Prevalence of child restraint system use and parental knowledge of such systems in Mianyang, China

doi:10.21203/rs.3.rs-1636546/v1

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Prevalence of child restraint system use and parental knowledge of such systems in Mianyang, China

https://doi.org/10.21203/rs.3.rs-1636546/v1

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Background

This study investigated the prevalence of restraint system use for children passengers in cars, and it assessed parental knowledge and attitudes about such restraint systems in Mianyang, China.

Methods

A cross-sectional survey was conducted between December 2021 and January 2022. Hospitals and kindergartens in Mianyang were randomly selected for inclusion and parents with cars were surveyed about whether they owned and used child restraint systems and about their knowledge and attitudes towards such systems. Factors associated with CRS use were explored using binary logistic regression.

Results

A total of 4,764 questionnaires were distributed to families with children 0–6 years old. Among the 4,455 responses received, 50.8% of families owned child restraint systems, most of which were front-facing child seats (42.0%). Just under half of families (44.4%) reported using a child restraint system at least sometimes, but only 19.6% used one all the time. Possession and use of a child restraint system varied significantly with parental education level, age of the child, place of residence, number of children, family income, travel frequency, and travel distance. Logistic regression showed that frequency of car travel with a child and monthly family income significantly affected CRS use. Most parents (85.2%) wrongly believed that adult seat belts in cars are effective at protecting their children in the event of a crash. The most frequent reason that parents cited for not using a child restraint system was that it would lead children to travel in the car less often.

Conclusions

Although approximately half the parents in our sample owned a child restraint system, most used them rarely, if at all. Educating parents about the safe ways for children to ride in a car and about safety restraint systems and safety belts may promote the use of restraint systems.

Child passenger safety

Child restraint system

Knowledge

Attitude

With the continuous growth of China's economy, the number of Chinese households that own cars has increased annually[1, 2]. In 2019, there were 24,767 traffic accidents in China, resulting in 62,763 deaths and direct property losses of approximately 20197.4 USD [1]. In China, traffic accidents are the second leading cause of death among children younger than 1 year[3], and the death rate of children in traffic accidents in China is 2.6 times that in the United States and twice that in Europe[4].

Child restraint is one of the most important and useful measures to prevent injury and death of child passengers in traffic accidents[5]. In the event of a traffic accident, child restraint systems (CRS) can reduce the death rate among infants younger than 1 year by 71%, and the rate among children 1–4 years old by 54–80%[6, 7].

Legislation mandating the use of CRS can promote their use and reduce the number of automobile-related injuries among children[9, 10]. Since 1975, when child road safety laws were introduced, 96 countries have passed laws mandating the use of CRS[11, 12]. Many developed countries have adopted a combination of compulsory legislation and driver education to promote CRS use[13–15]. In some developed countries, the prevalence of CRS use is as high as 95%[12]. China, in contrast, did not formally regulate CRS or mandate their use at the national level until 2021. As a result, the prevalence of CRS use in China is only 1%[12], and it is quite low even in more economically developed cities, such as Shantou and Shenzhen, where it remains below 25%[16, 17].

Little is known about CRS use in the less economically developed central and western regions of China[16, 18]. The present study investigated the prevalence of CRS use and parental knowledge and attitudes about them in Mianyang, the second largest city in Sichuan province in western China. Car owners in Mianyang account for 12.5% of all car owners in the entire province. The results of this study underscore the need to increase CRS use, and they identify several factors that can be targeted during advocacy, education and enforcement.

Participants

This survey was conducted in Mianyang, China from December 2021 to February 2022. In this cross-sectional study, cluster random sampling was used to select hospitals and kindergartens. The study protocol was approved by the relevant authorities at the participating hospitals and kindergardens. Participants indicated their consent when they filled out the paper or electronic questionnaire (see below).

The population of children from hospitals were mainly 0–3 years old, while those from kindergartens were mainly 4–6 years old. Each kindergarten and hospital was randomly assigned a number and then the random number table was used to select our targets. We aimed for a sample of at least 1,300, since power calculations using G-Power (3.1) suggested that such a sample would provide 95% power to detect the effect size (0.9) at an alpha of 5%, based on a two-sided chi-squared test. Finally, three hospitals and 20 kindergartens were included in the study. To be included in the study, parents had to own a car.

Questionnaire

A questionnaire was custom-designed for the present study based on literature review and expert consultation. The questionnaire requested general demographic information and asked respondents about their ownership and knowledge of child restraint systems, attitudes towards CRS use, and factors that might influence CRS use.

