OBJECTIVE. High rates of use of child safety seats have been achieved. A remaining challenge in child passenger safety is to reach the Healthy People 2010 objective of child safety seat use to 100%. Several factors have been reported to influence child safety seat use. A child safety seat Hassles Scale was developed to explore hassles that are associated with child safety seat nonuse.
METHODS. Focus groups with violators of the California Child Passenger Safety Law provided data to construct the 29-item Hassles Scale. The scale was used in an interview that was conducted with 132 parents who were cited for violation of the law and whose children were 12 to 47 months of age and weighed 20 to 40 pounds. Interviews were conducted 3 months after parents paid the fine for the citation. Each hassle was rated 0 to 3 on frequency and intensity. Parent report of child safety seat use was obtained. Factor analysis was used to construct subscales. Relationship of subscale frequency and intensity scores to reported child safety seat use was assessed with linear regression.
RESULTS. The sample was 86% Latino, 45% Spanish-speaking, and 55% with income <$30000. Thirty-one percent of the parents reported that the child did not now always use a child safety seat. Four subscales were identified: child, crowding/inconvenience, busy, and vehicle. Only the frequency of the child subscale items (eg, resists, gets out of seat) and the frequency and the intensity of the crowding/inconvenience subscale items (eg, child safety seat takes up too much room, too many passengers) were related to child safety seat nonuse. Sixty-nine percent agreement with parent report of child safety seat use was achieved using only the frequency scores for the 9 items in the 2 subscales child and crowding/inconvenience, compared with 65% for the 29-item scale.
CONCLUSIONS. In this low-income largely Latino population of violators, self-report of “always using a child safety seat” when transporting their child was low (59%). Child safety seat nonuse was related to hassles that are associated with child behaviors and vehicle crowding/inconvenience. The child safety seat Hassles Scale documented barriers and difficulties with the use of a child safety seat in a high-risk population for nonuse. These concepts can be explored by clinicians and others who work to increase consistent child safety seat use. Additional evaluation and development of the instrument requires validation for its use as a screening or educational tool.
For young children, the most significant risk factor for death and serious injury in a car crash is lack of child safety seat (CSS) use.1,2 In the United States in 2003, 34% of the 471 motor vehicle passenger fatalities among children who were younger than 5 years were unrestrained.3
Remarkably high rates of CSS use have been achieved. Nationally, the 2004 rates of CSS use were 98% for children who were younger than 1 year and 93% for toddlers who were aged 1 to 4 years.4 In 2004, observational studies that were conducted in California documented nearly 90% CSS use among young children.5
These high CSS use rates have been achieved by a number of strategies. Two evidence-based strategies that are recommended by the Centers for Disease Control and Prevention Task Force on Community Preventive Services have been widely implemented: (1) mandatory CSS use laws and (2) distribution and education programs.6 Both enforcement of state child passenger safety laws and media campaigns also have been used.
The next challenge in child passenger safety is to convert the small proportion of non- or part-time users to consistent users of age-appropriate, properly secured CSSs. The US Department of Health and Human Services Healthy People 2010 objectives include the goal of increasing the use of CSSs to 100%.7 To reach the Healthy People 2010 goal, 1 approach is to develop tools to predict nonuse or inconsistent use of CSSs and explore barriers to consistent use. In low-income populations, access and cost of CSSs and booster seats have been factors in nonuse. Distribution programs have been effective in increasing use.8 In our study of violators of the California Child Passenger Safety Law (CPS Law), however, nonownership was not a significant issue for nonuse.9
Factors for nonuse of a CSS identified in our studies as well as those of others can be categorized as follows: child, vehicle, trip, and parent factors.10–14 Child-related factors include behaviors that make it difficult to get the child in or keep the child in the CSS. Vehicle-related factors include size of the vehicle in relation to number of other occupants, CSS installation, and convenience issues. Ease of use has been shown to have an impact on correct use.15 Trip factors relate to duration of trip,9,16 other passengers, and availability of a CSS.10 Non–family member driving17–19 and parent not using a seat belt are additional factors that are associated with a child's not using a CSS.4,20–22 Studies on barriers to use of booster seats reveal similar child, vehicle, and trip factors.23–25
Crnic and Greenberg26 developed a hassles scale to determine the impact of external minor daily stresses such as irritating, frustrating, annoying, and distressing occurrences on parent–child relationships. The frequency and the intensity of the hassle was measured. Building on Crnic's concept and our previous studies on violators of the California CPS Law, we explored issues that can influence CSS use. These issues include the demands, events, and barriers to CSS use, which we defined as hassles. We developed the CSS Hassles Scale to measure both the frequency of occurrence and the intensity of hassles that are associated with use of a CSS. The purpose of this analysis was (1) to test the scale in a sample of parent violators of the California CPS Law, (2) to determine which hassles are associated with CSS nonuse, and (3) to describe potential uses of the CSS Hassles Scale.
