Evaluating the impact of child safety seat check-up events.Abstract: Properly installed car seats can be effective in preventing death or serious injury for children in moving vehicles. Despite increased awareness, child safety seat use rates remain low and misuse rates are high. The objective of this study was to evaluate the impact of a child safety seat 'check-up' event on parental self-efficacy and knowledge. A case-crossover design was used to determine changes in knowledge and self-efficacy over time among participants. Results indicate that self-efficacy increased by 11% and knowledge increased by 14%. Conclusions are that check-up events can provide an means for increasing proper use of child safety seats. ********** Riding unrestrained or improperly restrained in a safety seat is the greatest risk for death and injury among children in motor vehicles. Restraining RESTRAINING. Narrowing down, making less extensive; as, a restraining statute, by which the common law is narrowed down or made less extensive in its operation. children in child safety seats (CSS (1) See Cascading Style Sheets. (2) (Content Scrambling System) The copy protection system applied to DVDs, which uses a 40-bit key to encrypt the movie. ) protects them, the driver, and other vehicles on the road. A properly restrained child can reduce the risk of death by up to 70% for an infant and by 50% for a toddler. (NHTSA NHTSA National Highway Traffic Safety Administration (US government) , 2001) CSS can also reduce the need for hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. by 69% for children ages 4 and under. There are many reasons why parents choose not to buckle up their children. Many of these problems relate to the lack of knowledge parents have regarding the need for CSS. (Spanier, Mercante, & Barkemeyer, 2002; Vaca, et al., 2002) Other issues facing parents are the difficulty of correctly installing CSS, securing the child in the seat correctly, and knowing which type of seat (infant, convertible, or booster Booster - A data-parallel language. "The Booster Language", E. Paalvast, TR PL 89-ITI-B-18, Inst voor Toegepaste Informatica TNO, Delft, 1989. ) a child should use. One study in Kentucky (USDHHS USDHHS, n.pr See United States Department of Health and Human Services. , 1996) found that three fourths of children in CSS were incorrectly installed and another in Louisiana found 94% incorrect. (Kohn, Chausmer, & Flood, 2000) Three common errors identified in CSS installations were 1) car seat not belted into vehicle tightly, 2) safety seat harness straps not snug, and, 3) harness retainer A contract between attorney and client specifying the nature of the services to be rendered and the cost of the services. Retainer also denotes the fee that the client pays when employing an attorney to act on her behalf. clip not at armpit arm·pit n. The hollow under the upper part of the arm below the shoulder joint, bounded by the pectoralis major, the latissimus dorsi, the anterior serratus muscles, and the humerus, and containing the axillary artery and vein, the infraclavicular part level.(Kohn, Chausmer, & Flood, 2000; USDHHS, 1996; Winston & Durbin, 1999) Community-based approaches can be an effective strategy at providing skills and knowledge on safety practices to parents and caregivers. (Coyle, Welsh, & Mcmullen, 2003; Klassen, et al., 2000; USDHHS, 1996) One specific type of educational intervention is a CSS check-up event. A check-up event can provide 1) a means to distribute seats to loan for parents that don't have a CSS; 2) hands-on skills to parents; and, 3) general knowledge and local and state laws concerning CSS. The purpose of this study was to evaluate the impact of a community sponsored check-up event on parental knowledge regarding CSS and their self-efficacy related to the installation of CSS. METHODOLOGY PARTICIPANTS The participants for this study were a convenience sample of parents or caregivers who attended a CSS check-up event from May to October of 2002 and completed a pre- and post-survey. SURVEY INSTRUMENT The survey instrument was a 20-item survey administered before and after the check-up event. The survey instrument was developed using the theories of self-efficacy (Bandura ban`dur´a n. 1. A traditional Ukrainian stringed musical instrument shaped like a lute, having many strings. , 1997) and a previous survey on CSS knowledge.