Respondents were asked whether they owned a CRS and, if so, what type it was and how often they used it. Frequency of use was indicated on a five-point Likert scale (never, rarely, sometimes, often, or always). To assess CRS knowledge, respondents were asked to indicate whether statements about CRS, seat belts, or airbag were correct or incorrect; alternatively, respondents could indicate that they did not know whether the statement was correct or incorrect. Five points were awarded for each correct response, while no points were awarded for incorrect responses or responses of “I don’t know”. Respondents' attitudes toward CRS were assessed by giving them statements such as “Are you willing to use CRS?” and “Whether CRS can protect children?”, to which they had to respond on a five-point Likert scale (strongly disagree, disagree, neutral, agree, or strongly agree). Respondents were also asked to choose the reasons for their unwillingness to purchase CRS and the factors that influenced their use. Data were also collected on the frequency and distance of trips made regularly by child passengers. A pilot study indicated a Cronbach’s α of 0.768.

Administration of questionnaire

Survey administrators were trained in the study’s inclusion criteria for parents and in how to explain the survey questions and how to complete the survey. Parents who had brought their children to the study hospitals were asked whether they had brought the child in their own private vehicle. If so, they were invited to fill out the questionnaire while waiting in the hospital.

Study kindergartens provided information about the parents of children 4–6 years old, and the questionnaire was handed to the parents by the teacher when they picked up their children at the kindergarten. Parents were able to fill out the paper survey on-site or to complete an electronic questionnaire on their mobile phones. A brief description of the study was either orally explained by the questionnaire administrator or sent to the respondent’s mobile phone.

Statistical analysis

Data were analyzed using SPSS 25.0 (IBM, Chicago, IL, USA) [20] and a significance threshold of p < 0.05. The rate of CRS ownership was calculated as the percentage of all respondents who answered that they owned CRS. The prevalence or rate of CRS use was calculated as the percentage of all respondents who indicated that they used CRS sometimes, often or always.

Differences in CRS use between groups of respondents with different demographic variables were assessed for significance using the chi-squared test. Factors associated with CRS use were explored using binary logistic regression, in which the dependent variable was whether the child safety seat was always used (yes = 1, no = 0). Regression results were reported as odds ratios (ORs) and 95% confidence intervals (CIs).

A total of 4,764 questionnaires were distributed to families with children 0–6 years old, and 4,455 responses were received, corresponding to a response rate of 93.5%. Among the respondents, 74.8% were mothers, and the average age of all respondents was 33.33 ± 4.59 years. Most parents (66.6%) had completed a bachelor's/college degree or above. The ratio of children 0–3 years old to children 4–6 years old was 1:1.5.

Half of families (2261/4455) reported owning CRS, which were predominantly front-facing child seats (42.0%). The CRS use rate was 44.4% (1977/4455), but only 19.6% of families (874/4455) used it all the time (≥ 9 of 10 rides). Ownership and use of CRS varied significantly with parental education level, age of the child, place of residence, number of children in the household, family income, travel frequency and travel distance (Table 1).

Table 1

Sociodemographic and travel characteristics of survey respondents (N = 4,455).
Characteristic		All	CRS owners ^a (n = 2,261)	χ^{2 b}	CRS users ^c (n = 1,977)	χ^{2 b}
Education of parents	Primary school	30 (0.7)	6 (20.0)	207.487	3(10)	188.505
	Junior middle school	415 (9.3)	154 (37.1)		126(30.4)
	High school/technical secondary school	1044 (23.4)	384 (36.8)		331(31.7)
	Undergraduate/Junior college	2707 (60.8)	1530 (56.5)		1352(49.9)
	Postgraduate and above	259 (5.8)	187 (72.2)		165(63.7)
Age of child	0–3 yr	1312 (29.5)	725(55.3)	15.115	638(48.6)	13.614
	4–6 yr	3143 (70/5)	1536 (48.9)	15.115	1339(42.6)	13.614
Number of children in family	One Two Three or more	2456 (55.1) 1926 (43.2) 73 (1.6)	1303(53.1) 918(47.7) 40(54.8)	13.033	1105(44.9) 836(43.4) 36(49.3)	12.069
Monthly household income, RMB ^d	≤ 5000 5001–10000 10001–20000 ≥ 20000	724 (16.3) 1753 (39.3) 1315 (29.5) 663 (14.9)	281(38.8) 813(46.4) 757(57.6) 410(61.8)	111.760	229(31.6) 717(40.9) 669(50.9) 362(54.6)	106.803
Trip frequency for children	Every day/almost every day 2–3 times a week 2–3 times a month	1069 (24.0) 1292 (29.0) 768 (17.2)	708 (66.2) 746 (57.7) 383 (49.9)	335.066	645(60.3) 663(51.3) 343(44.7)	362.183
	Once a month or less	264 (5.9)	117(44.3)	335.066	94(35.6)
Travel distance of children, km	< 3 3–5 6–10 ≥ 10	543 (12.2) 998 (22.4) 1003 (22.5) 849 (19.1)	298(54.9) 620(62.1) 562(56.0) 474 (55.8)	278.038	260(47.9) 567(56.8) 500(49.9) 418(49.2)	303.945