Development of Hassles Scale Items
Reasons for CSS nonuse were identified from focus groups of parents who violated the California CPS Law.9 Participants had been cited for violation of the California CPS Law for failure to restrain their child properly in an age-appropriate CSS. This included nonuse, misuse, and age-inappropriate restraints. These participants were recruited for the focus groups through a court-required class “Family Safety in the Car” (conducted by Passenger Safety Services, Whittier, CA). A majority (83%) of the children were 2 or 3 years of age. Each focus group consisted of 6 to 10 people. Two of these groups were conducted in English, and 1 group was conducted in Spanish. Using the results of a thematic analysis of the focus groups, we developed the 29-item CSS Hassles Scale. The items included problems (hassles) that might interfere with CSS use.
Three months after payment of the fine, in-home interviews were conducted with 139 parents who had been cited for violation of the California CPS Law and whose children were aged 12 to 47 months and weighed 20 to 40 pounds.9 Violators were cited for nonuse, misuse, or age-inappropriate restraint use. These parents were recruited using the same methods as those who were recruited for the focus group study or police-operated CSS checkpoints.9 A monetary incentive was given to each parent who consented for the study. The University of California Institutional Review Board approved the protocol. The parents were given the option of conducting the interview in Spanish or English. The same bicultural-bilingual interviewer conducted all of the interviews. The instrument was translated and back-translated into Spanish as in the previous study of violators.
Questions and Scoring
The parents were asked about a list of CSS hassles. All of the questions were asked with reference to the child for whom they had been cited. Each parent was asked to rate the frequency of the hassle as never, seldom, sometimes, or often and coded from 0 to 3. When the hassles occurred at all, the parent was asked to rate whether the hassle was not a problem at all, just a little bit of a problem, somewhat of a problem, or a big problem, also coded from 0 to 3. The mean frequency and intensity scores were calculated.
Separate questions assessed how often their child rode on someone's lap in a vehicle, rode unrestrained in a vehicle, used a seat belt, and rode in a CSS. The possible responses were never, seldom, sometimes, nearly always, and always. Because some parents reported that the child was always in a CSS but sometimes or seldom in 1 of the other categories, we defined always using a CSS as responding “always” to this category and “never” to the other categories. Any other response was defined as not always using a CSS.
The data were analyzed using SPSS (SPSS, Inc, Chicago, IL). For each item, we calculated the mean frequency score. The mean intensity score was calculated for respondents with a frequency score ≥1.
We used factor analysis to identify groups of related items that may represent the same underlying variable. We used frequency scores rather than intensity scores for factor analysis because the intensity score was not collected when the frequency score was 0. The factor analysis was restricted to items with a mean frequency score >0.20. Factor analysis produces factor loadings that are correlation coefficients between the items and the unmeasured underlying variables. Subscales were constructed by assigning items that had any factor loading ≥0.45 to the factor for which they had the greatest loading. Subscale reliability was measured with Cronbach's α. In addition to the subscale frequency scores, intensity scores were calculated assigning a problem score of 0 when the frequency score was 0. For the subscale frequency and intensity scores, we report the means and interquartile range (from the 25th percentile to the 75 percentile) for parents who reported that their children were always restrained in a CSS and for parents who reported that their children were not always in a CSS. The means for these groups were compared using analysis of variance controlling for language and for the interaction of language and CSS use. We dichotomized each subscale at the 59th percentile, corresponding to the percentage of children who were always in a CSS, and determined the percentage of children for which this classification agreed with the parents' report.
