OBJECTIVE: Observed racial disparities in child safety seat use have not accounted for socioeconomic factors. We hypothesized that racial differences in age-appropriate restraint use would be modified by socioeconomic status and child passenger safety information sources.
METHODS: A 2-site, cross-sectional tablet-based survey of parents seeking emergency care for their 1- to 12-year-old child was conducted between October 2011 and May 2012. Parents provided self-report of child passenger safety practices, demographic characteristics, and information sources. Direct observation of restraint use was conducted in a subset of children at emergency department discharge. Age-appropriate restraint use was defined by Michigan law.
RESULTS: Of the 744 eligible parents, 669 agreed to participate and 601 provided complete responses to key variables. White parents reported higher use of car seats for 1- to 3-year-olds and booster seats for 4- to 7-year-olds compared with nonwhite parents. Regardless of race, <30% of 8- to 12-year-old children who were ≤4 feet, 9 inches tall used a booster seat. White parents had higher adjusted odds (3.86, 95% confidence interval 2.27–6.57) of reporting age-appropriate restraint use compared with nonwhite parents, controlling for education, income, information sources, and site. There was substantial agreement (82.6%, κ = 0.74) between parent report of their child’s usual restraint and the observed restraint at emergency department discharge.
CONCLUSIONS: Efforts should be directed at eliminating racial disparities in age-appropriate child passenger restraint use for children <8 years. Booster seat use, seat belt use, and rear seating represent opportunities to improve child passenger safety practices among older children.
- ED —
- emergency department
- HMC —
- Hurley Medical Center
- MVC —
- motor vehicle collision
- RA —
- research assistant
- UM —
- University of Michigan
What’s Known on This Subject:
Age-appropriate child safety seat use in the United States is suboptimal, particularly among children older than 1 year. Minority children have higher rates of inappropriate child safety seat use based on observational studies. Explanations for observed differences include socioeconomic factors.
What This Study Adds:
White parents reported greater use of age-appropriate child safety seats for 1- to 7-year-old children than nonwhite parents. Race remained a significant predictor of age-appropriate restraint use after adjusting for parental education, family income, and information sources.
Suboptimal child passenger restraint practices contribute to crash-related injuries, which remain a leading cause of childhood death in the United States.1 Children who are unrestrained or sitting in the front seat face the greatest risk for death in motor vehicle collisions (MVCs).2–6 Age-appropriate child safety seat use reduces injury risk by 50% to 75%7–9 and provides increased protection over seat belts in crashes.7,9,10 Although child passenger safety practices in the United States have improved over time,11–13 premature transitions to booster seats and seat belts persist,13–18 and racial disparities exist.8,17,19–23
Minority children have higher directly observed rates of both being inappropriately restrained8,20–22 and unrestrained8,17,19,20 compared with white children. Driver minority race/ethnicity, lower education, and lower household income are associated with driver-reported suboptimal restraint use among children <9 years old who have been involved in an MVC.22 Information sources influence safety behaviors,24–27 and misinformation about child safety seats in minority populations has been described.28,29
In this study, we explored racial differences in age-appropriate restraint use among 1- to 12-year-old children by using parent self-report and direct observation data. Our results build on the published literature by determining the impact of both socioeconomic status and child passenger safety information sources on parent-reported age-appropriate restraint use. Understanding the impact of contextual factors on racial disparities in child safety seat use is important for targeting interventions to promote optimal child passenger safety practices.
A 2-site, cross-sectional survey of parents seeking emergency care for any reason for their 1- to 12-year-old child was conducted at the University of Michigan (UM) C.S. Mott Children’s Hospital Emergency Department (ED) and the Hurley Medical Center (HMC) ED between October 2011 and May 2012. Parent-reported restraint use was verified by direct in-vehicle observation among a subset of children discharged during their recruitment shift. The Institutional Review Boards of the UM Medical School and HMC approved the study.
