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Abstract
Background Older children are at an increased risk of injury due to less commonly being in an appropriate child safety seat (CSS). Proper installation and consistent use of CSSs can significantly reduce child and infant automobile injuries. While research exists around parent behaviours concerning CSS use (or lack), little research takes place at the county level to identify normative beliefs as they contribute to risk factors.
Methods Through a mixed-methods approach, this evaluation retrospectively determines the Salt Lake County Health Department’s impact on CSS usage, as well as identify normative parent behaviours that impact CSS usage.
Results Results indicated that parents’ level of education and being in the car with family/friends was significantly associated with overall CSS usage.
Discussion More research is needed to specify parent normative beliefs around CSS use (or lack).
- Risk Perception
- Socioeconomic Status
- Attitudes
- Behavior Change
- Booster Seat
- Safe Community
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Parent health literacy level impacts child safety seat (CSS) usage.
Older children are less likely to be in the safest CSS available.
Accessibility to CSSs is a persistent issue.
WHAT THIS STUDY ADDS
Sources of social pressures parents face around CSS usage in Salt Lake County.
Parent reasoning around the specific type of CSS they use with their child in Salt Lake County.
Sources of information parents are likely to go to first regarding CSS usage in Salt Lake County.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Findings can inform the Salt Lake County Health Department’s car seat programme on how to decrease CSS misuse among its population.
Inform other local health departments how they can begin to assess this issue in their area.
Introduction
In 2020, out of 607 children (0–12 years old) in the USA who died in a car crash, 230 (38%) were not using a child safety seat (CSS) or seatbelt.1 In Utah specifically, 11 children died from car crashes in 20212 (first data at state level to count children (0–12) deaths), with the Salt Lake County Health Department’s (SLCoHD) car seat programme observing a 92% CSS misuse from 2022 to 2023. Several factors can affect CSS usage or misusage. For example, a study3 found that low health literacy levels in parents were associated with lower usage of preventative behaviours for their children, such as CSSs. Older children (8 and up) were also reported as less likely to use booster seats, with a study4 reporting only 10% of US children using them. To assess appropriate CSS use in Salt Lake County Utah, an outcome evaluation of the SLCoHD’s car seat programme took place.
Methods
A retrospective scan of the car seat programme’s 2021 data was completed to assess current outcomes. This data included participant demographics, and self-reported knowledge before and after participating in the programme’s educational component within CSS check events. All data was tested for significant relationships using the Fisher’s exact test. Based on findings, a survey was created via Qualtrics software V.02/2023 (Provo, UT) in both English and Spanish to assess what social norms programme parents face related to CSS usage, and under what trip lengths they are most likely to use (or not use) any form of CSS. Any surveys that included missing data were deleted after 1 week.
Three focus groups were held with participants (8–12 per group) using a semi-structured discussion guide led by a facilitator. Based on survey data, this guide focused on identifying why programme parents chose to use/not use CSSs for their child. Three weeks were allotted for participant recruiting, with a goal of at least one focus group consisting of primary Spanish speakers. However, no primary Spanish speakers signed up, so all focus groups took place in English over Cisco Webex. These discussions took 1 week to complete. A $25 gift card was offered as an incentive for participation prior to registering, with participation being defined as voluntary in the verbal consent. Focus group analysis took place in an open-coding format, where themes were placed into corresponding groups to avoid bias.
Results
The initial scan of programme data from 2021 found that 489 CSSs were checked. Out of 489 checks, 243 (50%) checks (parents) indicated that they did not previously have a car seat because they could not afford one. The barrier of access to CSSs due to cost is magnified by 2021 programme data detailing that out of 762 CSSs distributed, 594 (78%) went to children who did not previously have one due to cost. After going through the educational component of the car seat check, parents reported a significant (p<0.05) increase in comfort level around installing car seats from ‘not comfortable at all’ to ‘very comfortable’. Children less than 3 years old were significantly more likely to be served in the programme.
Since no survey was previously made to identify parent CSS use as it relates to education level and societal norms, the research team made its own survey. From a total of 132 responses, there was a significant relationship between parent education level, and CSS usage. Findings also showed a significant relationship between parents consistently using CSSs on highways and short trips when in the car with extended family and/or friends.
From the three focus groups that took place, four primary themes in order emerged:
Parent justification for CSS-related actions (n=56).
