Background. Nonuse of child car safety seats (CSSs) remains significant; in 2000, 47% of occupant fatalities among children <5 years of age involved unrestrained children. Nonusers and part-time users of CSSs represent small proportions of the US population that have not responded to intervention efforts. Our study examined the factors contributing to nonuse or part-time use of CSSs and the effects of exposure to a class for violators of the California Child Passenger Safety (CPS) law.
Methods. Focus groups (in English and Spanish) were conducted with individuals cited for violation of the law (N = 24). A thematic analysis of notes made by an observer, supplemented by audiotapes of the sessions, was conducted. In addition, a study of the effects of exposure to a violator class on knowledge and correct CSS use was conducted among violators. Certified CPS technicians conducted the classes and interviews. Subjects were parents cited as the driver with a child of 20 to 40 pounds, between 12 and 47 months of age. One hundred subjects recruited from the class were compared with 50 subjects who did not attend a class. Follow-up home interviews, with inspection of CCS use, were conducted 3 months after payment of the fine and completion of all court requirements. Fisher’s exact test was used for 2 × 2 tables, because some of the tables had small cell sizes. The Mann-Whitney rank sum test was used for child restraint use, knowledge, and correct use scales, because some of these variables were not normally distributed. Linear and logistic regression models were used to examine the effects of several variables on these parameters.
Results. Factors influencing CSS nonuse were 1) lifestyle factors, 2) transportation and trip circumstances, 3) nonparent or nondriver issues, 4) parenting style, 5) child’s behavior, and 6) perceived risks of nonuse. Violator subjects were mostly Hispanic and female, with incomes of less than $30 000 per year. Those exposed to the class (citation and education group) scored 1 point higher on a knowledge test and had 1 more item correct on a CSS use instrument than did the group not exposed to the class (citation only group). In the logistic model, the citation and education group scored higher on the 2 items that were corrected by the instructor during the class.
Conclusion. Our focus group study of CPS law violators revealed that multiple complex factors influence consistent use of a CSS. The interplay of the particular vehicle, the trip circumstances, and family/parent/child factors affected the use of a CSS at the time of parent citation. Addressing transportation issues and parenting skills in CPS programs is necessary. Among parents who had been ticketed for not restraining their children, exposure to a violator class demonstrated some benefit, compared with a fine alone. Correct CSS use improved most on items corrected by the instructor. Violator classes that include “hands-on” training show promise for improving rates of correct use of CSSs.
The first US child passenger safety (CPS) law was passed in Tennessee in 1978. Since that time, all states and the District of Columbia have enacted mandatory child restraint use laws, albeit with significant variations in provisions, exemptions, and gaps in coverage.1 The laws in all except 1 state cover children through 4 years of age. Evidence-based studies have revealed the effectiveness of CPS laws in increasing child restraint use and reducing the numbers of both fatal and nonfatal injuries.2
Car safety seat (CSS) use rates of >90% have been achieved as a result of multiple strategies, including education, media campaigns, public policies mandating use, and enforcement of laws.3 Estimates of effectiveness with respect to reductions in the numbers of deaths in motor vehicle crashes with CSS use are 71% for infants and 54% for children 1 to 4 years of age.4 The full benefits of CSS use have not been realized because of high rates of misuse.5–9 Nonuse remains a significant issue; in 2000, 47% of passenger occupant fatalities among children <5 years of age involved unrestrained children.10
Nonusers and part-time users of CSSs represent small proportions of the population that have not responded to intervention efforts. Disparities in the use of occupant protection systems remain. Lower rates of restraint use and higher occupant fatality rates have been detected among Hispanics and African Americans and among low-income US populations.11–19 Vaca et al20 found that lower income, fewer years of education, and lack of fluency in English were associated with less knowledge of child occupant protection issues. Others21,22 reported similar findings. The readability of CSS manuals has been found to be above the literacy level of most Americans, which may affect the proper use of CSSs among some populations.23
Educational programs to increase CSS use have demonstrated mixed results. Education with CSS distribution has been an effective strategy in the general population.2 Hands-on education has resulted in higher rates of correct use, compared with education alone.24 Community-based programs in Latino populations have demonstrated increased rates of both child CSS and seat belt use.15,25 To our knowledge, there have been no studies of programs for those ticketed for nonuse.
