Child safety seat knowledge among postpartum mothers in an urban setting.

ABSTRACT

Background. To help direct future educational efforts, this study was conducted to assess the knowledge and attitudes relating to child safety seat use in an urban postpartum population.

Methods. An oral survey was administered to postpartum patients at two urban hospitals (one private and one public) to collect demographic information and to assess knowledge of proper use of a child safety seat.

Results. Mothers in the private hospital scored higher on knowledge assessment than those in the public hospital. The most important factors relating to knowledge were maternal education and reported previous child safety seat education, while having a previous child had no significant influence.

Conclusions. In this urban setting, educational interventions are most needed in mothers with lower levels of education, and mothers with previous children should be included in such efforts, Additional investigation is needed to enhance infant safety for a large number of mothers who travel by public transportation.

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MOTOR VEHICLE CRASHES are the leading cause of unintentional injury and death in children, with children less than 5 years of age accounting for 575 deaths in the United States in 1998. (1-3) In more than half of these deaths, the child was unrestrained, despite the known effectiveness of child safety seats in reducing morbidity and mortality in such crashes. (3,4) In addition, child safety seats are effective in reducing noncrash injuries such as those that occur with sudden stops, turns, and opening the door of a moving vehicle. (5) Among the many factors related to child safety seat use, driver restraint use, and younger child age are directly related to increased use. (6,7) Studies have reported conflicting results when evaluating the factors of parental education and income levels. (8-10)

In addition to nonuse, misuse of child safety seats significantly limits the benefits these seats can provide. Nationally, child safety seats are misused more than 80% of the time. (6) A recent observational study reported 96% child safety seat use for children less than 20 pounds, but only 21% were used correctly. (11) With increasing child age and size, use rates decline while misuse rates remain high. Child safety seat misuse has been associated with injuries ranging from minor bruises to severe head trauma and accounts for 7% of all trauma-related emergency room visits for this age group. (12) Misuse occurs frequently because parents lack knowledge or understanding about the benefits of child safety seats. (13,14) Information sources often contain superficial information focusing on the importance of child safety seat use and not the proper recommendations for use. (14,15) Appropriate manufacturers' instructions and prenatal instructors have been shown to have a positive effect on parental knowledge. (15) The complexity of the proper use of some child safety seats has resulted in requests for designs that are more user friendly, especially for users with lower educational levels. (6)

With the frequency of child safety seat nonuse and misuse, and the risks involved, there is a role for intervention. The postpartum period has been proposed as an ideal time to reinforce child safety seat information for new parents. (1,13,16) The purpose of this study was to assess knowledge and attitudes relating to child safety seat use in a postpartum population in two urban hospitals to determine where educational interventions should be directed.

METHODS

Mothers were eligible to participate if they were 18 years of age or older and had had an uncomplicated term live birth within the previous 48 hours. All patients were hospitalized at one of two hospitals, one a public hospital and the other a not-for-profit private hospital, each serving an urban population from the same geographic area. Data were collected over a continuous 21-day period.

After collection of basic data including age, hospital, race, and gestational age from the mother's chart, the mother was approached in her room and asked whether she was willing to participate in the study. A standard dialogue was then initiated that included informed consent, a survey to obtain additional demographic information, and a knowledge-based survey. The knowledge-based part of the survey contained nine multiple choice questions of increasing difficulty. These questions were derived from child safety seat recommendations published by the American Academy of Pediatrics (16,17) and the National Highway Traffic Safety Administration. (18) After the survey was completed, the mother was offered an opportunity to discuss the correct answers. The mother was then given more information on child safety seats including an information sheet about the study, a pamphlet about the proper use of child safety seats, and the phone number of the National Highway Traffic Safety Administration so additional informatio n could be obtained if desired.

