You are here

Article Text

Article menu

Download PDFPDF

Brief report
Exploring child car passenger safety practices in China: experience from a parental survey in Shanghai
  1. Shuming Pan1,2,
  2. Wei Du3,4,5,
  3. Fan Jiang2,6,
  4. Lynne E Bilston3,7,
  5. Julie Brown3,8,
  6. Xiaoming Shen2
  1. 1Emergency Department, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
  2. 2Shanghai Paediatric Research Institute, Shanghai Key Laboratory of Children's Environmental Health, Shanghai, China
  3. 3Neuroscience Research Australia, University of New South Wales, Sydney, Australia
  4. 4Institute of Population Research, Peking University, Beijing, China
  5. 5The George Institute for International Health, Faculty of Medicine, University of Sydney, Sydney, Australia
  6. 6Department of Developmental and Behavioural Paediatrics, Shanghai Children's Medical Centre, Shanghai, China
  7. 7Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
  8. 8School of Medical Sciences, University of New South Wales, Sydney, Australia
  1. Correspondence to Dr Xiaoming Shen, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Institute for Paediatric Research, Shanghai Key Laboratory of Children's Environmental Health, Shanghai 200092, China; xmshen{at}shsmu.edu.cn

Abstract

Little is known about child passenger safety practice in China. This study aims to describe child passenger seating and restraint practice in Shanghai. Information on 970 children enrolled in five randomly selected kindergartens in the Songjiang and Pudong districts of Shanghai was collected from a parental survey during 2008–2009. The adjusted rate ratios for optimal (rear-seated alone) versus suboptimal seating position (including front-seated or sitting in adult laps) and restraint use versus non-use of restraints among child passengers were evaluated using multivariate binomial regression. Suboptimal seating position (16.9%) and non-use of restraints (60.8%) was common among child passengers. Younger age (≤4 years) and having parents who are licensed drivers decreased the likelihood of being rear-seated alone; whereas having a tertiary-educated mother increased the likelihood of a child being seated optimally. Compared with unlicensed parents, guardian parents who have a driver's licence were more likely to use restraints for their child passengers. This study suggests restraint non-use and suboptimal seating position are common for child passengers in the Songjiang and Pudong districts of Shanghai, and identifies risk factors influencing restraint use and seating position choice for child passengers. There is an urgent need to improve child passenger safety in China and these findings indicate potential targets for educational interventions in the absence of child restraint laws.

  • Child car passengers
  • seating position
  • child restraints
  • safety practice
  • motor vehicle
  • occupant
  • epidemiology
  • statistical issues
  • child
  • engineering
  • spinal cord
  • restraint
  • head injury
  • MVTC
  • standards
  • passenger
  • child
  • equipment

https://doi.org/10.1136/injuryprev-2011-040049

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    Child road trauma is a significant public health problem in China.1 The WHO estimates that road crashes result in more than 40 000 casualties across all road users every day in China,2 and at least 10% of these are children including child passengers.3 These casualty numbers are set to increase with the rapid motorisation currently occurring in China, where more than 18 million new passenger cars were sold in 2010, an increase of 32.4% over 2009.

    Much child passenger trauma is preventable. It is well established that rear seating4–6 and restraint use5 7 reduce injury risk in crashes. In China, known effective countermeasures such as mandatory child restraint legislation and community-based campaigns to improve child passenger safety are lacking.3 Although new seat belt laws were introduced in 2004, they are not widely enforced. Moreover, although seat belt information is included in the driver training and licensing programmes, no child passenger safety knowledge is addressed. It is therefore not surprising that previous observation has reported that many child passengers are unrestrained or are seated in the front seat.8 Routley et al8 observed urban seat belt use in two cities in eastern China (Nanjing and Zhoushan), and among the subset of child passengers aged 0–8 years, they reported that 98% of occupants were unrestrained, none used child restraints and approximately 20% were front seated. A parental self-report study in a convenience sample in a Beijing shopping mall found that 64.8% of children aged 0–14 years used some restraint and that 31.1% were front seated.9

    Prioritising appropriate countermeasures to reduce child passenger casualties (such as increasing child restraint use and rear seating) requires an understanding of the social context, especially child and parental attributes, which have been shown to influence how children travel in cars in Western nations.10–12 These factors are likely to be different between China and North America or Australia because there are inherent differences in demographics, for example, family size due to the one-child policy in China, as well as differences in the historical levels of motorisation. Widespread access to motor vehicle transport is a more recent phenomenon in China and so there is unlikely to be similar cultural norms in safety practice in China as are present in other countries. However, this information is currently missing from the literature related to child passenger safety in China.