The UM Pediatric ED is located in a suburban, tertiary care, academic hospital with a predominantly white and privately insured patient population. The HMC ED is located within an urban community hospital where higher proportions of patients are African American and covered by Medicaid compared with UM.
Parents of 1- to 12-year-old children who arrived to the EDs during peak hours (2 pm–9 pm) were potentially eligible for the study. Parents were not approached if their child was critically ill or injured (Triage Category 1 or treated in a resuscitation bay), was evaluated for suspected child abuse, or was in the process of admission, because this precluded our ability to observe restraint use at ED discharge. Parents were excluded if they were <18 years or did not speak English; if their child was taller than 4 feet, 9 inches; or if the child required a special child passenger restraint (eg, travel vest or wheelchair).
The study team developed survey questions and pilot tested the instrument with 21 parents. Survey questions that were confusing in pilot testing were modified. Items related to the presented results (Supplemental Information A) had a Flesch-Kincaid grade level of 5.1.30
Data collection occurred during the busiest hours to maximize recruitment. Recruitment days varied to ensure weekday and weekend enrollment. Research assistants (RAs) used a standard script to approach parents after the child was in their treatment room. Written informed consent was obtained after the RA reviewed study procedures, including the possibility of in-vehicle restraint type verification. Parents directly entered survey responses on a study tablet computer using the Qualtrics survey platform (Qualtrics Laboratories, Inc, Indiana, PA). Parents were offered a $20 incentive for completing the survey and provided with information about local safety seat installation programs.
In-Vehicle Restraint Type Verification
To determine the degree of agreement with parent self-report, RAs trained to identify restraint types directly observed child restraint use among participants who were discharged from the ED. When not busy with another subject, the RA screened the ED patient tracking board for discharges among children of study participants. Participants who indicated an interest in completing restraint type verification during initial recruitment were approached. The RA accompanied willing families to the parking area and recorded the restraint type in use after the child was placed in their vehicle. RAs provided parents with scripted information to address any obvious misuses. Parents received an additional $5 for allowing in-vehicle verification.
Passenger Safety Items
Parents indicated if their child sits in the front seat. Parents also were asked if their child ever used a passenger restraint. Parents who answered yes were provided sketched image examples of child passenger restraints and asked to select the restraint(s) they use for their child and indicate the child’s usual restraint. Parents were provided 2 lists of resources and asked to select all that apply to determine (1) how they learned to use their child’s safety seat and (2) where they had gone to obtain child passenger safety information. Parents were asked if they received car safety information at their child’s last doctor visit (yes versus no/I don’t remember). Parents reported their own seat belt use when driving and as a passenger (always versus sometimes/never).
Parents provided their race/ethnic background by selecting all that apply from a 6-option list. Other demographic information included parent age, gender, and relationship to child, highest education level attained, and annual household income in strata. Child age, gender, and chief complaint were obtained from the ED record.
The seat location outcome was based on parental report of the child ever sitting in the front seat. The age-appropriate restraint use outcome was defined by Michigan Child Passenger Safety Law, which states that children aged <4 must use a car seat and children aged 4 through 7 years must use a car seat or booster seat unless they are 4 feet, 9 inches tall.31 For analyses, age-appropriate restraint was defined as follows: 1- to 3-year-old children using car seats, 4- to 7-year-old children using car seats or booster seats, and 8- to 12-year-old children using booster seats or seat belts. When parents selected >1 type of restraint, the “worst-case scenario” (the least protective restraint or unrestrained) was used in age-appropriate restraint analyses.
Descriptive statistics were calculated for each variable. Agreement between parent-reported usual restraint and observed restraint at ED discharge was assessed with the κ statistic. Sensitivity and specificity for parent-reported age-appropriate restraint were calculated. χ2 statistics were calculated to test for bivariate associations between the outcome variables (sitting in the front seat and age-appropriate restraint use) and the predictor variables (sociodemographic characteristics, parent seat belt use, and child passenger safety information sources). Variables with a P value <.10 in bivariate analyses, restricted to the subjects with no missing responses, were included in multivariable logistic regression analyses to determine the independent effects of sociodemographic variables and information sources on age-appropriate restraint use. Site was included in multivariable analyses based on the potential for local variation in social norms. Interaction effects and multicollinearity were assessed. Survey responses were exported from Qualtrics to an Excel file and converted into Stata 10.0 (Stata Corp, College Station, TX) for analysis.