A total of 132 of 139 parents who were interviewed answered the CSS hassles questions. Seven violators who did not answer the CSS hassles questions, including 2 who reported that their children were almost always or always unrestrained, were among those who were not included in this report. The 132 respondents were 45% Spanish-speaking Latinos, 41% English-speaking Latinos, and 14% non-Latino respondents who were interviewed in English. Sixty-two percent were female, and 48% were younger than 30 years. Fifty-five percent had a household income <$30000 per year. Overall, 41% reported that the child did not “always use” a CSS.
Nine items (shown in Table 1) had a mean score ≤0.20 on the 0 to 3 frequency scale and were excluded from factor analysis. The remaining 20 items were included in a factor analysis. Eighteen of the items had a weight ≥0.45 on 1 of 4 factors, which we named child, crowding/inconvenience, busy, and multiple vehicles (Table 2).
Five items that were related to the child's behavior, needs, and preferences regarding the CSS were included in the child subscale (α = 0.83). Four items that were related to too many people in the vehicle, difficulty getting the child into the CSS, and the need to get rides from other people were used for a subscale that we named crowding/inconvenience (α = 0.68). Six items that were related to the parents' trips and being in a hurry were included in the busy subscale (α = 0.76). Three items that were related to using >1 vehicle compose the multiple vehicles subscale (α = 0.67). Two items did not load on any of the subscales. Among Latino respondents, the frequency and the intensity scores on the busy and multiple vehicle subscales and the intensity score on the child subscale were lower for Spanish-speaking respondents than for English-speaking respondents.
CSS Use for the Child
Seventy-eight (59%) of the violators reported that their child now always rides in a CSS; 18 (14%) reported that the child now is always restrained, sometimes in a seat belt; and 36 (27%) reported the child now is seldom or sometimes unrestrained. Table 3 shows the comparison of the responses of parents whose children were always in a CSS with those of parents whose children were not always in a CSS. The P value for the difference in the scores between these groups was calculated using analysis of variance controlling for language and the interaction of language and CSS use. The significant differences (P = .05) are indicated in the footnotes. The frequency scores for the child and crowding/inconvenience subscales, the sum of all frequency items, and the crowding/inconvenience intensity score differed by CSS nonuse but not by language. The multiple vehicles frequency score was higher only in English-language interviews of parents who did not always restrain their child in a CSS (data not shown). The child and busy intensity scores were lower for Spanish-language interviews but did not differ by CSS use. The intensity score and the combined frequency and intensity score for all items were lower for Spanish-language interviews and for parents who did not always restrain their child in a CSS. When the 9 items in the child and the crowding/inconvenience subscales were combined, the resulting score was higher among parents who did not always restrain their child in a CSS and did not differ by language.
Each of the subscales was dichotomized at the 59th percentile, corresponding to the percentage of children who were reported to be “always in a CSS.” The percentage of children for which this classification agreed with the parents' report is shown in the final column of Table 3. Using the frequency and intensity scores for all 29 items, 65% of the children were classified in agreement with the parents' report. However, 69% agreement with parents was achieved using only the frequency scores for the 9 items in the child and crowding/inconvenience subscales.
On the basis of the thematic analysis of our focus group study of parents who were cited for violation of the California CPS Law,9 we developed the CSS Hassles Scale. We tested the scale on a convenience sample of 132 parent-violators of the law. This sample was largely Latino and low income. Three months after payment of the fine for violation of the California CPS Law, only 59% reported that now they always used a CSS for their child. We did not ask about usual CSS use at the time of the citation. Parents who reported that they now always use a CSS may have increased their use since the citation, they might have considered the citation an exception to their usual pattern, or they may have been cited for misuse.