In this study, all hypothesis tests were two-tailed and P values [less than or equal to] .05 were considered statistically significant. Performance on the knowledge-based survey was assessed by using the number of correct answers. The demographic data of the entire group were evaluated by calculating mean and standard deviation for continuous variables and proportions for categorical values. In comparing data between hospitals, t tests were used for continuous data such as gestational age and maternal age, and chi-square analysis or Fisher's exact test was used for categorical variables such as car ownership. A two-way contingency table analysis using a chi-square test was used to evaluate self-reported seat belt use with relation to history of child safety seat use. Multiple regression analysis was done on selected demographic factors to evaluate possible relationship to the number of correct responses.

RESULTS

All but 3 of 182 eligible mothers chose to participate, for a response rate of 98.4%. Table 1 shows the population demographic profile for the total population and the study population by individual hospital.

The majority of mothers enrolled were of African American descent, with a high-school education and an income less than $15,000 annually. While 88.8% of surveyed mothers owned a child safety seat, most lacked a driver's license and did not own a car. While private car was the most frequent mode of transportation, 22.9% of mothers relied on bus transportation, and 3.9% relied on cab transportation as their primary mode of travel.

We found no statistically significant differences between hospitals in maternal age, race, driver's license possession, car ownership, child safety seat ownership, and mode of travel. Significant differences were found between hospitals in the number of children, maternal education status, and income. Mothers at the private hospital were more likely to have fewer children, higher educational attainment, and higher income.

No statistically significant difference was found between the hospitals in self-reported seat belt use. Of the total population, 63.7% reported using a seat belt always, 21.2% reported using one most of the time, and 15.1% reported using one some of the time or never. Multiparous mothers were asked about the history of child safety seat use with their other children. Of 118 multiparous participants, 76.3% reported using a child safety seat always, 13.6% reported using one most of the time, and 10.1% reported using one some of the time or never. No statistically significant difference was found between the hospitals regarding self-reported history of child safety seat use. A statistically significant relationship was found between self-reported seat belt use and history of child safety seat use (P = .004). If a mother reported always using her seat belt, then the likelihood was greater that she would report always using a child safety seat with her previous children.

The nine knowledge-based multiple choice questions were analyzed according to correct versus incorrect response (Table 2). Five basic questions on child safety seat use were answered correctly more than 90% of the time. Four questions involving more detailed practical information were less likely to be answered correctly, with correct response rates ranging from 21.2% to 81.6%. Overall, these four more difficult questions were significantly more likely to be answered correctly by mothers at the private hospital than by those at the public hospital. The mean number of correct responses for all participants was 7.1 [+ or -] 1.2, with the mean private hospital score of 7.6 [+ or -] 1.1 correct being significantly better than the mean public hospital score of 6.9 [+ or -] 1.1 (P= .001).

Among all participants, educational level attained was the most significant influence on the number of correct responses (P = .0001). Although there were associations individually between African American race and fewer correct responses and between lower income and fewer correct responses, when controlling for education level, these associations were no longer significant.

In an attempt to identify the population most in need for educational intervention, participants were grouped as high scorers (those who answered at least 8 of the 9 questions correctly) and low scorers (those who answered fewer than 8 of the 9 questions correctly). Overall, 40.8% of participants qualified as high scorers, with the percentage of high scorers at the private hospital (59.3%) being significantly greater than that at the public hospital (32.8%) (P = .001). No difference was found between high and low scorers by age, race, or income, but high scorers were more likely to have a higher educational level (P = .048). No significant difference was found between the high and low scorers for the reported use of safety belts and child safety seats.

In an attempt to assess the impact of previous children on knowledge, scores of multiparous mothers were compared with scores among first-time mothers. No relationship was found between previous parenting experience and number of correct responses (previous experience 7.0 [+ or -] 1.1, no previous experience 7.3 [+ or -] 1.3, P = .21). Additionally, high scorers were more likely to have fewer children than low scorers (2.0 [+ or -] 1.3 vs 2.6 [+ or -] 1.6, P= .015).