At the time of this study, the California CPS law required children <4 years of age and <40 pounds to be properly secured in a CSS meeting federal standards. (The law was subsequently revised to require the use of a CSS until 6 years of age or 60 pounds.) The law provides for primary enforcement and imposes a fine of $100 and added penalty assessments (total of $271) for violation of California Vehicle Code section 27360.26
This study was designed to examine the factors contributing to nonuse or part-time use of a CSS and the effects of exposure to a violator class for those cited for violation of the California CPS law. Our intent was to compare knowledge and correct use between parents/drivers who were cited and exposed to a class and those who were cited and not exposed to a class.
This study involved 2 phases. First, focus groups were conducted with individuals who had been cited for violation of the CPS law. Results from the focus groups were used to guide the development of a study of an existing violator class for CPS law violators.
Focus Group Study
Three focus groups (6–10 participants in each) were conducted. Two groups were conducted in English and 1 was conducted in Spanish. Participants were recruited from among violators registering for a class required by several courts in Los Angeles County (Family Safety in the Car, conducted by Passenger Safety Services, Whittier, CA). The focus group sessions were 90 minutes long and occurred just before the violator class. Facilitators familiar with child occupant protection and child development led the groups. Topics included CSS ownership and use, difficulties with CSS use, and reasons for nonuse. We completed a thematic analysis of notes made by an observer, supplemented by audiotapes of the sessions. The University of California institutional review board approved the protocol.
Study of Effects of Exposure to Violator Class
We compared CSS use and knowledge among CSS violators who received a citation and were required to attend an educational class (citation and education group) with use and knowledge among violators who received a citation in a nearby jurisdiction that did not require attendance at an educational class (citation group). Subjects were cited between October 1998 and June 2000, and the study was restricted to parents who had been cited as drivers for failure to restrain their own children. The children for whom the citation was issued were required to weigh 20 to 40 pounds and to be 12 to 47 months of age at the expected time of follow-up assessment, 3 months after payment of the fine and completion of all court requirements. These criteria were selected to identify a group of parents with children who were required to be restrained in a CSS and who would be expected to use a forward-facing CSS with a harness. CSSs included convertible and combination seats.
Subjects for the citation and education group were recruited from later sessions of the same mandatory educational program from which the focus groups were recruited. The class was 2 hours long and included a videotaped presentation, a discussion, and a classroom inspection of the violators’ CSSs, with correction of any errors in the harness slot position or reclining position. Violators paid a $30 fee to attend the class. None of the violators had been cited at a police checkpoint.
Subjects for the citation group were recruited from areas near the jurisdictions of the courts that required violators to attend the educational program. We attempted to recruit these subjects in 4 ways, as follows: 1) an announcement of the study was included in courtesy notices that reminded violators to pay their fines; 2) an interviewer attempted to recruit violators coming to the court building to pay their fines; 3) police officers were asked to distribute a flyer to violators when they were cited; and 4) direct recruitment was conducted at police-operated CSS checkpoints. Almost all of the subjects in the citation group were recruited at police checkpoints.
Follow-up home interviews and CSS inspections were scheduled 3 months after payment of the fine and completion of all court requirements. Parents were requested to have the car and child present, with the assumption that CSS users would also have the car seat available. The University of California, Irvine, institutional review board approved the protocol. The interviews included questions regarding usual CSS use, CSS use on the last trip, and “hassles” associated with CSS use and assessment of the installation of the CSS, including the fit of the CSS to the car and to the child for whom the citation was issued.