(Sachs & Tombrello, 2000) Face validity face validity (fāsˑ v  ·liˑ·di·tē),n of the instrument was obtained through evaluation of experts in child passenger safety. The survey was piloted in a similar study conducted in 2001. (Herring herring, common name for members of the large, widely distributed family Clupeidae, comprising many species of marine and fresh-water food fishes, including the sardine (Sardinia), the menhaden (Brevoortia), and the shad (Alosa). , Nunez, & Jones, 2002) Five questions were asked to determine the level of self-efficacy the participants reported regarding CSS use before and after a CSS check-up event. The questions were developed by trained child safety seat technicians and represented the universal items necessary to measure a parent's confidence to properly secure most types of child safety seats. The questions were in a five point Likert scale Likert scale A subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc that ranged from 'Definitely can't do it' to 'Definitely can.' The responses from each of the five items in the scale were summed for each participant to create a 'total self-efficacy' score and each participant was placed in a low self-efficacy category or a high self-efficacy category. To provide for an even division of high and low self-efficacy scores, the median score of the pre-survey was chosen as the midpoint mid·point n. 1. Mathematics The point of a line segment or curvilinear arc that divides it into two parts of the same length. 2. A position midway between two extremes. . An additional survey item queried participants on the ability of the CSS to protect their child in the event of a crash. This item determined the participant's response efficacy and could be predictive of a parent's intention to use a CSS. There were four questions that assessed the knowledge of the participants regarding CSS and installation procedures. The four items represented the common knowledge that parents should know about most types of child safety seats. Other questions were considered, but were more specific to the location or were questions regarding laws and regulations that were transitory TRANSITORY. That which lasts but a short time, as transitory facts that which may be laid in different places, as a transitory action. and could change from year to year and from state to state. Local child safety seat technicians reviewed the questions for validity. If the participants answered all four questions correctly, then the subject was placed in the high knowledge group. If the subject answered three or less questions correctly then the subject was placed in the low knowledge category. Demographic information such as age, race, and gender was assessed at the closing of the survey. The results were coded to create anonymity and no personal identification of any subject was noted. DATA COLLECTION During check-up events in May through October of 2002, researchers and trained University students provided participants with the survey prior to the check-up event. The participants were informed about the survey and its purpose, that it was voluntary, and confidential. It took participants about 5 minutes to complete. At the end of the survey, the participants were informed that someone would con tact them 2-3 months after the check-up. The postsurvey was the same instrument used in the pre-survey. The post-survey was administered via phone interview. The researchers read a script informing the participants that the survey was voluntary, and that the participants' identification would remain anonymous. Upon agreement from the participants, the researchers proceeded with the survey. Data was written down on a standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. form by the researchers and then each survey sheet was coded to secure anonymity. The survey was approved by the University institutional review board for human participants prior to administering the pre-survey. DATA ANALYSIS A case-crossover design was used to analyze the change in self-efficacy and knowledge over time among the study participants. This design is a technique that allows for measurement of a temporary change in risk related to a transient exposure. (Maclure & Mittleman, 2000; Mittleman, Maclure, & Robins, 1995; Redelmeier & Tibshirani, 1997; Sorock, Lombardi, Gable gable Triangular section formed by a roof with two slopes, extending from the eaves to the ridge where the two slopes meet. It may be miniaturized over a dormer window or entranceway. , Smith, & Mittleman, 2001) For this study the risk is the level of knowledge or self-efficacy and the exposure is the check-up event. Each person served as his or her own control and thus eliminated confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor for all demographic characteristics. Descriptive statistics descriptive statistics see statistics. were performed to obtain frequencies for the study variables. Univariate analysis was conducted to obtain the odds ratios and 95% confidence intervals confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. for the total self-efficacy, total knowledge, between pre-and post-surveys. RESULTS DEMOGRAPHICS The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. The pre-survey resulted in 104 completed surveys. The post-survey resulted in 31 completed surveys for a response rate of 30%. The mean age for the participants was 32 years. The ages ranged from 20 to 55 years of age. The majority of participants were female, white, and between 20-35 years of age (see Table 1). SELF-EFFICACY AND RESPONSE-EFFICACY QUESTIONS Total self-efficacy among the participants increased almost 11% after the check-up. Participants were over 15 times more likely to be in the high self-efficacy category after the event (OR 15.47, 95% CI [3.13-76.35]). Ali items in the self-efficacy scale increased after the check-up. Participants responding with high confidence were 87% in the post-survey as compared with 29% in the pre-survey. The item that increased the most was the participant's confidence to adjust the straps to fit their child correctly increasing almost 17%. This item obtained the lowest pre-survey score and obtained the highest post-survey score. The responses to the self-efficacy scale items are detailed in Table 2. The response efficacy didn't change significantly (OR=0.92, 95% CI[0.86-1.031]). However, the number of people reporting high confidence in the ability of a CSS to safely protect their child in a car crash was 100% (31) in the post-survey as compared with 92% (24) in the pre-survey. KNOWLEDGE QUESTIONS The average total knowledge on child safety seat installation pre-survey was 2.94/4 and 3.48/4 postsurvey representing a 14% increase. The number of participants correctly answering all knowledge items increased from 8 pre-survey to 19 post-survey. The change from pre-survey to post-survey was significant with participants over four times more likely to be placed in the high knowledge category (OR 4.55, 95% CI [1.54-13.42]). The only item that increased significantly was the question on positioning of the harness clip (Table 3). Two other items had positive increases in correct responses but were not significant and one item decreased by one participant the number of correct responses. CONCLUSION/DISCUSSION Studies have indicated misuse rates of CSS at check-up events. (Kohn, Chausmer, & Flood, 2000; USDHHS, 1996) However, studies on the behavioral impact on parents is minimal. (Spanier, Mercante, & Barkemeyer, 2002; Vaca, et al., 2002) This study attempted to provide some evidence of CSS check-up events' influence on self-efficacy and knowledge. The results of this study indicate that CSS check-up events were making an impact. Findings indicate that self-efficacy was increased and knowledge increased slightly. Studies have identified misuse of CSS as a major problem. A parent's lack of confidence may be a reason for misuse. It was indicated that parents believed CSS work. Parents had the motivation and knowledge but not the confidence needed to assure the CSS was installed correctly. This may indicate why knowledge didn't increase significantly as self-efficacy for this study. Limitations include the small non-random sample and participant bias. Due to the small sample size of 31 participants, statistical analysis was restricted and lacks power to determine differences between pre and post surveys if differences existed. However, even with only 31 participants, there were statistical differences from pre and post survey. If the response rate were higher, this difference would most likely be greater. Over two thirds of the pre-survey participants could not be reached by the phone due to no longer existing phone numbers and wrong numbers. Also, parents that attended the check-up could have been more informed and concerned about CSS installation than non-participants. It was not queried if study participants had attended a prior check-up that would influence their responses. Lastly, participant's confidence in the effectiveness of CSS indicates possible bias. The correct installation of CSS can be a challenging and difficult task for parents. Further, recommendations on installation are changing to reflect current research and knowledge concerning the most efficient and safe use and installation of CSS. Parents and caregivers should use check-ups to update their knowledge on current CSS standards. Check-ups used on a regular basis can provide an effective approach in disseminating dis·sem·i·nate v. dis·sem·i·nat·ed, dis·sem·i·nat·ing, dis·sem·i·nates v.tr. 1. To scatter widely, as in sowing seed. 2. the latest knowledge as well reinforce CSS use. REFERENCES Bandura, A. (1997). Self-efficacy. Harvard Mental Health Letter. 