Of all participants, 25.4% reported having some form of previous child safety seat education. Mothers who had previous child safety seat education scored higher than those without previous education (7.8 [+ or -] 0.9 vs 7.0 [+ or -] 1.1, P = .001). No statistically significant difference was found between the two hospitals regarding reported history of previous education, but the type of educational intervention was different between hospitals. The private hospital offered a more organized overall prenatal education program that included a presentation by a certified child safety seat instructor and the use of appropriate literature.

DISCUSSION

The value of child safety seats to prevent injury and death is well accepted. It has been shown that a lack of knowledge about child safety seats may contribute to underuse or improper use of these devices. (9,14) This study helps to further understand factors associated with a lack of knowledge about child safety seats.

The patients enrolled in this study represent two separate hospitals that serve a population from the same urban geographic area. While there were similarities between hospitals with the majority of enrolled mothers of African American descent and low socioeconomic status, there were also some significant differences between hospitals, mothers at the private hospital being more likely to have attained a higher level of education and income. Although no difference was found between hospitals in the percentage of mothers who had reported previous child safety seat education, the private hospital had a more structured prenatal education program, including specialized instructors in child safety seat use.

In assessing the results of the knowledge assessment survey, the fact that more than 90% of participants were able to answer 5 of the 9 questions correctly reflects a background level of child safety seat awareness and knowledge. The lower percentages of correct answers for the 4 more difficult questions involving more specific details about child safety seat use reflects a stratification in this population in more detailed, practical child safety seat knowledge. Given that a lack of knowledge about such details may contribute to underuse or improper child safety seat use, identifying and educating this less informed population should help improve proper child safety seat use and potentially reduce injuries and deaths.

Despite previous public education projects, there are obvious gaps in child safety seat knowledge in the general population. Each of the four questions with the lowest percentages of correct answers involves issues that have been publicized by the American Academy of Pediatrics and the National Highway Traffic Safety Association. (16-18) One of the questions that most participants answered incorrectly involved how tight a restraint should be on a child. In a previous observational study in this population, this lack of tightness of harness straps was one of the most common problems encountered in improper child safety seat use (Written communication, Kerry Chausmer, Director, Louisiana SAFE KIDS Coalition, January 2000).

Education level was the single most important factor relating to better performance on the knowledge assessment survey. Additionally, the minority of mothers who had previous child safety seat education had higher scores. Other factors such as age, race, income, and previous children were riot independently associated with scores. This supports the use of educational interventions to improve child safety seat knowledge and suggests that mothers with lower education attainment should be specifically targeted, regardless of age, race, or income. The lack of improvement in scores by multiparous mothers suggests that having previously had a child did not result in increased child safety seat knowledge for these mothers. It should not be assumed that mothers with a previous child are knowledgeable on child safety seat issues, since without intervention, these mothers may continue with child safety seat nonuse or misuse with subsequent children. Child safety seat education should be provided to all mothers at deliv ery, regardless of previous maternal experience.

In assessing the difference in knowledge scores between hospitals, it is likely that both a background higher educational level and an improved child safety seat education program were contributory to the higher scores at the private hospital. In addition to a certified child safety seat educator nurse, the use of an informative pamphlet at the private hospital likely added to maternal knowledge. While increased educational efforts have a role in improving appropriate child safety seat use, the results of this study and others illustrating widespread limitations in the knowledge and use of child safety seats suggest the need for child restraint systems that are simpler to use (6,19)

One of the potential limitations of this study is the lack of heterogeneity in the patient population, with most of the patients being African Americans of lower socioeconomic status. The ability to extrapolate this information to other populations is unproven; however, Margolis et al (19) also reported educational status as an important factor in the nonuse and misuse of child safety seats in their study of a predominantly white population of higher socioeconomic status.