We asked the respondents about their children’s usual restraint use in 4 categories (child CSS, seat belt, unrestrained, or lap), with 5 responses to describe the frequency of use (never, seldom, sometimes, almost always, or always). We identified 4 groups of responses. The first group included respondents who said that their children were always restrained in a CSS. The remaining respondents were divided into those who reported that their children were always restrained, sometimes with a seat belt; seldom or sometimes restrained; or never or rarely restrained.
Correct CSS use was assessed by the interviewer, who was a National Highway Traffic Safety Administration-certified CPS technician. The assessment used a procedure and form developed by SafetyBeltSafe USA (Torrance, CA). Twelve specific items of correct use were coded from the form. We divided these into 2 items that were corrected in the classroom inspection (use of appropriate harness slots and adjustment of the CSS to the proper angle for the child) and 10 items that were addressed in the class instruction.
Fisher’s exact test was used for 2 × 2 tables, because some of the tables had small cell sizes. The Mann-Whitney rank sum test was used for child restraint use, knowledge, and correct use scales, because some of those variables were not normally distributed. Linear and logistic regression models were used to examine the effects of several factors on those variables.
Focus Group Study
The 3 focus groups included 24 individuals who had been cited for violation of the California CPS law. Eighteen of those individuals were parents and 20 were drivers. Eighty-three percent of the citations were for children 2 or 3 years of age. Nearly all participants knew that children should be restrained, but there was variability in knowledge regarding the specific features of the law. Almost all of the parents owned a CSS. Most were inconsistent users, with a number restraining children <4 years of age with seat belts.
Respondents reported several lifestyle and transportation issues that could lead to CSS nonuse. Many respondents did not have reliable transportation and frequently needed to obtain rides with others. In such situations, the respondents thought that the CSS would be an imposition on the person providing the ride. In some situations, the vehicle was too small to accommodate all of the passengers and the child’s CSS.
For a number of respondents, CSS nonuse was attributed to the circumstances of a particular trip. Respondents with >1 vehicle sometimes left the CSS in 1 vehicle and the child traveled in another car, or the CSS was in a vehicle that was being repaired. Unexpectedly obtaining a ride in a private vehicle after leaving home via public transportation was another situation that resulted in CSS nonuse.
In addition to parents, other caregivers were cited for transporting children without CSSs. In some situations, the other caregiver did not have a CSS and the parents did not leave the CSS when they left the child. Some drivers who had given a ride to a parent who had no CSS were cited, and some drivers were cited when another passenger took the child out of the CSS.
Parenting factors influenced nonuse. Some parents in the same family differed with respect to the importance of CSS use or were inconsistent in their requirements that a child travel in a CSS. Parents also “gave in” to children who resisted CSS use, often citing a need to keep the child quiet to avoid distracting the driver. Parents also thought it was necessary to remove fidgety or sleepy children from the CSS.
Child factors were cited as reasons for nonuse of a CSS. The reasons cited included the child not wanting to sit in the car seat or “refusing.” Beginning at age 2 to 2.5 years, children often wanted to ride like older children, using seat belts.
Although all focus group members knew that CSSs are protective, many did not seem to perceive the risks of nonuse. Many respondents did not expect to be in a crash and thought that seat belts were adequate protection for their children. One respondent did not use the CSS at night, thinking that a police officer could not see into the car in the dark.
In summary, 6 factors influenced nonuse, namely, 1) lifestyle circumstances, 2) circumstances of particular trips, 3) nonparent or nondriver issues, 4) parenting style, 5) child’s behavior, and 6) risks related to CSS nonuse not being perceived. For these nonusers, the competing factors identified in the focus groups outweighed the perceived benefits of CSS use. Nonownership was not a problem.
Study of Effects of Exposure to Violator Class
We recruited 100 violators who received education and 50 who did not. Eleven interviews were excluded, 2 for which the referent child had not yet reached the first birthday, 2 for which the child had passed the fourth birthday, and 7 for which the child weighed >40 pounds but was <4 years of age. A total of 91 violators attended the class and 48 did not.
