Skill, Attitudes and Behaviors on Child Passenger Safety among Expectant Mothers and Parents of Newborns: A Qualitative and Quantitative Treatment
Conceived and designed the experiments: XC LL XL. Performed the experiments: XL. Analyzed the data: XL. Wrote the paper: XL LL JY.
Abstract
Objective
To investigate the skill, attitudes, and intended behaviors about use of child safety seats among parents of newborns and explore expectant mothers’ views and decisions regarding child safety seats use.
Methods
A cross-sectional survey and semi-structured interview were conducted in the maternity departments of two hospitals in China. Parents of newborns were recruited after delivery and surveyed on their skill, attitudes and behaviors regarding child safety seats use. Pregnant women were also interviewed to learn about their views and decisions regarding child safety seats use. Both quantitative and qualitative methods were used to analyze the data collected.
Results
Of a total of two hundred forty two parents of newborns recruited in the quantitative survey, two hundred two (83.5%) parents had heard of child safety seats and one hundred forty nine (61.6%) parents reported they would use child safety seats for their babies. Parents’ skill, car ownership, occupation, and income were significantly associated with their decision regarding use of child safety seats. Three themes were identified from the qualitative interview of thirty pregnant women: (1) the pregnant women perceived child passenger safety as significant; (Two) the car ownership and price and quality of child safety seats were major influencing factors of their decisions on use of child safety seats; and (Three) lack of awareness and lack of laws requiring use were perceived to contribute to low use of child safety seats in China.
Conclusion
Lack of skill and awareness on child passenger safety were found to be two most significant factors associated with low use of child safety seats. Effective interventions are urgently needed to improve parents’ skill before laws are enacted and implemented.
Introduction
Motor vehicle crash related injuries and deaths among children is becoming an enhancing global public health problem[1]. Road traffic crashes have become the 2nd leading cause of injuries and deaths for children ages five to 14, 2nd only to infectious disease[Two]. A report from World Health Organization showcased that road traffic injuries accounted for approximately 262,000 child deaths among children and youth aged 0–Nineteen years—almost 30% of all injury deaths among children[Three]. In China, road traffic injuries are the leading cause of death in children under age 14. In two thousand twelve alone, Legitimate,500 children under age fourteen died in motor vehicle crashes[Four]. Albeit the number of motor vehicles in China is less than half of that in the United States, motor vehicle crash related deaths among children in China are three times the rate in the United States[Five]. Of all the road users who died in traffic crashes in China from two thousand to 2008, passengers accounted for 24.3%, 2nd only to pedestrians[6]. Child passengers are a vulnerable population, with high risk of crash-related injuries and deaths[1].
The decent use of child restraint seats reduce risk of fatality among infants by 71% and among toddlers by 54%[7]. Several existing studies on child passenger safety conducted in China showcased that usage of child passenger restraint was very low [8–Ten]. A survey explore conducted in Shanghai found that of nine hundred seventy child passengers aged three to seven years, 60.8% were not restrained by child safety seats (CSS) or booster seats, and 32.0% were sitting on an adult’s lap[8]. The researchers confirmed similar findings in their observation probe conducted in Shantou in 2013[Ten]. Of Three,333 child passengers observed, only twenty two (0.6%) used CSS or booster seats, and for infants, toddlers, and preschool children, more than 95% were not placed in child restraints[Ten].
In more latest years, efforts have been made to improve child passenger safety in China[11,12]. These include targeting birthing mothers in the maternity wards to educate them about the importance of CSS use[11], and providing the parents of children ages three to eight with free CSS to increase use[12]. Despite of these efforts, CSS use rate is still very low. One of the reasons for such low usage is lack of legislation. In the entire country of China, there were no laws or regulations on child passenger safety until March 2014, when Shanghai passed local child passenger safety legislation. The fresh legislation requires that child passengers junior than age four be restrained by CSS and that child passengers junior than age twelve must sit in the back seat[13]. Following the enactment of legislation in Shanghai, several other provinces and cities in China, including Shandong province[14] and Shenzhen city[15] have also passed and enacted local legislation. However, presently, there is no national policy or legislation in China that specifies how to securely transport newborn babies from the hospital to home. Most of the infants leave the hospital unrestrained[11]. Hospitals in China do not bear any responsibility if there are injuries to the newborn on the way home due to not restraining the child in a CSS. Thus, it becomes parents’ responsibility to protect their newborns and ensure safe transportation.