By report, 64% of the subjects in this study use seat belts all of the time, and 76% of those with a previous child reported using a child safety seat all of the time. Significant overlap was found in these populations, such that mothers who reported personal seat belt use all of the time were likely to report child safety seat use all of the time. These self-reported data are similar to observational data reporting 80% use of child safety seats. (8) These results are consistent with those of other studies showing a positive correlation between parental use of seat belts and the use of appropriate child safety seat. (6)

An interesting observation in the data reported is the relatively large number of patients in this population who do not rely on a private car for transportation; 22.9% of mothers relied on bus transportation for their primary mode of travel, and 3.9% relied on cabs. With such a large segment of the population relying on these forms of transportation, the availability of appropriate child restraint systems on public transportation is an issue that needs to be addressed. Current legislation on child safety seat use focuses on private passenger cars and not on buses, cabs, and other alternative transportation forms. (20) Concerns over costs and liability have had limited efforts to date to provide secure ways for children to travel on many of these forms of public transportation. More research needs to be done on child safety issues in these other types of vehicles.

CONCLUSIONS

The value of appropriately used child safety seats to reduce the risk of injury and death in motor vehicle accidents is well accepted. Unfortunately, nonuse and misuse of these child safety seats continues to be a problem, and a lack of knowledge about their proper use is a significant contributing factor. This study identifies a need for educational intervention among postpartum mothers in an urban setting. Specifically, mothers of lower educational levels are most in need of educational intervention. Maternal age, race, income, and parity were not significant as individual factors in child safety seat knowledge in this population. Ongoing issues that need to be addressed include the design of child safety seats that are easier for all parents to use and safe methods for children to travel on public transportation.

TABLE 1.

Study Population Demographics

                                                     Public
Variable                           Total            Hospital

No. of patients                     179                125
Maternal age (years)         24.4 [+ or -] 5.4  24.5 [+ or -] 5.7
No. of children               2.3 [+ or -] 1.5   2.5 [+ or -] 1.6
School grade achieved        12.0 [+ or -] 1.7  11.8 [+ or -] 1.6
High school graduate               65.9%              60.0%
Annual income
   <$15,000                        69.3%              73.9%
   $15,000-30,000                  19.3%              19.1%
   >$30,000                        11.4%               7.0%
Race
   African-American                86.6%              87.2%
   White                            9.5%               7.2%
   Other                            3.9%               5.6%
Driver's license possession        43.0%              39.2%
Car owner                          32.4%              28.8%
Child safety seat owner            88.8%              86.4%
Mode of travel
   Car                             73.2%              71.2%
   Bus                             22.9%              24.0%
   Cab                              3.9%               4.8%

                                  Private         P
Variable                         Hospital       Value

No. of patients                     54           NA
Maternal age (years)         24.0 [+ or -] 4.8   .56
No. of children               2.0 [+ or -] 1.1   .02
School grade achieved        12.5 [+ or -] 1.9   .01
High school graduate               80.0%         .01
Annual income
   <$15,000                        58.8%         .02
   $15,000-30,000                  19.6%
   >$30,000                        21.6%
Race
   African-American                85.2%         .07
   White                           14.8%
   Other                            0
Driver's license possession        51.9%         .12
Car owner                          40.7%         .12
Child safety seat owner            94.4%         .12
Mode of travel
   Car                             77.8%         .53
   Bus                             20.4%
   Cab                              1.8%
TABLE 2.

Survey Question Results

                                      Correct
           Question                  Responses

Are you required to use a child        98.9%
  safety seat all of the time?
Where is the best place for a child    97.2%
  to sit in a car?
If a child weighs less than 20         81.6%
  pounds, which way should they
  face in a car?
At what level should a child safety    77.1%
  seat's retainer clip rest on a
  chlid?
Can you leave a child unattended       96.6%
  once they are buckled in their
  child safety seat?
If your baby is crying in the car      98.9%
  seat while riding in the car, is
  it okay to take him/her out?
If your child is older than 1 year,    21.2%
  how much should your baby weigh
  before putting him/her in a child
  safety seat that faces forward?
Is it okay to put a child safety       92.2%
  seat in the front seat of a car
  with an airbag?
How tight should the child harness     48.9%
  strap be made on a child safety
  seat?

