seat users also anticipated resistance from their children as they get older. One parent commented on her son’s behavior: "My son used to complain because he couldn’t do it himself, because of the way the thing was configured. When he was in the car seat, he could do the car seat himself and then when he moved up to the booster seat, he had to have someone buckle him in so he thought that was a step down instead of a step up."
Inconvenience
Some parents, particularly parents of seat belt users, complained that booster seats were inconvenient. Parents commented that the seats were big and bulky and difficult to transport from vehicle to vehicle. This contributed to some parents’ decisions to transition their children to the seat belt.
Cost
Although not mentioned as an important barrier, cost was indicated as a deterrent to booster seat use by some parents. After purchasing multiple safety seats for children, the added expense of another booster seat was a deterrent. One parent who used a seat belt for her child commented in an in-depth discussion that "the cost is high. We protect infants but as they get older, we resist paying another $100 for another safety seat."
Insights From Children
Several children in the focus groups indicated that they had brothers or sisters who could buckle themselves in seat belts. Many of the children indicated that they could not buckle themselves into their booster seats and would like to be able to do so.
Children in the groups also tested several different designs of belt-positioning booster seats. Most of their comments were about the comfort of the seats. They liked ones that were large enough for them and disliked ones that seemed or felt "too skinny." Comfort seems to be a significant issue for children. The children did indicate, however, that they would ride in a seat that was comfortable for them.
Strategies to Increase Booster Seat Use
Importance of Extending Booster Seat Use
Many parents of seat belt users reportedly did use booster seats for their children in the past. These parents, however, incorrectly thought that boosters were to be used for children ages 3 to 3.5 years rather than for children older than 4 years. Several parents suggested emphasizing the importance of continued booster seat use. They stressed that it was easier to keep a child currently in a booster seat and to continue its use to an older age than to convince a child in a seat belt to move back into a booster seat.
Successful Parenting Approaches
Parents of booster seat users particularly stressed parenting skills as an important way to increase booster seat use. They stressed that consistency and nonnegotiability in restraint use were key. These parents set boundaries with their children. Although negotiating on bedtime or bath time may be acceptable, safety was nonnegotiable.
Impact of Information
Many parents of both seat belt and booster seat users believed that simply getting the message out would help. Using the media, school programs, or programs at other locations (eg, the Sheriff’s office) would help parents understand the importance of booster seat use.
Importance of Proper Seat Belt Fit
As mentioned earlier, parents in all groups expressed great surprise at the 4 feet 9 inches and 80 pounds criterion for graduating a child to a seat belt. They believed that communicating the importance of proper seat belt fit (when sitting back in the seat, the lap portion should fit low on the hips and the shoulder portion should cross the chest and shoulder) would help parents determine when their child was ready for the seat belt. This way, parents can also communicate to their children why they need to use booster seats.
Laws
Although not mentioned by all parents, parents of seat belt users particularly commented that they believed both enforcing current child passenger safety laws and upgrading existing laws to include booster seats could increase belt-positioning booster seat use. They believed that it would be easier to "sell" booster seat use to their children if they could tell them that it was the law.
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
This study identified that lack of knowledge was but one of many barriers that parents face to restrain their children optimally. Barriers were not universal and were perceived by parents as surmountable, given their identification of targeted educational and legal-related strategies. Our results compared responses of parents, according to their chosen method of child restraint practice, that revealed key barrier differences found to exist in areas such as parenting style, perception of risk, and awareness/knowledge. In addition, results related to children and the laws are highlighted.
The concept of "negotiability" regarding booster seat use and parenting style in response to resistant child behaviors was first explored in our study. Differences in negotiation were of paramount importance and played a key role in the parent’s success or failure to practice optimal child restraint. Whereas negotiability was not an option among parents who used booster seats to restrain their children, it was an alternative among parents who practiced suboptimal child restraint through the use of seat belts.