Of the 1337 parents of 1- to 12-year-old children who arrived to the EDs during study shifts, 1084 (81.0%) were approached for recruitment into the study and 669 (89.9%) of 744 eligible parents agreed to participate (Fig 1). In-vehicle restraint use was observed for 131 (69.7%) of the 188 subjects discharged when an RA was available. Enrollment numbers were equal between sites and well distributed throughout the week (44.4% Friday through Sunday and 55.6% on weekdays). More parents refused survey participation at UM (13.7%) than HMC (6.2%; P = .001). Complete responses on sociodemographic variables were provided by 601 (91.9%) of the 654 parents who finished the survey.
Characteristics of the study sample are provided in Table 1. Race/ethnicity was dichotomized into white and nonwhite based on the distribution of responses (non-Hispanic white: 63.1%, n = 379; non-Hispanic black: 26.8%, n = 161; Hispanic: 4.8%, n = 29; and non-Hispanic other race: 5.3%, n = 32). Eight parents self-identified as Hispanic white and were analyzed in the white group. The nonwhite population was smaller at UM (23.0%) than at HMC (54.3%). Parents from UM were older and of higher education and income levels. Children were more commonly evaluated for medical (78.9%) than injury-related complaints (21.1%). Injury-related complaints most frequently indicated an injured body area without specific mention of mechanism of injury (n = 87). Five children had a chief complaint of MVC.
In-Vehicle Restraint Type Verification
There was substantial agreement (82.6%, κ = 0.74) between parent-reported usual restraint and observed restraint among the 115 children with both data points. Among the 20 cases with discrepancies, 8 (40%) children were observed using a more protective restraint, and 12 (60%) were observed using less protective restraints than their parent-reported usual restraint. Levels of agreement were consistently high and not significantly different by race (86.7% white vs 75.0% nonwhite, P = .12) and by site (88.3% UM vs 76.4% HMC, P = .09; κ values 0.65–0.84). Observed age-appropriate restraint use did not differ by parent race (85.5% white vs 76.6% nonwhite, P = .20) or site (85.3% UM vs 79.0% HMC, P = .35) among the 131 children who completed in-vehicle verification.
Sources of Information
Child passenger safety information sources and comparisons by parent race are presented in Table 2. Reading the instruction manual and just figuring it out were the most frequently selected ways parents learned to use their child’s safety seat. Thirty-five parents selected both options. The Internet/Web and family or friends were the most frequently selected sources of information about car safety for children followed by doctors and nurses. One-quarter of parents recalled receiving car safety information at their child’s last regular checkup.
Sitting in the front seat was associated with child age (2.7% of 1- to 3-year-olds, 10.0% of 4- to 7-year-olds, and 34.0% of 8- to 12-year-olds, P < .001). Race was associated with sitting in the front seat only for 4- to 7-year-old children (6.4% white vs 16.0% nonwhite, P = .014). Few parents with a bachelor’s degree or higher reported their child ever sat in the front seat (4.5%) compared with 12.2% of parents with high school education or less and 14.7% of parents with technical/associate degrees (P = .005). Sitting in the front seat was less common for children of parents who reported always using a seat belt compared with those who did not (6.7% vs 14.1%, P = .004). Parent gender, relationship to the child, and family income were not associated with report of the child ever sitting in the front seat.