Pregnant women are required to make a series of decisions regarding child safety even before the baby is born. One of the very first decisions these expectant mothers need to make is how to rail home securely from the hospital after providing birth. In China, about 50,000 infants are born every day, with the vast majority of them born in hospitals. Understanding of the mothers’ and/or expectant mothers’ concerns regarding child passenger safety, and factors influencing their intended and actual use of CSS is an significant very first step in protecting children from traffic related injuries and deaths. In this investigate, we investigated the skill, attitudes and behavioral intention regarding use of CSS among parents of newborns, using a quantitative treatment. We also explored expectant mothers’ views and decisions regarding CSS use, using a qualitative treatment. It is our hope that the skill gained from this probe will help in the development of interventions targeting expectant mothers and/or parents of newborns to increase their skill, intention and behaviors associated with protecting their child passenger from traffic related injuries and deaths.
Methods
Both quantitative surveys and qualitative interviews were used in this probe to understand the factors influencing the expectant mothers’ decision of use of CSS and the factors influencing the parents’ use of CSS. A quantitative survey was utilized to investigate the skill, attitudes, and behaviors on child passenger safety among parents of newborns, while a qualitative interview among expectant mothers was used to help better understand and explain the quantitative results. A detailed description of the explore procedure is shown in Fig one . The investigate protocol, along with the consent process, was approved by Medical Ethics Committees of Shantou University Medical College.
Quantitative Survey
Survey participants
Two hospitals in Shantou, a coastal city located in China, were randomly selected: (1) Shantou Women’s and Children’s Hospital, a general hospital tooled with sixty ward beds with about three hundred infants delivered per month, and (Two) Shantou University-the Very first Affiliated Hospital, a general hospital tooled with fifty ward beds with two hundred fifty infants delivered per month. Both were non-profit hospitals. Pregnant women from these two hospitals have similar demographic characteristics, such as language, income, educational background and occupation (P>0.05), and thus, they may share similar views on CSS use. A convenience sample of parents of newborns was recruited to accomplish a questionnaire in person in the maternity wards after delivery. The inclusion criteria were: (1) the parent of a newborn; (Two) both the parent and the newborn were healthy without any adverse postpartum symptoms; and (Trio) agreed to participate through a signed consent document. Parents who did not speak mandarin or could not read or write were excluded. In the investigate, no one was excluded because they did not meet the criteria.
Survey instrument
The survey instrument was developed by the research team based on the published work and team’s previous work in this area[Ten]. The questions asked included four parts: Socio-demographic characteristics; skill; attitudes; and behaviors about child passenger safety. The reliability and construct validity of the survey instrument was 0.73 and 0.78 respectively.
Survey data collection
Four trained medical graduates conducted the survey at two participating hospitals’ maternity wards after delivery. Following the approval of the two hospitals, the head nurse of the maternity wards in the respective hospitals received training on the probe protocols. The head nurse informed all the parents of newborns about the research project. Parents who voiced interest in participation were introduced to the research staff. During the meeting, research staff confirmed the parents’ interest, answered any questions the parents had, obtained informed consent, and administered the paper survey. The data collection was conducted inbetween October two thousand fourteen and April 2015.
The returned surveys were reviewed by two investigators before coming in into the computer to ensure quality of data. A total of fifty eight returned surveys were excluded from analysis, including fifty five incomplete surveys, two blank surveys, and one illegible survey.
Main outcome measures
Skill of child passenger safety was measured by eight questions, asking participants about their awareness of the car seat, airbag, CSS, and other related issues. Attitudes among newborn parents was measured by three questions including their favorability and resources to obtain child safety information, their view of current CSS legislation in China, and reasons and attributable factors of current low use of CSS in China. Behavior of child passenger safety was measured by three items regarding CSS use and four items about their own driving safety behaviors. These included whether the participants intend to use a CSS. would buy a CSS, or would rent a CSS when the option is available; and whether the participants had ever driven after drinking, had ever smoked while driving, had used a cell phone while driving, or had worn seat belt.