Many parents who used seat belts to restrain their children viewed the premature use of a seat belt as a gateway behavior that was very difficult to reverse and emphasized the need to extend booster seat use according to best practice guidelines. However, parents who used booster seats to restrain their children likened the behavior to that of bicycle helmet use, a behavior that was also enacted and perceived as a nonnegotiable safety requirement or rule. The importance of safety-related rules also was relevant to the findings of Caplow and Runyan,7 who revealed that the implementation of a community bike helmet law along with parents’ initiation of helmet use rules contributed to the use of bike helmets among their children. In our study, the recognition of problems associated with negotiation prompted parents to identify the need for improved parenting skills through education regarding nonnegotiability of safety actions or priority/boundary setting as a strategy to increase booster seat use.
Additional suboptimal child restraint use and identified strategies for improvement focused on parents’ perception of risk and child passenger safety awareness/knowledge. In brief, our study indicated that parents who used seat belts to restrain their children perceived less risk of child-related injury, were less aware of child passenger safety issues, and were less proactive in seeking child passenger safety information from sources such as web sites or special articles in parent magazines when compared with parents who used booster seats to restrain their children. Parents identified the need for education in these areas and suggested the use of media campaigns to increase knowledge of injury risks associated with suboptimal restraint and benefits to booster seat use. In particular, parents of seat belt users suggested the need for passive messaging.
Previous studies that examined booster seat use support our identified needs for education regarding perceived risks8 and child passenger safety awareness/knowledge to emphasize best practice guidelines.9 Although Stevens8 demonstrated that education increased risk perceptions among parents of children who are not properly restrained in booster seats, Ramsey et al9 found that nearly 50% of all interviewed parents whose children were not using child safety seats or booster seats responded that their children were too large for booster seats and inaccurately cited a 40- to 60-pound upper weight limit for the use of booster seats. Lack of knowledge regarding best practice was also evident in our study, given the participants’ self-reported widespread use of shield boosters, a practice no longer recommended by the American Academy of Pediatrics.10,11 In addition, some parents expressed surprise regarding the upper limits of booster seat use (according to best practice guidelines at the time of the study).
The importance of child passenger safety laws and their influence on the practice of optimal restraint was apparent in this study. It was clear that the law was more important to parents of seat belt users and was relied on to guide their choice of child restraint. Unfortunately, current best practice guidelines for optimal restraint are not consistently included within the law. For example, many states permit children to be restrained in safety belts when a child safety seat or booster seat is the most appropriate choice based on the child’s size and weight.12 Consequently, the promotion of premature graduation can occur, a practice that primarily affects 2 groups of children: 1) children under 40 pounds, who should be restrained in child safety seats; and 2) children over 40 pounds, who have outgrown their child safety seats and been moved to seat belts but should be restrained in booster seats. As a result, parents may be misguided and provided with a false sense of security regarding the safety of their children. Although child passenger safety laws are improving, parents should be cautioned against using this source as the sole determinant of child restraint choice. Suggestions from parents in this study focused on developing and enforcing laws to emphasize the importance of including provisions for booster seat use by young school-aged children are on target with efforts to optimize child restraint.
Insights from young children in this study suggest consideration of normative influences and the child’s level of comfort when using booster seats. Seats that are currently available were viewed as acceptable by the children, but given the choice to increase comfort, they suggested a seat that was wider. Normative influences among several children were more complex, as evidenced through a comparison of their own inability and desire to buckle up in a booster seat versus their sibling’s ability to buckle up while using a seat belt. Normative influences of children, either positive or negative, can be a critical factor in reducing the risks of injury, whether it is through the use of booster seats or bike helmets. For example, Dannenberg et al13 found that positive normative influences—having friends that wore helmets—were associated with higher self-reported helmet use among students.