    This study aimed to describe child passenger safety practices in China and determine how child and parental attributes influence child passengers' seating position and restraint use.

    Methods

    During the October 2008–October 2009 period, parental surveys were conducted in five randomly selected kindergartens in the Songjiang and Pudong districts of Shanghai (details of questions are provided in table 1). These two rapidly developing urban districts have a kindergarten population of more than 96 000 children. Principals and administrative boards assisted survey implementation to achieve a high response rate. All parents of enrolled children aged ≤7 years (N=1010) were recruited (one parent per family), and all children were from one-child families. This survey was approved by the Shanghai Jiaotong University ethics committee.

    View this table:
    Table 1

    Seating position and restraint use questions in the survey

    Participating parents took home the survey questionnaires. Upon return of the survey, data fields with missing and/or incomplete information were examined, and where necessary, further clarification was sought from the respondents. To improve survey data quality, we used follow-up telephone calls to parents to crosscheck answers and clarify any unclear responses. Double entry of the data into a custom-designed database was used to minimise potential data entry errors.

    Data coding

    For statistical analysis, two outcomes were evaluated: seating position and restraint use by child car passengers. We categorised seating position irrespective of being restrained or not as binary, that is, optimal (rear seated other than on an adult lap) or suboptimal (including always front seated, sitting on an adult's lap in either the front or the rear or sometimes front seated); restraint use as any restraint use (including child safety seat, booster or seat belt) or no restraint use; each child's age as either ≤4 years (preschool age) or >4 years (school age); gender as male or female; parental licence status as licensed (more likely to be drivers) or not (more likely to be passengers); family income as high (>¥10 000 a month), low (≤¥10 000 a month) or unknown; and tertiary education for mothers as yes or no.

    Statistical analysis

    All data analyses were conducted using SAS V.9.1.3.13 We calculated frequencies and proportions for age group, gender, seating position and restraint use where appropriate. Controlling for children's age group and gender, parental licence status, family income and mothers' tertiary education, we used multivariate binomial regression to estimate the adjusted RRs14 for the two outcome variables (ie, optimal compared with suboptimal seating positions and any restraint use compared with no restraint use). Robust variance estimation was used to calculate 95% CIs accounting for potential correlation of parental attributes clustering within centres.15 We set p value <0.05 as statistically significant.

    Results

    A total of 1010 parents participated in the survey, with a participation rate of 100%. The final study population comprised information for 970 children aged 3–7 years enrolled at kindergartens during the study, whose characteristics were similar to those of 40 children (5%) excluded from the study due to missing information on seating position, parent's education level and family income: the proportion of no restraint use in the study population was 60.8% (vs 65.0% in those excluded), the proportion of children aged ≤4 years was 44.0% (vs 42.5%) and the proportion of boys was 56.0% (vs 54.4%).

    In this study, 78.0% (n=759) of parents reported having heard of child restraints (including booster seats) but very few owned them (about 5.9%, n=57) or used them (about 1.2%, n=12), whereas 29.4% (n=285) of parents reported that their children travelled in cars almost every day. Among all children, 44.0% (n=427) were aged ≤4 years; 83.1% (n=806) of parents reported that their child always sat separately in the rear seat (ie, not on an adult's lap) (table 2), and 39.2% (n=380) of parents reported that their children used some form of restraint (table 3). The proportion of seating position differed by age (table 2), whereas the proportion of restraint use differed by parental licence status (table 3).

    View this table:
    Table 2

    Variation of seating practices for children aged 3–7 years with child and parental characteristics

    View this table:
    Table 3

    Variation of restraint practices for children aged 3–7 years with child and parental characteristics

    Younger children (aged ≤4 years) were less likely to be seated in the rear compared with children aged >4 years (RR 0.82, 95% CI 0.77 to 0.87) (table 4). Compared with parents who were unlicensed, parents holding a driver's licence were slightly less likely to report that their child occupied an optimal seating position (RR 0.95, 95% CI 0.91 to 0.99), but they were more likely to report restraint use by their children (RR 1.44, 95% CI 1.18 to 1.75) (table 4). Mothers with a tertiary education were slightly more likely to report that their child occupied an optimal seating position compared with those who did not have tertiary education (RR 1.08, 95% CI 1.03 to 1.13) (table 4).