Data shown as n (%) unless otherwise indicated. CRS, child restraint system.

^a Defined as those who reported owning CRS.

^b P < 0.0001

^c Defined as those who indicated using CRS at least sometimes.

^d 1 RMB is approximately 0.15 USD.

Logistic regression showed that the frequency of travel by car with a child passenger and monthly family income significantly affected the use of child safety seats (Table 2).

Table 2

Regression analysis to identify factors influencing use of child safety seats (n = 1,977)
Factor	B	Standard error	Wald	P	OR(95%CI)
Monthly household income, RMB ^a
≤ 5000					1.000
5001–10000	-0.044	0.147	0.091	0.763	0.957(0.718–1.275)
10001–20000	-0.018	0.149	0.015	0.904	0.982(0.734–1.315)
> 20000	-0.326	0.163	3.996	0.046	1.385(1.006–1.907)
Frequency of car travel with child
Every day					1.000
2–3 times / week	0.242	0.151	2.555	0.110	1.273(0.947–1.713)
2-3times / month	0.480	0.167	8.301	0.004	1.616(1.166–2.240)
Once a month or less	0.530	0.228	5.392	0.020	1.699(1.086–2.657)
^a 1 RMB = 0.15 USD.

A majority of parents (51.4%) obtained knowledge about CRS from the Internet and the instruction manual from the child safety seat packaging. Nearly all parents (98%) correctly indicated that the statement "mounting child seats on the passenger seat" was wrong. Only small percentages of respondents correctly indicated that the following statements were wrong: "car seat belts can effectively protect children in the event of a car crash" (14.8%) and "car airbags can effectively protect children in the event of a car crash" (40.9%). Thus, most parents in our sample mistakenly believed that seat belts and airbags are effective in protecting children.

The most frequent reasons that parents indicated for not installing CRS were that children had less chances to ride (25.7%) and that large seats took up too much space in the car (13.7%). Only 16.6% of parents who did not already own a car seat were considering buying one soon. When purchasing CRS, 43.8% of parents took into account product quality, 38.1% were willing to buy CRS in shopping malls, and 22.6% found a cost below 1000 RMB (approximately 150 USD) acceptable.

This study describes the prevalence of CRS use among child passengers in Mianyang, a city in western China. The results show that the rate of CRS ownership is moderate, falling between the 0.1% reported in a 2017 survey in Shantou, Guangdong Province [16] and the 81.5% reported in Shanghai in 2018 [19] and 64.1% reported in Shenzhen in 2016 [17]. The rate in our study is much lower than rates in more developed countries such as the United States (90.8%)[21] and the Netherlands (88%)[22]. While our survey identifies low CRS ownership as a problem, it also reveals a deeper issue: even when parents own CRS, they often do not use them. Only 19.6% of CRS owners in our survey reported using them all the time.

In our study, children were least likely to be placed in car seats for infrequent or short trips. This may reflect that many parents mistakenly believe that short trips pose little risk to safety[23]. Given that two-thirds of accidents occur within 15 km of home, short trips in fact involve substantial risk to child passengers [24].

The Practice Guidelines of the American Academy of Pediatrics recommend the use of rear-facing child safety seats in motor vehicles for children under 2 years of age[25]. Our study found that the proportion of rear-facing child safety seats was quite low (7.18%), which is consistent with other studies[26]. This difference may be due to the mistaken belief of some parents that rear-facing child safety seats are unsuitable for infants and toddlers, and that holding the child on the lap is safer than using a car seat[8]. Most parents (67.2%) in our study preferred holding their children while riding in the car, especially children 1–3 years old. This may reflect a widespread belief that adults can use their arms to protect child passengers in the event of a traffic accident [9]. However, when a vehicle crashes at 50 km/h, the mere collision between adult and child can be fatal to the child [27].