Pressures they face around CSS usage (n=55).
Types of CSSs and what age they typically use them for their child (n=55).
Where they go for sources of information (n=43).
Justification most mentioned was the visible comfort of the child (n=29). Second the size of the child (n=19), such as the child’s leg touching the back of the seat. Finally, the maturity of the child (n=8), maturity meaning whether the child had the capacity to stay in their seat, and not roam the vehicle.
Participants most mentioned that they felt an internal pressure (n=31) to use a CSS for their child. Secondarily, they mentioned that there was a mostly positive form of pressure that came from their family/friends (n=24) around making sure they used a car seat.
For CSS types, a rear-facing car seat until the child turns 12 months old (n=7) and a forward-facing seat when the child turns 2 years old (n=9). Then when children turned 8 years old, parents were mixed on whether it was most appropriate to start using booster seats or lap and shoulder belts (n=6).
For sources of information, participants mentioned that they value information around CSSs from professionals (ie, medical doctors and car seat manufacturers) (n=18). Friends and family were the second most mentioned (n=14). With online sources being the least mentioned (n=11). It was suggested from participant comments that professional, or family/friend sources were more trustworthy because they came with first-hand experience. Online sources were mainly used to confirm information that was already acquired.
Discussion
With Utah state law only requiring the use of a CSS for children until 8 years old, many children remain too small to fit in a seat belt correctly as found by the SLCoHD car seat programme. With SLCoHD Technicians and other experts recommending that a booster seat be used until the child is at least 57″. In line with current literature, findings suggest that children (8 and up) are at an increased risk of CSS misuse (or non-use).5 To encourage sustained usage, more research around booster seat usage in Utah would be beneficial.
Parent education level (health literacy) was identified as a factor in CSS familiarity within the data analysis, and a lack of familiarity regarding CSS best practices and its accessibility presented itself in the focus groups. This is aligned with current literature that suggests a lack of uniformity in CSS best practices is a contributor to CSS misuse.6 While SLCoHD data suggests misuse is still high among all populations, it will continue to prioritise low health literacy populations, such as non-primarily English-speaking citizens to maximise programme outcomes.
Participants from the focus groups referenced the ease of getting information from the internet, but that professional sources such as medical practitioners were more trusted. However, medical practitioners can rely on outdated recommendations. To address this, the SLCoHD car seat programme would benefit by partnering with local medical practitioners and share CSS best practices to ensure that up-to-date information is being shared with parents. While increasing knowledge/awareness of the importance of CSS use, this could also help influence Utah norms related to booster seat usage among parents.
Limitations
Certain factors the research team experienced limit potential findings. More specifically, the sample population for the focus group and the survey differed. This was because a parent participating in the car seat programme shared the focus group signup sheet with parents outside the car seat programme. These participants often spoke over participants who were confirmed to have participated in the programme, limiting the feedback programme participants were able to provide. Internet connectivity problems disrupted the audio of some participant responses, forcing the research team to exclude these responses from the transcript. Focus groups consisted of primary English speakers due to sampling availability.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants but the reason an approval was not obtained was because it was believed that this meets the criteria listed under exemptions under 'Subpart A of the Basic HHS Policy for Protection of Human Research Subjects'. https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/common-rule-subpart-a-46104/indexhtml. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank the SLCoHDs Health Equity Bureau and Car Seat Programme for providing translation services for all created materials from English to Spanish.
Footnotes
Contributors MT and SH from the Salt Lake County Health Departments (SLCoHD) Analytics and Evaluation Bureau and LM from the SLCoHD Car Seat Safety programme designed the framework for evaluation and analysis, as well as provided feedback for the analysis. All authors drafted the manuscript for submission.
Funding This project was supported by the Office of Minority Health of the US Department of Health and Human Services (HHS) as part of a financial assistance award totalling $3 844 568.00 with 100% funded by the Office of Minority Health/OASH/HHS (grant number: CPIMP211256). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by the Office of Minority Health/OASH/HHS, or the US Government. For more information, visit https://www.minorityhealth.hhs.gov/.
Competing interests None declared.
Patient and public involvement statement Programme clients (public) were not involved in the design of this study. The research question, outcome measures were developed and informed by a previous year's (2021) programme data, and brief literature review.
Provenance and peer review Not commissioned; externally peer reviewed.