Survey data analysis
Survey data were entered into EpiData version Three.0 for windows and then analyzed using SPSS version Nineteen.0. All the data was double-entered to ensure quality. The frequencies for all variables were computed. The differences in skill and attitudes of parents of newborns across the subgroups were compared. The factors associated with intent and actual behaviors of CSS use were assessed using logistic regression.
Qualitative Interview
Interview participants
Pregnant women who sought prenatal care at Shantou Women’s and Children’s Hospital were recruited for a semi-structured interview. The inclusion criteria were: (1) women were more than twelve weeks pregnant; (Two) wielded a car; and (Trio) agreed to participate through signed consent. Pregnant women who were diagnosed with high risk of pregnancy or who were incapable to finish more than fifteen minutes of an in-person interview were excluded. The targeted sample size was thirty to reach saturation.
Interview guide
A semi-structured interview guide was developed based on existing literature, the objective of the research, and the results of the survey. The key questions included (1) what main concerns the pregnant women had regarding child passenger safety; (Two) what factors may potentially influence their decision on whether or not to use CSS, and (Trio) what they believe the reasons are for current low use of CSS in China.
Interview data collection
The in-depth interviews were conducted face-to-face by one of the two authors who were trained in qualitative interviewing and examine protocols. Before the interview, the pregnant women who voiced interest were informed about the purpose and process of the interview, were screened for eligibility, and signed the informed consent. Each interview was conducted in a private room in the hospital and lasted about thirty minutes. All interviews were audio recorded and transcribed into electronic documents word-for-word on the same day by another author of this manuscript before data analysis.
Qualitative data analysis
The transcribed electronic documents were imported into software NVivo 8.0 and read repeatedly by two researchers, who coded and analyzed thematically. Based on the content of the documents, the research team developed unified coding rules. Each coding was discussed by two researchers. If they encountered disagreement in the process of encoding, the researchers discussed and refined codes together until consensus could be achieved. Through this coding process, key words or themes and unified ideas which described the factors that influenced their decision of use of CSS and the reasons of low use of CSS in China were identified as the themes and sub-themes. All of the thirty coding documents were ultimately generated and categorized into three final themes. The data and results were assessed by researchers who speak English, Chaozhou-Shantou dialectal and Mandarin, the languages used by the participants.
Results
Characteristics of Parents of Newborns in the Quantitative Survey Examine
A total of three hundred questionnaires were distributed and two hundred forty two valid surveys were returned, with a response rate of 80.7%. The socio-demographic characteristics of the participants are shown in Table one . Of two hundred forty two participating parents, ninety three (38.4%) were masculine and one hundred forty nine (61.6%) were female, with one hundred sixty five (68.2%) of participants aged from twenty one to thirty years. The average age of the participants was 28.7 (±Four.395). Almost two-thirds (65.7%) of participating parents resided in Shantou. More than two-fifths of them had received undergraduate or higher education (masculine and female accounted for 44.6% and 43.4% respectively).
Past Driving-Related Behaviors of Parents of Newborns
Of the total (242) respondents, one hundred ninety four wielded at least one car, one hundred eight (55.7%) considered buying a CSS when they bought their car; ten (Five.2%) reported that they had ever driven after drinking; thirty one (16.0%) had ever smoked cigarettes while driving; one hundred thirty six (70.1%) had answered phone calls while driving. A majority of the participants (n = 153, 78.9%) reported wearing seat belts every time as a driver, but only one hundred twenty seven (65.5%) participants reported wearing seat belts every time they were the front passenger ( Fig two ).
Parental Skill of and Attitudes toward Child Passenger Safety
The parental skill and attitudes towards child passenger safety are shown in Table two . Of two hundred forty two respondents, one hundred thirteen (46.7%) parents thought that seat belts could protect child passengers who were twelve years and junior, and one hundred thirty five (55.8%) parents thought airbags could protect child passengers aged twelve years and junior. Almost one-fourth (n = 60, 24.8%) of parents believed holding their baby on the lap was safer. A majority of (83.5%) respondents had heard of CSS, and one hundred sixty eight (83.2%) thought it was necessary to use CSS in order protect child passengers. When asking about their preferred methods and channels to receive child passenger safety information, 57.8% of parents indicated that they preferred to receive brochures, while 22.3% preferred to search for such information by themselves. Almost three quarters of respondents (n = 147, 72.8%) indicated that the present price of CSS on the market was high, and only seven (Three.5%) participants thought the CCS price was very affordable. When asking about the reasons why CSS was not popular in China, the participants indicated that poor awareness and skill of child passenger safety was the top reason (78.7%), followed by high price (Ten.9%), and a lack of mandatory national legislation (8.9%); the other reasons included inconvenience to use, occupying too much interior space, and having a car that cannot have a CSS installed.
