Objective—To assess parental decision making in the acquisition of an infant walker and the influences surrounding that decision.
Design/methods—Caretakers of children attending a residents' continuity practice during a one month period were invited to participate in a structured interview to assess various aspects of infant safety. Ten questions specifically addressed infant walkers and the decision to acquire one; seven questions collected demographic data.
Results—One hundred and fifty four primary caretakers participated. Of these, 77% (n=119) of caretakers used infant walkers for their child. For children who were not first born, 85% of caretakers had used walkers with their other children. No statistically significant differences were found between walker users and non-users with respect to the sex or birth order of the child, race, education, or (type of) caretaker. Also, no differences were found between these groups with respect to having received safety information from the pediatrician. For users, 97% heard about walkers before their baby's birth, but 65% did not decide to use one until after the birth. In addition, 61% of walker users stated that no one influenced their decision to get a walker and 75% bought their own. These decisions were not affected by caretaker education or birth order of the child. Finally, 78% believed that walkers were beneficial, and 72% believed that walker use accelerated development of independent walking skills.
Conclusions—Mothers purchased walkers because of no uniformed perception of benefit. A period of time, up to several months in length, exists from when the first mother hears about walkers until she decides to purchase one. Until legislation can be passed banning walkers, this period of time may provide a window of opportunity for appropriate anticipatory guidance in the form of intense media assisted, antiwalker campaigns.
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Although used in the western world for several centuries, infant walkers have only become a household item in the United States within the last several decades.1 Several studies have reported that between 64–92% of children less than 1 year of age use walkers.1–7 Reasons for using walkers are varied and include keeping the infant quiet and happy, encouraging mobility and promoting walking, providing exercise, and keeping the infant safe.1, 3, 6
Despite parents' good intentions, in 1993, 25 000 children aged 5–15 months were treated in American hospital emergency units for walker related injuries.8 In addition, population surveys reveal that there may be as many as 10 times that number of injuries not serious enough to warrant a visit to the hospital.3 While in a walker, the infant's weight is supported, therefore allowing him or her to ambulate before the normal developmental stage of walking. This increased mobility exposes children to hazards for which parents are unprepared.7 It is estimated that 12–50% of children who use walkers are injured.1–4, 9, 10
In spite of increasing numbers of reports of injuries from walkers and recommendations from the American Academy of Pediatrics not to use them,9 parents continue to purchase walkers. This study assesses decision making in the acquisition of a walker and the influences surrounding that decision.
This study is one section of a three part survey designed to assess various aspects of infant and child safety. Subjects, primary caretakers of children seen in a continuity practice for pediatric residents during a five week period in the summer of 1996, were invited to participate.
The questionnaire was administered as a structured interview by three students trained in interview techniques by an experienced social worker. Ten questions specifically addressed infant walkers, including the decision to acquire a walker; other questions gathered demographic data.
Analysis by χ2 was initially used to compare demographic factors between walker users and non-users. Logistic regression then determined whether birth order (first born or not) or maternal education (high school graduate or not) influenced the timing of the decision to purchase a walker (before or after birth).
One hundred and fifty four primary caretakers participated and only six refused. The majority of caretakers were mothers (90%); others represented included fathers (3%), grandmothers (3%), and other relatives (4%). Racial distribution of the sample included African American (79%), white (18%), Hispanic (2%), and other (1%). Birth order of the study subjects' children was 45% first born, 27% second born, 19% third born, and 7% fourth born or greater. Maternal education included from no high school (21%), some high school (29%), high school graduate (27%), some college (13%), and college graduate (10%).
Forty two per cent of participants said that they consider the pediatrician as a source of safety information. Maternal grandmothers (16%), television (21%), magazines (13%), books (14%), and “no-one” (18%) were the other major sources of safety information used by caretakers. When specifically asked if their pediatrician ever spoke to them about child safety issues, 81% responded positively. A review of a sample of medical records demonstrated documentation (checklist) of physician provided anticipatory guidance about infant walkers at both the four month and six month visits.