Placing a child in optimal restraint involves a complex interplay of various factors. In addition to the ones previously discussed, the importance of parental attitudes (booster seats unsafe and difficult to use) was obvious in our study. For parents to practice optimal child restraint, it is essential that they hold beliefs that are supportive of the behavior. Beliefs undergird additional factors such as attitudes, subjective or social norms, perceived behavioral control and/or self-efficacy, and intention that ultimately have been associated with explaining and/or predicting various health- or safety-related behaviors.14–16 Although parents are primarily responsible for ensuring optimal child restraint, it is helpful if children are also aware of the need for appropriate restraint and also hold positive beliefs about using booster seats (eg, riding in a booster seat makes me feel safe, my booster seat is comfortable).
In this study, that differences were found to exist between groups of parents suggests that parents may also have different intentions and/or levels of readiness for action or change. Examination of this hypothesis is quantitative in nature and beyond the scope of this study. However, it is an extremely important consideration for future research so that behavioral antecedents to optimal restraint can be understood accurately and targeted interventions can be developed appropriately. Development of interventions guided by theories that examine concepts such as attitudes and intentions,17,18 self-efficacy,19,20 perceived susceptibility (risks),21 and stages of readiness for action or change22–24 may provide a more comprehensive and targeted approach to meet the needs of parents who are challenged in newly adopting or maintaining the practice of optimal child restraint through the use of booster seats.
Although this study provided a range of barriers that could have been more inclusive of other populations, our results, in line with other research, highlight several key factors that influence optimal child restraint use. Qualitative approaches used in this study afforded us the opportunity to extend previous research by taking a unique approach that elicited 1) insights from children, a population often overlooked and directly affected by the use of booster seats; 2) child passenger safety awareness/knowledge-seeking behaviors of parents; and 3) parent-informed strategies to improve optimal child restraint. In addition, whereas several studies end in identifying barriers to optimal child restraint, our study probed deeper into the issue to raise the awareness and significance of this problem through identification of differences among parents according to their chosen method of restraint: seat belt versus booster seat.
Results of this study create a foundation from which an effective research methodology for determining parental differences regarding optimal child restraint can be further developed. Accordingly, different approaches that may be useful in guiding future research and the development of targeted interventions for varying constituencies of parents were identified. In addition, the feasibility and effectiveness of elicited parent-derived strategies, aimed at reducing barriers to optimal child restraint use, affirmed that many barriers were not insurmountable, and on the basis of the literature, their potential feasibility and effectiveness are promising. The magnitude and significance of this problem accentuated the timeliness of this research that revealed the need for a multipronged targeted intervention approach: education, legal, and behavioral. It is from this premise that programs should be aimed to increase the acceptability and sustainability of booster seat use on both a short-term and long-term basis.
Pediatricians, law enforcement agents, parents, and others have been called on to promote booster seat use in 4- to 8-year-old children. As this is a new area for anticipatory guidance, advocates must be prepared to recognize the perceived barriers that parents face when using booster seats. This article arms pediatricians and other advocates with insights from parents about their perceptions regarding booster seats and how parents think that the booster seat message can be most effectively delivered. Key issues that likely will emerge during anticipatory guidance include 1) lack of awareness of the benefits of booster seat use versus associated risks of nonuse or premature graduation, 2) lack of awareness of best practice guidelines for child restraint, 3) gaps in child passenger safety laws specific to the state in which they reside, and 4) parenting skills related to nonnegotiability of safety actions and priority/boundary setting. This study provided insights from parents on approaches that can be taken to address these issues.
|
ACKNOWLEDGMENTS |
|---|
This research was supported by the National Highway Traffic Safety Administration, US Department of Transportation, under Contract No. DTNH22-98-C-05142. The opinions, findings, and recommendations contained herein are those of the authors and do not necessarily represent those of the National Highway Traffic Safety Administration.
We acknowledge Andrea McGruther for expert conduct of the focus groups and in-depth discussions, Dr David Grossman of the Harborview Injury Prevention and Research Center for review of the manuscript, and members of TraumaLink: The Interdisciplinary Pediatric Trauma Research Center at Children’s Hospital of Philadelphia and the other expert participants for input into the focus group guides.
|
FOOTNOTES |
|---|
Received for publication Mar 12, 2001; Accepted Mar 13, 2002.