Factors Influencing CSS Use
Use of CSS was statistically significantly higher among participants who were female, who were fathers with undergraduate or higher level of education, who were not stay at home mothers, and who possessed a car ( Table one ). Additionally, participants who had not heard about CSS before, or who believed that feeding a child in a driving car was safe had low use of CSS. After adjusting for gender, household income per capita, education level, occupation, car ownership, and skill of child passenger safety, results from multivariable logistic regression analysis demonstrated that occupation of father, occupation of mother, household income per capita, car ownership, and skill of child passenger safety were significantly associated with CSS use ( Table three ).
Characteristics of Pregnant Women in the Qualitative Investigate
Of thirty pregnant women interviewed, twenty three (76.7%) were pregnant for the very first time while seven (23.3%) were in their secondary pregnancy, with ages ranging from twenty two to 40. Twenty-five of the thirty participants were native to Shantou, and the rest were originally from other parts of China and were working and living in Shantou during the examine. All participants possessed at least one private car, and four of them drove the car by themselves, while the rest railed in a car with their husbands to and from work daily.
Three Key Themes Identified
The three key themes identified from interview data were: (1) the pregnant women lack skill about child passenger safety; (Two) the car ownership, and the price and the quality of CSS the main factors influencing their decision regarding CSS use, and (Trio) lack of awareness and lack of laws on child passenger safety in China were perceived to contribute to low use of CSS in China.
The sub-themes of parents’ practices and practices related to child passenger safety were derived from the three major themes. Respective supporting quotes were:
I feel that holding children on laps is safer. It is a natural human response that people would hold children tightly when a car brakes. If a child is restrained in a safety seat, I feel I could not protect my child when a car abruptly brakes.
———A pregnant woman who had held her child passenger
I think the CSS is fairly necessary. Especially when the unplanned hard brakes or traffic accidents happen, it acts as a buffer. The child is likely to be left out without the buffer of an installed device. Having not used CSS, I don’t know how much it costs. Of course, I don’t know how to install it either.
The mainly reason is the legal vacancy. For example, fresh laws on front seat passengers indicate that sitting in the front seat without wearing a seat belt will be disciplined two points and fined two hundred Chinese Yuan. With enactment of such laws, everybody is required to wear seatbelts. So to improve CSS use, fresh laws on child passenger safety are urgently needed.
———A pregnant woman who drove her car to work everyday
We found that parents with poor awareness of child passenger safety often exhibited risk behaviors, including holding or feeding a baby in a moving car. To protect child passengers, parents must be targeted for their awareness of child passenger safety. The results from this investigate indicate that the major factors that influence parents’ decision of CSS use were whether they own a car, and the price and quality of CSS. In addition, a lack of mandatory legislation was an significant factor contributing to the low CSS use in China. These findings were confirmed through both quantitative and qualitative approaches, and provide the foundation for a future intervention focused on reducing child passenger injuries.
Discussion
While there is a bod of literature on child passenger safety using quantitative approaches[1,Five,Ten,11,16–Nineteen], little has been done using qualitative approaches[20,21]. Existing studies have little been specifically focused on expectant mothers[21,22]. This is the very first probe conducted in China examining pregnant women’s attitudes and behavioral intention regarding CSS use. Focusing on pregnant women as a potential target population for child passenger safety has several advantages. Very first, as prospective parents, pregnant women, especially those who are pregnant for the very first time, desire to stay close to the child for taking care of them[21]. 2nd, as the mothers to be, they are more like to be trained to practice child passenger safety behaviors[23]. Eventually, most pregnant women go to the hospital for regular prenatal care, so implementing child passenger safety education program during their visit has practical value[21].