Most members of both groups were female, and most were Hispanic (Table 1). However, greater proportions of the citation group were female and were <30 years of age. Nearly one-half of the interviews were conducted in Spanish. Nearly one-half of the citation group and three-fifths of the citation and education group had annual household incomes of less than $30 000. Approximately 80% of respondents in both the citation group and the citation and education group said that they always used a seat belt.
The mandated fine for violation of the California CPS law, including court costs, was $271. One hundred eighteen violators reported the amounts of their fines.
At the time of follow-up assessment, there was little difference in reported restraint use rates between the groups (Table 2). More than one-half of the violators in each group reported that they always used a CSS. An additional 15% of the violators in each group reported that their children were always restrained, although sometimes with a seat belt. Approximately one-fourth of the children were reported to be seldom or sometimes restrained. Only 3 violators admitted that their children were never or rarely restrained, and none of those violators owned a CSS.
At the time of follow-up assessment, the citation and education group scored ∼1 point higher than the citation group on a knowledge scale composed up of 10 agree/disagree statements (Table 3). More than 90% of each group responded correctly to 4 statements, regarding an adult restraining an infant in arms, the importance of CSSs for toddlers, the modified California CPS law (effective 2000), and the necessity of seat belts in cars with airbags. Three statements received correct responses from <90% of the subjects and from a greater proportion of the citation and education group, compared with the citation group, ie, those addressing the appropriateness of restraining a 10-month-old child weighing 23 pounds in a forward-facing CSS, the legality of restraining a 3-year-old child weighing 45 pounds with a seat belt, and the protection of children by airbags. In a linear model of the knowledge score (data not shown), the citation and education group scored 1 point higher than did the citation group, and none of the variables shown in Table 1 was related to the score.
All subjects were asked to have the child and the vehicle present at the time of the home interview, and we expected that the CSS would be present if the child and the vehicle were present. Thirty-five of 48 citation group subjects (73%) and 78 of 91 citation and education group subjects (86%) had a CSS present at the time of the interview (P = .07) (Table 4). Of the 26 subjects who did not have a CSS present at the time of the interview, 23 reported that they had a CSS appropriate for the child’s weight. (Most of those subjects reported that the CSS was in a vehicle that was not present, and 1 refused an inspection of the CSS.) Three parents, all in the citation group, reported that they had no CSS (the same subjects who reported that their children were always unrestrained) (Table 2).
Among the CSSs that were present, 7 were not appropriate for the child (Table 4). Three were infant seats being used for children weighing >20 pounds, and 4 were damaged or had missing parts. Six subjects did not demonstrate the CSS with the child in the vehicle; these cases included 3 cases in which the child was not present, 1 case in which the child refused, and 2 cases in which the vehicle was not present. In addition, 6 CSSs were not comparable to the convertible and combination CSSs used by the majority of subjects, including 1 infant seat (used by a 12-month-old child who weighed 20 pounds), 2 belt-positioning boosters used without harnesses, and 3 shield boosters. Therefore, there were 94 complete demonstrations of convertible and combination car seats. A logistic model comparing these 94 subjects with the other 45 subjects did not indicate statistical significance (data not shown, P = .10).
Table 5 presents the numbers and percentages of subjects who correctly used the CSS for each of 12 items, among subjects with a full demonstration of an appropriate convertible or combination CSS. The citation and education group demonstrated a total score of 1.0 more correct item, compared with the citation group. A greater proportion of subjects were correct regarding 2 specific points of use, ie, using the appropriate harness slots and adjusting the harness snugly. Corrections during the classroom inspection, rather than education, might have been responsible for the higher rate of correct use of harness slots. However, with exclusion of items 1 and 2 (the 2 items corrected during the inspection), the citation and education group still scored 0.5 points higher.