    View this table:
    Table 4

    RRs (95% CI) for children being restrained or seated in the rear when travelling in cars, Shanghai 2008–2009

    Discussion

    This study demonstrates that the child's age, parental licence status and mothers' tertiary education were associated with how children in China are seated, and only parental licence status was associated with whether children used restraints in cars. The results highlight the need for improved restraint and seating practice for child passengers in China and provide some insight into the demographic factors influencing these practices.

    Prevalence of rear seating alone/restraint use

    The prevalence (83.1%) of rear seating among child passengers is higher in this study than that (68.9%) reported among 843 parents surveyed in a shopping mall in Beijing,9 whereas prevalence of restraint use by children (39.2%) is lower than that reported (64.8%) for children aged 0–14 years from the Beijing survey.9 This could be partly due to the different ages of children (2–7-year-olds vs 0–14-year-olds), different data collection sources (five kindergartens vs a shopping mall) and/or analysis methods; for example, we used robust variance estimator to adjust for factors influencing child passenger safety practice. In addition, there may be regional cultural differences between Shanghai and Beijing influencing the results. It is interesting to note that prevalence of rear seating is higher in this study than that found in two cities in the USA.16 Apart from cultural and/or knowledge differences, the number of children travelling in the same car may be different between countries, and this may influence rear-seating practices observed here compared to that reported in other motorised countries.16 Unfortunately, we did not explore this question in the survey because of the study sample comprising only one-child families; that is, a family car would normally transport one child passenger. However, there are situations where more than one child might travel in the same car in China. Further roadside observational studies in China might provide further insight on this issue.

    The prevalence of restraint use among children in this study was lower than that seen in developed countries, for example, 83–98% in the USA.17 This difference may be attributed in part to the lack of comprehensive strategies such as widespread child restraint education campaigns, police enforcement targeting restraint use and compulsory child restraint use legislation. This study found that approximately 40% of children were unrestrained, which is lower than the findings of a previous study reporting that about 98% of children were unrestrained.8 Some study design elements may explain this difference, for example, study location (ie, Shanghai vs Nanjing and Zhoushan), data collection method (ie, self-report survey vs observation) and study population (ie, preschool population aged 3–7 years vs children aged 0–8 years).

    Factors influencing optimal seating position

    This current study found that younger children (aged ≤4 years) were less likely to be always rear seated, which is opposite to the trend in Australia18 and in European countries.16 This difference may be explained by the higher use of child restraints among younger children in Australia and in European countries, which require rear seat installation. Other cultural differences may play a role in this difference between these countries; for example, Chinese parents may want to sit their children beside them in the front when driving. The current study also found that a parent having a driver's licence was associated with a reduced likelihood of reporting that their children used a rear seat position. It may also be more likely for parents who have a driver's licence to be the driver of the vehicle rather than the front seat passenger; the front seat is more likely to be free than to be occupied by the child. Parental attributes such as having a tertiary education were associated with an increased likelihood of reported rear seat use. This finding may imply that better-educated parents may have better child passenger safety knowledge.

    Factors influencing restraint use

    Compared with unlicensed parents, those who hold a driver's licence were more likely to report that their children used restraints. Because passing a safe driving knowledge test is a prerequisite to obtaining a driver's licence in China and the benefit of restraint use for drivers is a compulsory exam component, licensed parents may use restraints for themselves and for their child passengers as well. This finding may also imply that enhanced parental knowledge for safe car travel may improve child passenger safety. Prior to developing interventions to target age-appropriate restraint use, it is necessary to better understand the reasons behind the low rate of restraint ownership and dedicated child restraint use. In this study, the majority of parents reported having heard of child restraints but very few owned them or used them. Whether this is due to a lack of knowledge about the safety benefits of child restraints or other factors (eg, economic or other practical issues related to access to or use of dedicated child restraints) remains unknown.