Age-Appropriate Restraint Use
Overall 79.4% of parents reported that their child used the age-appropriate restraint on every trip. Parent-reported age-appropriate restraint use did not differ significantly between those who completed in-vehicle verification and those who were ineligible or declined. Parent-reported age-appropriate restraint use had a sensitivity of 95.3% and specificity of 63.6% among those who completed in-vehicle verification (Supplemental Information B).
Significantly higher proportions of white parents reported their 1- to 3-year-old and 4- to 7-year-old children always used the age-appropriate restraint compared with nonwhite parents (85.3% vs 61.3% and 88.5% vs 69.1%, P < .001 for both comparisons). Table 3 presents the worst-case scenario restraint for each age group by parent race. Premature transitions were significantly more common among nonwhite parents of children aged <8 years. Parents of 8- to 12-year-old children reported similar restraint use patterns regardless of race. In the full sample, age-appropriate restraint use was associated with higher education level and personal seat belt use (Table 4). Age-appropriate restraint use was higher among parents who read the instruction manual and lower among parents who just figured it out or selected teacher/day care provider as an information source.
Adjusted Analysis of Age-Appropriate Restraint Use
Results of the logistic regression analyses are presented in Table 5. White parents had 3.62 (95% confidence interval 2.31–5.68) higher unadjusted odds of reporting age-appropriate restraint use compared with nonwhite parents. White parents maintained significantly higher odds (3.86, 95% confidence interval 2.27–6.57) of reporting age-appropriate restraint use compared with nonwhite parents after adjusting for education, income, parent age, parent seat belt use, information sources, and study site.
The interaction between race and site was significant (P = .016). The model including this interaction term resulted in postestimation probability of age-appropriate restraint use being highest among white parents at HMC (0.92) followed by white parents at UM (0.87), nonwhite parents at UM (0.73), and nonwhite parents at HMC (0.67; P = .014). Interactions between race and sociodemographic variables were not statistically significant. All parents (n = 23) who both learned from the instruction manual and an installation station used the age-appropriate restraint. This interaction term was collinear; therefore, the installation station variable was omitted from the final model.
Our results demonstrate racial disparities in parent-reported age-appropriate restraint use among 1- to 7-year-old children despite overall improvements in restraint use relative to research spanning 30 years.11–13 Importantly, the proportions of nonwhite parents who prematurely transitioned their children to booster seats and seat belts were almost triple those of white parents. Although the magnitude of difference has shifted and methods vary, our findings are consistent with the published literature.20–22,32 In 2004, 28% of black 4- to 8-year-olds at a child restraint system inspection program were not appropriately restrained compared with 12% of whites.20 Surveys of insured drivers of children involved in a sample of crashes in 2000–2004 revealed more suboptimal restraint use among African American 1- to 3-year-olds and 4- to 8-year-olds than whites (8% vs 4% and 76% vs 64%, respectively).22
Parental education, family income, parental seat belt use, and some information sources were also associated with age-appropriate restraint use in our sample. However, these variables did not significantly alter the relationship between race and age-appropriate restraint. Other studies confirm associations between suboptimal child safety seat use and both lower socioeconomic status22 and nonprofessional information sources.33 The persistence of race as a significant predictor of age-appropriate restraint use suggests that modifiable factors not measured in our study, such as parental knowledge, motivation, barriers, and sociocultural norms,29,34–37 may contribute to disparities. The interaction of race and site indicates the potential for regional differences or local variation in dissemination of child passenger safety information.
The influence of information sources on reported age-appropriate restraint use is noteworthy. Parents who remembered receiving child passenger safety information at their child’s last checkup were more likely to report age-appropriate restraint use. Yet only one-quarter of participants recalled receiving such information. The American Academy of Pediatrics recommends coverage of child passenger safety at every visit.38 Parents in this study were either not retaining or consistently receiving this information. Our findings may result from less discussion of car seats after infancy39 or greater emphasis on other health supervision topics.40 Although approximately one-third of parents reported going to a clinician for car safety information, this was not associated with age-appropriate restraint use. Although not commonly selected information sources, day care providers/teachers were associated with lower age-appropriate restraint use. This warrants investigation because day care settings have been sites in successful child passenger safety programs.41–43 Racial differences in sources of information that were predictive of age-appropriate restraint use (eg, instruction manuals and the Internet/Web) may signal differential access to certain resources. The accessibility, quality, and content of information used by parents to guide their child passenger restraint choices requires further exploration.