Parents in our survey seemed to hold several misconceptions regarding safety of child passengers in cars, CRS and the use of seat belts. The American Academy of Pediatrics says that restraints should be chosen based on a child's height, weight and age[8]. The child safety seat used by young children cannot meet the needs of older children, who therefore require a heightening (“booster”) seat or pad [28]. In our survey, only 0.7% (30/4455) of parents used booster seats, and the likelihood of using an age-appropriate CRS decreased as the age of the child increased. This is consistent with the use of CRS in car crashes[30]. In fact, the rate of CRS ownership in the present study was lower among parents of children older than 3 years than among parents of children younger than 3 years. This implies that parents use only seat belts for older children. The vast majority of parents in our survey (85.2%) appear to believe that seat belts and airbags can protect their children, especially those older than 3 years. But the inappropriate use of seat belts for children increases the risk of serious injuries such as visceral and spinal cord injuries, collectively referred to as "seat belt syndrome"[29] [31]. The American Academy of Pediatrics recommends that children 4–8 years old not be strapped into seat belts until they exceed the maximum height/weight threshold set by the seat manufacturer[8].

We found that the use of CRS strongly correlated with parental educational level and family income. The more educated parents were, the more they understood what constitutes safety measures for child passengers and the more aware they were of the need to use safety seats. A small percentage of parents (6.6%) indicated that they did not plan to purchase CRS because of their high cost, and 9.0% of parents willing to buy CRS reported that price was a major factor in their decision. Further research should examine the economic barriers to CRS use.

Our study suggests low rates of CRS ownership and use in western China, which should be addressed by government, society and families. The government could implement electronic technology that assists law enforcement in detecting when child passengers are not properly secured, and the government could strengthen public outreach about compliance with child traffic safety laws. For example, Shanghai opened a child safety seat technology testing station that was free of charge for parents, who could come and receive explanations and guidance about CRS installation and use. Parents with financial constraints can be encouraged to acquire CRS through loans, low-cost leasing or free provision. In one scheme, Greek hospitals provided CRS to parents of newborns through a low-cost, short-term rental program (xx). Police could partner with educational and medical institutions to provide outreach and training to parents about CRS and child passenger safety.

This study has several limitations. First, the data were collected through a self-report questionnaire, which increases the risk of reporting bias. In particular, parents may be less willing to provide responses that they think society would judge negatively. Second, the questionnaire was filled out primarily by parents, yet grandparents in China are often the children’s primary care provider, and they can strongly influence the children's parents. Future studies should examine grandparents’ knowledge and attitudes about CRS. Third, we did not collect data on the children’s height or weight, making it impossible for us to assess whether parents who owned CRS actually purchased the appropriate system. Finally, although Mianyang accounts for a substantial proportion of car owners in Sichuan province, whether our results can be generalized to the entire province or to other parts of western China is unclear. Future work should verify and extend our findings with a multi-city survey.

Parental misconception about CRS contributes to low rates of CRS ownership and use in Mianyang and potentially more broadly in the less economically advanced parts of China. Government, civil society, and educational institutions should work together to improve parental knowledge about CRS and child passenger safety, and thereby promote safer behavior.

CRS

child restraint systems

odds ratio

confidence interval

ACKNOWLEDGMENTS

We would like to thank the parents who participated in our study. We are also very grateful to the medical staff and kindergarten teachers who underwent training and helped facilitate this survey.

AUTHOR CONTRIBUTIONS

XW and MH designed the study. XR collected data, which DW and YR analyzed. LW drafted the manuscript, which DW, YR, and CJ revised. All authors read and approved the final version.

AUTHOR INFORMATION

Dan Wen is from Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.

Xingli Wan is from Department of Nursing, West China Second Hospital, Sichuan University, Chengdu, Sichuan Province, China.

Yinghong Reng is from Department of Nursing, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.

Chao Jia is from Department of Nursing, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.

Xiuru Yang is from Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.

Mei He is from Hospital office, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.

FUNDING

Not applicable.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Verbal informed consent was obtained from the parents of the children.

CONSENT FOR PUBLICATION

Not applicable.

COMPETING INTERESTS

The authors declare that they have no competing interests.

Author details

¹Department of Nursing and Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China. ²Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China. ³Department of Nursing, West China Second Hospital, Sichuan University, Chengdu, Sichuan Province, China. ⁴Hospital office, Mianyang Central Hospital, Mianyang, Sichuan Province, China.

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No competing interests reported.

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Prevalence of child restraint system use and parental knowledge of such systems in Mianyang, China

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Abstract

Background

Methods

Results

Conclusions

Background

Methods

Participants

Questionnaire

Administration of questionnaire

Statistical analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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