    Implications

    In the absence of legislation mandating child restraint use among children and because of the lack of child passenger safety educational components in drivers' training and licensing programmes in China, increasing restraint use by child passengers must be addressed by education and other interventions to reduce child passenger causalities.19 In addition to targeting deficiencies in parental knowledge such as the benefits of restraint use and rear seating, efforts to improve child passenger safety should take into consideration factors such as accessibility and availability of child restraints, as well as vehicle design factors related to child restraint installation (seat belts, restraint anchorage points, etc). During this period of rapid motorisation in China, these efforts may be most urgent in regions with high motor vehicle ownership and use, where car travel is becoming a dominant mode of urban transportation. However, to develop effective child passenger injury prevention strategies, there is a need to understand who best to target with these strategies and who would be responsible for developing and delivering these strategies. For example, the addition of child passenger safety educational component to the driver licensing programme may potentially decrease the front-seating practice among children.

    Limitations

    This study used a self-administered parental survey from five randomly selected kindergartens in Shanghai to explore factors influencing child passenger safety practices. Known to be one of the most rapidly changing cities in the world, Shanghai has a population of almost 20 million, has millions of cars and is undergoing rapid motorisation and economic growth. This growth is only matched by a few other mega-cities in China such as Beijing and Guangzhou. Consequently, it is possible that the child population in this study may differ from the general population of child passengers in China, so did their family attributes such as average family income, which may not be applicable to other cities. There is also no guarantee that the selected kindergartens are a representative sample of kindergarten-aged children in Shanghai. Other factors that were not explored in this study include whether the family owns the car and whether the child sometimes or routinely travels in a car owned by his or her parent or guardian or in another person's private car or taxi. Care should be taken when making interpretation. Using parental self-reports rather than direct observations may result in overestimation of restraint use,20 especially when the respondents know what they should be doing. Although observational studies are still needed in China for definitive child restraint use figures, and although self-reports can be associated with reporting bias, this study provides useful information on the variation in these practices between different demographic groups including parents of different age and socioeconomic status.20 However, there is no child restraint legislation or large-scale education programme existing in China. Therefore, ‘poor’ knowledge of child passenger safety practice may restrict the size of such self-report bias. Nonetheless, the possible effect of self-report bias must be kept in mind.

    Conclusion

    By identifying child and parental attributes associated with restraint use and rear-seating position, this study sets out the case for urgent attention to child passenger safety in China as well as supports the development and implementation of child passenger safety regulations and/or education programmes in China.

    What is already known on the subject

    • Optimal seating position and correct restraint selection save lives and prevent injuries for child passengers.

    • Parental and child characteristics have an influence on child passenger safety practice.

    What this study adds

    • Many child car passengers are not seated optimally and are unrestrained when travelling on roads in China.

    • Parental knowledge may be an important target to promote safer travel for child passengers, especially those aged under 4 years in China.

    Acknowledgments

    We appreciate Shanghai Key Laboratory of Children's Environmental Health (Project ID: 10DZ2272200 and 09DZ2200900), the Non-Governmental International Cooperation Program of Shanghai Science and Technology Commission (Project ID: 09410707200) and the Faculty of Medicine of Shanghai Jiaotong University (Project ID: 2008xj022) for providing financial support to this project. We also thank all the people who have contributed to this study, including Feng Li, Ying Tian, Junyi Chen and Hongyan Wan, as well as all participating kindergartens.