Reprint requests to (F.K.W.) Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd, 3535 TraumaLink, 10th Fl, Philadelphia, PA 19104. E-mail: flaura{at}mail.med.upenn.edu
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
1. National Highway Traffic Safety Administration. Traffic Safety Facts 2000: Children. Available at: www.nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2000/2000chdfacts.pdf. Accessed February 6, 2001
2. Winston F, Durbin, D. BUCKLE UP! is not enough: enhancing protection of the restrained child.
JAMA.1999; 281
:2070
–2072
3. Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger of premature graduation to seat belts for young children.
Pediatrics.2000; 105
:1179
–1183
4. American Academy of Pediatrics. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents (RE9618). Available at: www.aap.org/family/01352.htm. Accessed May 1, 1999
5. National Highway Traffic Safety Administration, Emergency Nurses Association, American College of Emergency Physicians. Protect your kids in the car. Available at: www.nhtsa.dot.gov/people/injury/childps/rxflyer/rxflyer4.html. Accessed May 1, 1999
6. Krueger R, Casey M. Focus Groups 3rd Edition: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications; 2000
7. Caplow M, Runyan C. Parental responses to a child bicycle helmet ordinance. Am J Prev Med.1995; 11 :371 –374[Web of Science][Medline]
8. Stevens SL. Effects of Intervention on Booster Seat Purchase: A Field Study[master’s thesis]. Blacksburg, VA: Polytechnic Institute and State University; 2000
9. Ramsey A, Simpson E, Rivara FP. Booster seat use and reasons for nonuse. Pediatrics.2000; 106(2) . Available at: www.pediatrics.org/cgi/content/full/106/2/e20
10. American Academy of Pediatrics. 1999 Family shopping guide to car seats: safety and product information. Available at: www.aap.org/family/famshop.htm. Accessed May 1, 1999
11. American Academy of Pediatrics. 2001 Family shopping guide to car seats: safety and product information. Available at: www.aap.org/family/famshop.htm. Accessed February 5, 2001
12. National Highway Traffic Safety Administration. State Legislative Fact Sheets. Available at: www.nhtsa.dot.gov/people/outreach/stateleg/childpass.htm. Accessed February 6, 2001
13. Dannenberg AL, Gielen AC, Beilenson PL, Wilson MH, Joffe A. Bicycle helmet laws and educational campaigns: an evaluation of strategies to increase children’s helmet use.