13 (9), 4-7. Coyle, C., Welsh, S., & McMullen, M. (2003). Child car seat checkpoints: one urban community's experience. Journal of emergency nursing: JEN: official publication of the Emergency Department Nurses Association, 29(1), 52-54. Herring, A. B., Jones, C., & Nunez, C. (2002). Evaluating the impact of child safety seat check-up events on parental knowledge. The Journal of the Arkansas Medical Society, 99(6), 187-190. Klassen, T. P., MacKay, J. M., Moher, D., Walker, A., & Jones, A. L. (2000). Community-based injury prevention interventions. The Future of children / Center for the Future of Children, the David and Lucile Packard Foundation David and Lucile Packard Foundation, private philanthropic institution that funds nonprofit organizations. It was founded in 1964 by David Packard (1912–96), co-founder of Hewlett-Packard Co., and his wife Lucile (1914–87). , 10(1), 83-110. Kohn, M., Chausmer, K., & Flood, M. H. (2000). Anticipatory guidance about child safety seat misuse: lessons from safety seat "checkups". Archives of Pediatrics & Adolescent Medicine adolescent medicine n. The branch of medicine concerned with the treatment of youth between 13 and 21 years of age. Also called ephebiatrics, hebiatrics. , 154(6), 606-609. Maclure, M., & Mittleman, MA. (2000). Should we use a case-crossover design? Annual Review of Public Health. 21,193-221. Mittleman, M. A., Maclure, M., & Robins, J. M. (1995). Control sampling strategies for case-crossover studies: an assessment of relative efficiency. American Journal of Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause , 142 (1), 91-98. National Highway Traffic Safety Administration The National Highway Traffic Safety Administration (NHTSA, often pronounced "nit-suh") is an agency of the Executive Branch of the U.S. Government, part of the Department of Transportation. , U.S. Department of Transportation. (2002, April). Traffic Safety Facts 2000: Occupant occupant n. 1) someone living in a residence or using premises, as a tenant or owner. 2) a person who takes possession of real property or a thing which has no known owner, intending to gain ownership. (See: occupancy) protection. Retrieved July 13, 2003, from: http://www.nhtsa.dot.gov/pdf/ nrd-3O/NCSA/TSF2000/2000occfacts.pdf. Redelmeier DA, & Tibshirani RJ. (1997). Interpretation and bias in case-crossover studies. Journal of Clinical Epidemiology. 50, 1281n87. Sachs, M.K. & Tombrello, S.M. (2000). Car seat safety: buckling buckling Mode of failure under compression of a structural component that is thin (see shell structure) or much longer than wide (e.g., post, column, leg bone). Leonhard Euler first worked out in 1757 the theory of why such members buckle. up isn't always enough. Pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. Basics Gerber. 90, 10-24. Spanier, A. J., Mercante, D., & Barkemeyer, B. M. (2002). Child safety seat knowledge among postpartum postpartum /post·par·tum/ (post-pahr´tum) occurring after childbirth, with reference to the mother. post·par·tum adj. Of or occurring in the period shortly after childbirth. mothers in an urban setting. Southern Medical Journal, 95(9), 1017-1021. Sorock, G. S., Lombardi, D. A., Gabel, C. L., Smith, G. S., & Mittleman, M. A. (2001). Case-crossover studies of occupational trauma: methodological caveats. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 7 Suppl 1, 138-42. U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS . (1998). Improper use of child safety seats-Kentucky, 1996. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morbidity and Mortality Weekly Reports Morbidity and Mortality Weekly Report (MMWR) is a weekly epidemiological digest for the United States published by the Centers for Disease Control and Prevention. The 5 June 1981 issue of the MMWR published the cases of five men in what turned out to be the first report of AIDS. . 47 (26), 541-545. Vaca, F., Anderson, C. L., Agran, P., Winn, D., & Cheng, G. (2002). Child safety seat knowledge among parents utilizing emergency services emergency services Emergency care '…services …necessary to prevent death or serious impairment of health and, because of the danger to life or health, require the use of the most accessible hospital available and equipped to furnish those services' in a level I trauma center In the United States, a Level I trauma center provides the highest level of surgical care to trauma patients. A Level I trauma center is required to have a certain number of surgeons and anesthesiologists on duty 24 hours a day at the hospital, an education program, in Southern California Southern California, also colloquially known as SoCal, is the southern portion of the U.S. state of California. Centered on the cities of Los Angeles and San Diego, Southern California is home to nearly 24 million people and is the nation's second most populated region, . Pediatrics, 110(5), e61. Winston, F.K. & Durbin, D.R. (1999). Buckle up! Is not enough: enhancing protection of the restrained child. Journal of the American Medical Association JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world. . 