In the sample, 77% of the caretakers used infant walkers. For children who weren't first born, 85% of caretakers had used walkers for their other children. As expected, there were no differences between the walker users and non-users with respect to the sex or birth order of the child, race, maternal education, or type of caretaker. There was also no difference between these groups with respect to having received safety information from the pediatrician.
To help assess the decision making process, two questions were asked. The first question focused on when the caretaker first heard about walkers, and the second targeted the time frame when the decision to obtain a walker was made. Ninety seven per cent of caretakers heard about infant walkers before the baby was born. However, the decision to use walkers was made by only 35% of them before the baby's birth. The remaining 65% made the decisions when the baby was a few weeks old (4%), when the baby was a few months of age (53%), or at another time (8%). Logistic regression showed that timing of the decision to buy a walker, either before or after birth of the child , was not influenced by maternal education or by the child's birth order.
A third question was asked to determine who was the greatest influence on the caretaker's decision to acquire a walker. Interestingly, 61% of the subjects responded that no-one influenced them; they simply obtained a walker because they wanted one. In addition, of the 81% of caretakers whose pediatrician spoke about infant safety issues, 75% used walkers anyway.
Caretakers obtained walkers from several sources. The majority (75%) purchased them for their child, while 16% received them as a gift, and 7% received them as hand-me-downs or had one from a previous child. Thus, it appeared that the decision to acquire a walker was not influenced by individuals or other sources.
When asked if walker use was beneficial to their child, 78% of caretakers responded affirmatively and 72% believed that children who use walkers learned to walk earlier. Adverse consequences mentioned by those who did not think that walkers were beneficial included delayed walking, falling out of walker, and falling down stairs.
In this study, we confirmed a prevalence of infant walker use (77%) comparable with previous studies.1–6, 11 Mothers still believe a walker is beneficial. Some believe it promotes the development of independent walking skills, despite the fact that there is no justifying support for this view.5, 9, 11–14 Only 22% of those questioned believed that walkers were of no benefit to their children, and many parents were unsure why walkers were not good for them.
Pamphlets are available that discourage walker use.15 Although parents say that their pediatrician speaks to them about safety issues, and we can document that anticipatory guidance is provided about the danger of walkers, parents remain uninformed or misinformed about their use.
Our data suggest a “window of opportunity” for education from the time the mother hears about infant walkers before the birth of her baby until the time she decides to acquire a walker when her infant is several months old. This window of opportunity, up to several months in length, may be the best time for appropriate anticipatory guidance. New parents are motivated to make changes in their own lifestyles “for the good of the baby”.16 We can capitalize on this specific behavior with strong media campaigns and antiwalker promotions to reinforce the pediatricians' message. Media campaigns have been effective in advocating use of bicycle helmets17–20 and in the “Back to Sleep” program.21–23 Like these campaigns, efforts designed to prevent walker use should be widespread and not only involve the media, but extend into physicians' offices, the women, infants, and children office, and public health clinics. At present, physicians may be providing this guidance too late, or with too much other anticipatory guidance. Perhaps providing information on this single subject, in a repetitive manner, from the time of birth, would be more effective.
Pediatricians have repeatedly stated that infant walkers have no value and increase injuries. The American Academy of Pediatrics supports this view and recommends a ban on the manufacture and sale of infant walkers.9 There are mandatory and voluntary standards regarding infant walkers.9 Some of these have been successful in decreasing specific injuries. Several proposals have been advanced to further alter walker design, but these changes have not been implemented. Until changes are mandated, pediatricians need to work with their state legislatures to develop effective legislation banning the sale of infant walkers.
Children are being injured in a device parents look upon as beneficial for their children. It is crucial to intervene before the decision to acquire a walker is made. We suggest that there is a critical period where an intervention may make a difference. Until effective legislation is passed, it is necessary to utilize this window of opportunity to prevent walker use.
Presented in part at the Annual Academic Societies Meeting 3 May 1997, Washington, DC.
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