    References

    1. ↵
      1. Peden M,
      2. Oyegbite K,
      3. Ozanne-Smith J,
      4. et al.
      , eds. World report on child injury prevention. Geneva: World Health Organization, 2008.
    2. ↵
      1. Peden M,
      2. Scurfield R,
      3. Sleet D,
      4. et al.
      , eds. World report on road traffic injury prevention. World Health Organization, 2004.
    3. ↵
      1. Zhu B,
      2. Zhu X,
      3. Miao Q,
      4. et al
      . Present and future challenges of child passenger safety. Automobile & Parts Technology Jishu Yu Yingyong 2009;5:28–31.
      OpenUrl
    4. ↵
      1. Durbin D,
      2. Chen I,
      3. Smith R,
      4. et al
      . Effects of seating position and appropriate restraint use on the risk of injury to children in motor vehicle crashes. Pediatrics 2005;115:e305–9.
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. Smith K,
      2. Cummings P
      . Passenger seating position and the risk of passenger death in traffic crashes: a matched cohort study. Inj Prev 2006;12:83–6.
      OpenUrlAbstract/FREE Full Text
    6. ↵
      1. Lennon A,
      2. Siskinda V,
      3. Hawortha N
      . Rear seat safer: seating position, restraint use and injuries in children in traffic crashes in Victoria, Australia. Accid Anal Prev 2008;40:829–34.
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      1. Du W,
      2. Hayen A,
      3. Bilston L,
      4. et al
      . Association between different restraint use and rear-seated child passenger fatalities: a matched cohort study. Arch Pediatr Adolesc Med 2008;162:1085–9.
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Routley V,
      2. Ozanne-Smith J,
      3. Li D,
      4. et al
      . China belting up or down? Seat belt wearing trends in Nanjing and Zhoushan. Accid Anal Prev 2008;40:1850–8.
      OpenUrlCrossRefPubMedWeb of Science
    9. ↵
      1. Purc-Stephenson RJ,
      2. Ren J,
      3. Snowdon AW
      . An exploratory study of parents' use and knowledge of car safety seats in Beijing, China. Int J Inj Contr Saf Promot 2010;17:231–8.
      OpenUrlCrossRefPubMed
    10. ↵
      1. Agran PF,
      2. Anderson CL,
      3. Winn DG
      . Factors associated with restraint use of children in fatal crashes. Pediatrics 1998;102:E39.
      OpenUrl
    11. ↵
      1. Winston F,
      2. Chen I,
      3. Smith R,
      4. et al
      . Parent driver characteristics associated with sub-optimal restraint of child passengers. Traffic Inj Prev 2006;7:373–80.
      OpenUrlCrossRefPubMed
    12. ↵
      1. Bilston L,
      2. Finch C,
      3. Hatfield J,
      4. et al
      . Age-specific parental knowledge of restraint transitions influences appropriateness of child occupant restraint use. Inj Prev 2008;14:159–63.
      OpenUrlAbstract/FREE Full Text
    13. ↵
      SAS Institute. SAS: Statistical Software, Version 9.1. Cary, North Carolina: SAS Institute, 2002.
    14. ↵
      1. Spiegelman D,
      2. Hertsmark E
      . Easy SAS calculation for risk or prevalence ratios and differences. Am J Epidemiol 2005;162:199–200.
      OpenUrlFREE Full Text
    15. ↵
      1. Zou G
      . A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004;159:702–6.
      OpenUrlAbstract/FREE Full Text
    16. ↵
      1. Segui-Gomez M,
      2. Glass R,
      3. Graham JD
      . Where children sit in motor vehicles: a comparison of selected European and American cities. Inj Prev 1998;4:98–102.
      OpenUrlAbstract/FREE Full Text
    17. ↵
      1. Glassbrenner D,
      2. Ye T
      . Child restraint use in 2007—use of correct restraint type. National Center for Statistics and Analysis, National Highway Traffic Safety Administration (NHTSA). Washington, DC: US Department of Transportation, 2008.
    18. ↵
      1. Lennon A
      . A risky treat: exploring parental perceptions of the barriers to seating their children in the rear seats of passenger vehicles. Inj Prev 2007;13:105–9.
      OpenUrlAbstract/FREE Full Text
    19. ↵
      1. Du W,
      2. Finch C,
      3. Hayen A,
      4. et al
      . Relative benefits of population-level interventions targeting specific restraint use behaviours in child car passengers. Pediatrics 2010;125:304–12.
      OpenUrlAbstract/FREE Full Text
    20. ↵
      1. Simpson J,
      2. Wren J,
      3. Chalmers D,
      4. et al
      . Examining child restraint use and barriers to their use: lessons from a pilot study. Inj Prev 2003;9:326–31.
      OpenUrlAbstract/FREE Full Text

    Footnotes

    • Funding WD is supported by a National Health and Medical Research Council Australia–China exchange fellowship. LEB is supported by a National Health and Medical Research Council senior research fellowship. JB is supported by an Australian Research Council Fellowship. Funding was provided by Shanghai Key Laboratory of Children's Environmental Health, the Non-Governmental International Cooperation Program of Shanghai Science and Technology Commission and the Faculty of Medicine of Shanghai Jiaotong University.

    • Competing interests None.

    • Ethics approval Ethics approval was provided by Shanghai Jiaotong University.

    • Provenance and peer review Not commissioned; externally peer reviewed.