Am J Public Health.1993; 83
:667
–674
14. Thuen F, Rise J. Young adolescents’ intention to use seat belts: the role of attitudinal and normative beliefs.
Health Educ Res.1994; 9
:215
–223
15. Trafimow D, Fishbein M. The importance of risk in determining the extent to which attitudes affect intentions to wear seat belts. J Appl Soc Psychol.1994; 24 :1 –11
16. Terry DJ, O’Leary JE. The theory of planned behaviour: the effects of perceived behavioural control and self-efficacy. Br J Soc Psychol.1995; 34 :199 –220
17. Fishbein M, Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley; 1975
18. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980
19. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev.1977; 84 :191 –215[CrossRef][Web of Science][Medline]
20. Bandura A. The explanatory and predictive scope of self-efficacy theory. J Soc Clin Psychol.1986; 4 :359 –373
21. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and health belief model. Health Educ Q.1988; 15 :175 –183[Web of Science][Medline]
22. Weinstein ND. The precaution adoption process. Health Psychol.1988; 7 :355 –386[CrossRef][Web of Science][Medline]
23. Weinstein ND, Sandman PM. A model of the precaution adoption process: evidence from home radon testing. Health Psychol.1992; 11 :170 –180[CrossRef][Web of Science][Medline]
24. Weinstein ND, Lyon JE, Sandman PM, Cuite CL. Experimental evidence for stages of health behavior change: the precaution adoption process model applied to home radon testing. Health Psychol.1998; 17 :445 –453[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  W. Du, C. F. Finch, A. Hayen, L. Bilston, J. Brown, and J. Hatfield Relative Benefits of Population-Level Interventions Targeting Restraint-Use in Child Car Passengers Pediatrics, February 1, 2010; 125(2): 304 - 312. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. D. Johnston, E. Bennett, L. Quan, D. Gonzalez-Walker, B. Crispin, and B. Ebel Factors Influencing Booster Seat Use in a Multiethnic Community: Lessons for Program Implementation Health Promot Pract, July 1, 2009; 10(3): 411 - 418. [Abstract] [PDF]
|
|
|
|
 |
|
 L E Bilston, C Finch, J Hatfield, and J Brown Age-specific parental knowledge of restraint transitions influences appropriateness of child occupant restraint use Inj. Prev., June 1, 2008; 14(3): 159 - 163. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Lennon A risky treat: exploring parental perceptions of the barriers to seating their children in the rear seats of passenger vehicles Inj. Prev., April 1, 2007; 13(2): 105 - 109. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. K. Winston, M. J. Kallan, M. R. Elliott, D. Xie, and D. R. Durbin Effect of Booster Seat Laws on Appropriate Restraint Use by Children 4 to 7 Years Old Involved in Crashes Arch Pediatr Adolesc Med, March 1, 2007; 161(3): 270 - 275. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. L. Gunn, R. M. Phillippi, and W. O. Cooper Improvement in Booster Seat Use in Tennessee Pediatrics, January 1, 2007; 119(1): e131 - e136. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. F. Agran, C. Anderson, and D. G. Winn Development of a Child Safety Seat Hassles Scale in a Largely Low-Income Latino Population Pediatrics, July 1, 2006; 118(1): e85 - e91. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. G. Simons-Morton and F. K. Winston Translational Research in Child and Adolescent Transportation Safety Eval Health Prof, March 1, 2006; 29(1): 33 - 64. [Abstract] [PDF]
|
|
|
|
|
|
V L Gunn, R M Phillippi, and W O Cooper Racial differences in child safety restraint use in Tennessee Inj. Prev., December 1, 2005; 11(6): 340 - 342. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. A. Lapidus, N. H. Smith, B. E. Ebel, and F. C. Romero Restraint Use Among Northwest American Indian Children Traveling in Motor Vehicles Am J Public Health, November 1, 2005; 95(11): 1982 - 1988. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I G Chen, D R Durbin, M R Elliott, M J Kallan, and F K Winston Trip characteristics of vehicle crashes involving child passengers Inj. Prev., August 1, 2005; 11(4): 219 - 224. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. K. Winston, I. G. Chen, M. R. Elliott, K. B. Arbogast, and D. R. Durbin Recent Trends in Child Restraint Practices in the United States Pediatrics, May 1, 2004; 113(5): e458 - e464. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R Apsler, S W Formica, A F Rosenthal, and K Robinson Increases in booster seat use among children of low income families and variation with age Inj. Prev., December 1, 2003; 9(4): 322 - 325. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. R. Durbin, M. R. Elliott, and F. K. Winston Belt-Positioning Booster Seats and Reduction in Risk of Injury Among Children in Vehicle Crashes JAMA, June 4, 2003; 289(21): 2835 - 2840. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 OTHER ARTICLES NOTED (25 Oct 02 to 17 Jan 03) Evid. Based Nurs., April 1, 2003; 6(2): e1 - 7. [Full Text]
|
|
|
|
|
|
B. E. Ebel, T. D. Koepsell, E. E. Bennett, and F. P. Rivara Too Small for a Seatbelt: Predictors of Booster Seat Use by Child Passengers Pediatrics, April 1, 2003; 111(4): e323 - 327. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