Our study is unique among surveys because of the inclusion of children aged >8 years who are recommended to use booster seats. The majority of these children used seat belts, nearly 1 in 10 had been unrestrained, and 1 in 3 sat in the front seat. Social stigma associated with reporting children to be unrestrained and general awareness of Michigan Law requiring only seat belt use after a child’s eighth birthday may minimize racial differences among the older children in this study. Regardless of race, there is potential for MVC-related injury reduction among 8- to 12-year-old children by sitting in a rear seat, increasing restraint use, and using height to guide the transition to seat belts.3,6,9,10,44,45 Promoting consistent seat belt use among early adolescents may also represent a critical time to instill safety behaviors before these children become drivers. This hypothesis requires study to determine the lasting impacts of interventions to promote child passenger safety.
This study is subject to several limitations. First, our results underestimate the number of children traveling unrestrained compared with observational studies,14,15,17 likely because of social desirability bias. Social desirability also may bias parental report of the type of restraint their child uses, but the extent to which this affects racial disparities is not clear. Differences in awareness of recommendations and in socioeconomic/cultural norms for restraint use were not assessed. Second, misclassification bias may have occurred when parents indicated their child’s restraint(s). Even though images of child restraint systems were provided, racial differences in interpretation of these terms and images are possible. Interestingly, misclassification was noted in both directions, with some parent-reported usual restraints being more protective and others being less protective than the observed restraint. Third, informing parents of the potential for in-vehicle verification may have introduced selection bias and influenced parent-reported restraint use or restraint use at discharge. Fourth, by defining “age-appropriate” using Michigan Law (a less strict standard than the 2011 American Academy of Pediatrics Guidelines for Child Passenger Safety),38,46 we overestimate this outcome for some 1-year-olds using forward-facing car seats and many children age >8 years using seat belts before achieving proper fit. Finally, responses from parents in these 2 Michigan EDs, with small Hispanic populations, may not be generalizable to other areas or to populations that do not seek ED care.
Racial disparities in age-appropriate restraint use are complex and were not fully or partially explained by socioeconomic variables or child passenger safety information sources. Other factors including social norms, motivations for, and barriers to age-appropriate restraint use require further study. Among 8- to 12-year-olds, child passenger safety can be improved through rear-row seating and consistent use of booster seats until the seat belt fits properly. Clinicians caring for children have the potential to influence child passenger safety practices, and efforts should be directed at eliminating disparities through culturally appropriate interventions.
The authors appreciate the contributions of the RAs involved in subject recruitment and data collection. The authors are also grateful to the patients and families and the ED staff at both the UM C.S. Mott Children’s Hospital and HMC who made this research possible.
- Accepted November 14, 2013.
- Address correspondence to Michelle L. Macy, MD, MS, University of Michigan, Division of General Pediatrics, 300 North Ingalls 6C13, Ann Arbor, MI 48109-5456. E-mail:
Dr Macy conceptualized and designed the study, drafted survey questions, supervised the survey administration and data collection, carried out the analyses, and drafted the initial manuscript. Dr Cunningham contributed to the study design; mentored Dr Macy in acquisition of the data, data analysis, and interpretation of data; and critically reviewed the manuscript. Dr Resnicow contributed to the survey question design and interpretation of the data and critically reviewed and revised the manuscript. Dr Freed contributed to the study design and survey development as well as data analysis and interpretation and critically reviewed the manuscript. All authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by a grant from the Michigan Center for Advancing Safety Transportation Throughout the Lifespan. Dr Macy received support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant K23 HD070913). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2014 by the American Academy of Pediatrics