281(22), 2070-2077. HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY COMPETENCY, evidence. The legal fitness or ability of a witness to be heard on the trial of a cause. This term is also applied to written or other evidence which may be legally given on such trial, as, depositions, letters, account-books, and the like. 2. ADDRESSED Responsibility IV: Evaluating Effectiveness of Health Education Programs Competency C: Interpret results of program evaluation Program evaluation is a formalized approach to studying and assessing projects, policies and program and determining if they 'work'. Program evaluation is used in government and the private sector and it's taught in numerous universities. . Sub-competency 6: Make recommendations from evaluation results Ches Jones, PhD Ches Jones, Ph.D. is an Associate Professor of Health Sciences at the University of Arkansas The University of Arkansas strives to be known as a "nationally competitive, student-centered research university serving Arkansas and the world." The school recently completed its "Campaign for the 21st Century," in which the university raised more than $1 billion for the school, used . Address all correspondence to Ches Jones, Ph.D., Associate Professor of Health Sciences, University of Arkansas, 308 HPER HPER Health, Physical Education and Recreation Building, Fayetteville, AR 72701, PHONE: 479.575.4009, FAX: 479.575.5778, E-MAIL e-mail: see electronic mail. in full electronic mail Messages and other data exchanged between individuals using computers in a network. : ches@uark.edu
Table 1 Demographics of study population
% (N)
Age
18-29 47 (14)
30-39 33 (10)
40 and older 20 (6)
Gender
Female 82 (25)
Male 18 (6)
Race
White 87 (27)
Black 13 (4)
Table 2 Change in percentage of participants reporting high
self-efficacy by scale item from pre- and post survey's
Pre-survey Post-survey
Self-efficacy scale item % (N) % (N)
How confident are you in your ability to
adjust the straps to fit the size of your
child? 29 (9) 87 (27)
How confident are you in your ability to
reinstall the car seat safely? 52 (16) 81 (25)
How confident are you in choosing the safest
position in your vehicle for your child
safety seat? 58 (18) 84 (26)
How confident are you in your ability to
appropriately adjust the seat belt in your
vehicle when securing the child safety seat? 45 (14) 87 (27)
How confident are you in determining the age
and weight at which to adjust or change your
child safety seat? 23 (7) 61
[1.79-16.47]
Odds Ratio [95% CI]
Self-efficacy scale item
How confident are you in your ability to 16.5 [4.5-60.87]
adjust the straps to fit the size of your
child?
3.91 [1.26-12.16]
How confident are you in your ability to
reinstall the car seat safely?
How confident are you in choosing the safest 3.76 [1.14-12.40]
position in your vehicle for your child
safety seat?
How confident are you in your ability to 8.2 [2.31-29.07]
appropriately adjust the seat belt in your
vehicle when securing the child safety seat?
How confident are you in determining the age (19) 5.43
and weight at which to adjust or change your
child safety seat?
[1.79-16.47]
Table 3. Change in percentage of participants providing correct
answers on knowledge scale items from pre- to post-surveys
Pre-survey Post-survey
Knowledge scale item (%) (N) % (N)
Is it safe for your child to
ride in the front seat? 100 (31) 97 (30)
Correct answer: False
Should a car seat be used
after it has been in a crash? 90 (28) 97 (30)
Correct answer: No
When is it permissible to move a baby
from rear facing to forward facing? 45 (14) 68 (21)
Correct answer: When a child is both 1
year old and 20 pounds or more weight
At what level should the harness clip
be placed on a child? 58 (18) 87 (27)
Correct answer: level with the armpit
Knowledge scale item Odds Ratio [95% CI]
Is it safe for your child to
ride in the front seat? 1.03 [.97-1.10]
Correct answer: False
Should a car seat be used
after it has been in a crash? 3.21 [0.32-32-74]
Correct answer: No
When is it permissible to move a baby
from rear facing to forward facing? 2.55 [0.91-3.10]
Correct answer: When a child is both 1
year old and 20 pounds or more weight
At what level should the harness clip
be placed on a child? 4.88 [1.37-17.35]
Correct answer: level with the armpit
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