Our findings demonstrated that the parental skill on child passenger safety was poor, and that many parents did not have a good understanding of child restraint systems. Specifically, 46.7% of parents of newborns considered seat belts to protect child passengers aged twelve years and junior, and over half (55.8%) of parents of newborns thought that airbags could protect child passengers. Research has demonstrated that seat belts are a restraint system for adults, and that children’s bods are too petite to be protected effectively[12]. Studies have shown that child passengers aged five to nine who use an adult seat belt have an incidence of injuries that is Two.7 times that of adults[8]. Airbags are also an significant contributing factor to child’s head and neck harm, and the enormous impulse force at the moment of expansion can be fatal to a child passenger. Even in the case of equipping a car with a child restraint system, the child passenger should also be far away from the airbag.
The parents’ poor awareness of child passenger safety is one of the major contributing factors to the child passenger related risk behaviors. Over 80% of respondents had heard of CSS, and among them, 48.3% indicated it was necessary for child passengers to use CSS. During the interviews, we also learned that a majority of pregnant woman had seen CSS on television or at a CSS store, and thought it had a protective effect on child, but without using it, they didn’t know how to install it. While all of the parent participants in our quantitative survey explore possessed private cars, 63.2% of them had considered purchasing a CSS. However, actual purchase and use of CSS was infrequent. A latest explore demonstrated that 75.6% of child passengers didn’t use CSS in China[24]. Previous studies conducted in China displayed that the rate of CSS use was about 5% in Beijing[9] and in Shanghai[8], both metropolises with a large number of private cars. In the petite city of Shantou, it was less than1%[Ten].
Consistent with previous investigate findings[11], public education on child passenger safety was also identified as one of two effective approaches to prompt CSS use in our explore. Almost 80% (78.7%) of parents in our survey thought the reasons that CSS use was not popular in China was people’s poor consciousness coupled with a lack of skill. Thus, designing and implementing programs that concentrate on the improvement of parents’ skill of and attitudes toward child passenger safety might be the most significant very first step to help increase CSS use. These programs would be particularly practical in a puny city like Shantou, where the economic development of the city makes it challenging to instantly enact a law requiring every child passenger to use CSS. These programs should involve the efforts from the government, education department, hospitals, and CSS enterprises[11,25,26]. These programs could be delivered through TV, news broadcast, and other media, as many of our interview participants indicated that they gained skill of child passenger safety through these channels. Another effective strategy to improve CSS use is to have mandatory use legislation.
In our survey probe, almost 10% of respondents thought no mandatory national legislation was another reason for low CSS use in China, which was supported by the results of our interview explore. Mandatory legislation has been shown to effectively improve the utilization rate of CSS in other countries[Ten,25,27,28]. However, national legislation is unlikely to be put in place soon in China, albeit Shanghai and Shandong provinces have implemented local regulations, which require child passengers less than age four to use CSS. In the United States, after the legislation enforcement, the CSS utilization rate enlargened by 6% per capita, and child road traffic injuries decreased by 5% per capita[27]. Some researchers believe that the current skill level of CSS in Chinese parents is equivalent to the level of western countries in 2000[8], albeit traditionally, Chinese parents pay more attention to their children. Our findings, along with others, call for extra efforts on enactment of the laws and legislation to effectively increase the use of CSS and reduce road traffic injuries[1,28].
This examine has three limitations. Very first, the data on attitudes, and intended and actual use of CSS use was based on self-report, thus respondents may not report truthfully due to social desirability. 2nd, there was a selection bias. Both the qualitative and quantitative explore used convenience sampling to recruit subjects. Thus, the participants may not represent all expecting mothers and parents of newborns. Third, the sample in the quantitative research was puny in size. As fresh mothers need to rest after delivery, the father of newborn is busy taking care of the infant, the mother, and visiting friends and relatives. Even tho’ we made every effort to recruit fathers, we were not able to recruit a large sample. Eventually, because of the nature and purpose of this probe, advanced statistical methods were not used to control for confounding factors when assessing skill, attitudes, and intended behaviors about use of child safety seats among parents of newborns. Further research with larger sample sizes and more comprehensive analytic approaches are warranted.
Conclusions
This examine documented the skill, attitudes and behaviors towards child passenger safety among parents of newborns. Participants had a poor awareness of child passenger safety with low risk perception. Effective measures must be taken to improve parents’ skill and perceptions with child passenger safety promotion before legislative interventions are implemented.