CSS nonuse was associated with child behaviors and with issues of crowding/inconvenience. Child behaviors that make consistent CSS use difficult include the child's resisting being placed in the CSS, getting out of the CSS, not liking it, or needing attention. Such behaviors may cause inconsistent use. Alternatively, these behaviors may result from inconsistent use, leading children to believe that CSS use is negotiable. Others have reported these and similar behaviors related to CSS use.9,10,13,23 Christopherson27 demonstrated that traveling in a CSS reduced disruptive behavior. Child behaviors that are related to CSS use are developmentally typical behaviors and have been identified as parent concerns regarding child rearing.28 The parenting skills and strategies that are required for consistent CSS use carry over to many other injury risk behaviors and issues, such as sleeping and eating. Parents must learn to manage noncompliant behaviors effectively. Interventions such as behavioral parenting training,29 developing parent self-efficacy,30 and working with parents to assist them in developing strategies to deal with diverse child behaviors/situations may improve consistent CSS use.
The crowding/inconvenience items that were related to the circumstances of the trip were insufficient room for the CSS as a result of other occupants or vehicle size, difficulty getting the child ready for the trip, and difficulty securing the child in the CSS. These hassles relate to family size, transportation needs and planning, and child/CSS issues. Parents ultimately are responsible for safe transportation of their children. Addressing barriers to CSS use and assisting parents in developing strategies to overcome the barriers should improve use rates. For example, low-income families, including low-income Latino families, may not have reliable sources of transportation, may not have sufficient knowledge of CPS laws and use of age-appropriate CSSs,31 and, may not always have the appropriate restraint system available.24 They may use others for transportation and hence must rely on a nonparent vehicle and driver. To promote consistent CCS use, transportation strategies need to be explored with parents.
We included the language of interview and the interaction of language and reported CSS use in the analysis of variance to identify subscales that were related to reported CSS use but not to language. Subscales could differ by language because translated items were not equivalent, because of cultural differences in response patterns, or because of real differences in the circumstances under which children travel. Interaction between language and CSS use suggests that the subscales are not measuring the same constructs in the 2 language groups. Inclusion of subscales that differ by language would require adjustment for language in interpreting the subscale values. Subscales that were related to reported CSS use but did not differ by language or the interaction of language and reported CSS use are the best candidates for additional studies of CSS hassles in diverse communities.
On the basis of our analysis, a 9-item CSS Hassles Scale (from the 2 subscales child behavior and crowding/inconvenience) predicted parent report of CSS use as well as the sum of the 29-item scale. The frequency of the hassle rather than intensity and frequency can be used, because the former was significant in both subscales and did not differ by language or interaction of language and reported CSS use.
This study provides documentation of issues that are barriers to use of CSSs by a predominately high-risk population for nonuse. The concepts may be used by clinicians who provide counseling and by those who teach child passenger safety to parents and to violators of child restraint use laws. Barriers of factors that have an impact on use most frequently can be addressed. Building on the results to validate the tool also may prove useful.
There are several limitations to this study. The first is that the scale was tested on a convenience sample of violators of the California CPS Law in a largely low-income Latino population. The factor analysis used only the frequency scores. Different results might be obtained with the intensity scores. Intensity scores are necessarily 0 when the frequency is 0; therefore, the intensity ratings are skewed. Because the outcome was CSS use, which was based on parent report, we do not know whether this reflected observed use. Additional development of the CSS Hassles Scale requires linkage to observed CSS use. Testing in various populations that are at risk for nonuse also is needed
A very small proportion of children still travel unrestrained in motor vehicles. The focus of this study was to determine whether we could develop a scale to determine factors that could predict nonuse of CSS. These factors then would guide issues and strategies that should be addressed if we are to achieve the US Healthy People 2010 objective of 100% CSS use. In this low-income largely Latino population of violators, self-reported CSS nonuse was related to hassles that are associated with child behaviors and crowding/inconvenience, but the overall accuracy of the prediction still was low. The CSS Hassles Scale potentially is useful as a guide to address factors that may result in nonuse of CSS. Additional development of the instrument requires validation for its use as a screening or educational tool.
This study was supported by grant R49/CCR915456 from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
We appreciate the suggestions of an anonymous reviewer.
- Accepted February 13, 2006.
- Address correspondence to Phyllis F. Agran, MD, MPH, Department of Emergency Medicine, Center for Trauma and Injury Prevention Research, 101 The City Dr, Building 200, Suite 715, Orange, CA 92868. E-mail:
The views in this article are those of the authors and do not necessarily represent the official views of the National Center for Injury Prevention and Control.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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