Logistic models were used to compare subjects with both items 1 and 2 correct and subjects with either item incorrect (Table 6). A second model compared subjects with ≥8 correct responses on items 3 through 12 and subjects with <8 correct responses (Table 7). For the 2 items that were corrected in the classroom inspection, membership in the citation and education group was strongly associated with a higher score, and none of the demographic variables was significantly related to the score. None of the variables predicted higher scores on the other 10 items.
A linear model of the scores on items 3 through 12 (data not shown) yielded results similar to those of the logistic model shown in Table 7, except that age of ≥30 years was the only significant predictor of higher scores. No linear model was constructed for the scores on items 1 and 2 because 58% of the subjects had scores of 2, the highest possible.
Our focus group study of CPS law violators provided information on multiple transportation- and parenting-related factors that affect CSS use. All except a few of the individuals ticketed for a CSS violation owned a CSS, and all agreed that a CSS was protective. However, the CSS was not used at the time of citation because of unexpected conditions or factors. The reasons were grouped into the following categories: lifestyle circumstances, vehicle- or trip-specific circumstances, nonparent drivers, parenting style, and child behavior on the particular trip. Older vehicles without functioning seat belt systems required to secure a CSS, smaller vehicles with more passengers than seating positions, reliance for a ride on someone who was unable to accommodate the CSS, and child resistance to use were some issues detected in our focus group study.
Our study of exposure to a violator class revealed that CPS knowledge was high among violators of the CPS law, irrespective of exposure to the class. Those exposed to the class scored slightly higher on a CSS knowledge test and in an inspection of CSS use. Items on the CSS use scale that were corrected by the CPS technician at the class (hands-on correction) were correct more frequently among those who attended the class than among those who did not, with controlling for demographic factors. The most promising part of the class was the hands-on component.
Our study examined exposure to a program and did not evaluate a specific curriculum designed to increase knowledge and use of a CSS. It seems that development, implementation, and evaluation of a curriculum that addresses transportation barriers and parenting skills and provides hands-on training is indicated.
Unlike the mandatory class attended by the violators we studied, current law provides the option for low-income parent violators to attend a CPS class in lieu of a monetary fine. Implementation of this provision is variable. Two issues emerge, ie, violator classes are not always recommended (at the discretion of the judge) and a violator must take the time to appear in court. For low-income working parents who may not be able to take the time off work, this strategy seems problematic. Referral to violator classes should be handled administratively, without requiring a court appearance.
This study did not use a representative sample of violators but instead used a convenience sample. We do not know whether those cited for violation of the CPS law are representative of all violators. We were unable to recruit the case and control subjects with the same methods and in the same jurisdictions, and there were demographic differences between the groups.
At the follow-up home visits, we relied on reported CSS use and observed direct installation for a subsample that met inclusion criteria. We were not able to observe the actual frequency of use.
A limitation was a sample size decrease from knowledge testing to CSS inspection, because not all subjects had the CSS and the car available at the time of the home visit. In addition, the demonstration inclusion criteria eliminated some cases (if the CSS was not a forward-facing model, for example). This exclusion was performed because the correct use of different types of CSSs varies and we needed standard measures for correct use. Those who completed the demonstration may not be representative of the entire group.
Our focus group study of CPS law violators revealed that multiple complex factors influence consistent use of a CSS. The interplay of the particular vehicle, the trip circumstances, and family/parent/child factors affected CSS use at the time of parent citation. Addressing transportation issues and parenting skills in CPS programs is necessary. Among parents ticketed for not restraining their children, exposure to a violator class demonstrated some benefit, compared with a fine alone. Correct CSS use improved most on items corrected by the instructor. Violator classes that include hands-on training show promise for improving rates of correct CSS use.
This study was supported by grant R49/CCR 915456-01 from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Injury Prevention and Control.
We thank Liz Perez, our research assistant, for conducting the surveys and interviews and Cheryl Kim for providing access to the violator classes.
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- Copyright © 2004 by the American Academy of Pediatrics