References

(1.) Murphy JM: Child passenger safety. J Pediatr Health Care 1998; 12:130-138

(2.) Motor vehicle occupant injury--Fact Sheet. Washington, DC, National SAFE KIDS Campaign, December 1998

(3.) National Highway Traffic Safety Administration: Traffic safety facts 1998--Children. Available at: http://www.nhtsa.gov/people/ncsa/pdf/child98.pdf. Accessed April 2000

(4.) Johnston C, Rivara FP, Soderberg R: Children in car crashes: analysis of data for injury and use of restraints. Pediatrics 1994; 93:960-965

(5.) Egran PA, Dunkle DE, Winn DG: Motor vehicle childhood injuries caused by nonfatal crash falls and ejections. JAMA 1985; 253:2530-2533

(6.) Winston FE, Durbin DR: Buckle up! is not enough. enhancing protection of the restrained child. JAMA 1999; 281:2070-2072

(7.) Agran PF, Anderson CL, Winn DG: Factors associated with restraint use of children in fatal crashes. Pediatrics [serial online]. 1998; 102:39

(8.) Zempsky WT, Isaacman DJ, Sullivan KM, et al: Child restraint device use in patients leaving a children's hospital. Arch Pediatr Adolesc Med 1996; 250:1284-1287

(9.) Russell J, Kresnow MJ, Brackbill R: The effect of adult belt laws and other factors on restraint use for children under age 11. Accid Anal Prev 1994; 26:287-295

(10.) Haaga J: Children's seat belt usage: evidence from the national health interview survey. Am J Public Health 1986; 76:1425-1427

(11.) Decina LE, Knoebel KY: Child safety seat misuse patterns in four states. Accid Anal Prev 1997; 29:125-132

(12.) Graham CJ, Kittredge D, Stuernky JH: Injuries associated with child safety seat misuse. Pediatr Emerg Care 1992; 8:351-353

(13.) West R, Robinette C: Involvement of Arkansas hospitals in promotion of car restraint device use among young children. J Ark Med Soc 1992; 88:601-604

(14.) Ruffin MT, Kantor R: Adults' knowledge about the use of child restraint devices. Fam Med 1992; 24:382-385

(15.) Gaines SE, Layne BH, Deforest M: Promoting automobile safety for young children. Am J Maternal Child Nurs 1996; 21:148-151

(16.) Committee on Injury and Poison Prevention, American Academy of Pediatrics: Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents (RE9618). Pediatrics 1996; 97:761-762

(17.) Committee on Injury and Poison Prevention and Committee on Fetus and Newborn, American Academy of Pediatrics: Safe transportation of premature and low birth weight infants. Pediatrics 1996; 97:758-760

(18.) National Highway Traffic Safety Administration: Are YOU using it right? Available at: http://www.nhtsa.gov/people/injury/childps/useright/index.html

(19.) Margolis LH, Wagenaar AC, Molnar LJ: Use and misuse of automobile restraint devices. Am J Dis Child 1992; 146:361-366

(20.) Walter RS, Kuo AR: Taxicabs and child restraint. Am J Dis Child 1993; 147:561-564

RELATED ARTICLE: KEY POINTS

* In this urban postpartum setting, educational interventions with regard to child safety seat use are most needed in mothers with lower levels of education.

* Since having a previous child had no significant influence on maternal knowledge of child safety seat use, educational interventions should also be targeted to these mothers.

* Since a significant number of these mothers relied on public transportation for their travel, additional investigation is needed to enhance safety for those infants who travel by public transportation.

From the Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans.

Reprint requests to Brian M. Barkemeyer, MD, Louisiana State University Medical Center, Department of Pediatrics, 1542 Tulane Aye, New Orleans, LA 70112.