This study aimed to determine the impact of interventions on reducing child occupants’ unsafe behaviors using SEM. The results showed the intervention could reduce unsafe behaviors. The findings of other studies have revealed teaching safe traffic behaviors could change traffic users’ behaviors (18), especially children (2, 13). Thus, it is necessary to pay attention to training that leads to behavioral change (19). The number of deaths and injuries among children could be reduced through education and behavioral change.
Studies have indicated many children die and are injured in accidents (19). The injuries cause severe mental and financial problems for the family and society (4).
Education has an important role, so that it has been introduced as one of the axes of action and practice decade (2011–2020), which could reduce accidents involving children. Analyzing traffic accidents in Iran has shown human factor is the most common cause of accidents, i.e., in most cases, the human factor alone or jointly with other factors is responsible for accidents in Iran (21, 22). The child occupants’ behavior is among the human factors that could be improved through education in order to prevent from accidents and injuries in this vulnerable group. Permanent road safety education (PRSE) has been carried out in successful countries worldwide such as the Netherlands since 2000 in order to reduce traffic accidents and teach traffic culture from childhood to the end of life at all levels of society (23). Emphasis is placed on education from childhood, which could be the basis for subsequent human behaviors (24). Therefore, occupants’ safe behaviors should start from childhood and continue into adulthood. Our results showed almost 9% of the children used booster seats. Consistent with this finding, a research conducted in Pakistan showed 22% of parents who had children under the age of 12 years old used safety seats and 6.6% always used safety seats (8). However, 99% and 34% of children in Australia and Romania use booster seats, respectively (25). The frequency of using safety seats is low in Middle Eastern countries such as Iran and Pakistan, which could increase the risk of death and severe injury among children. Therefore, the importance of safety seat use should be highlighted in these countries and programs should be prepared and implemented on reducing traffic accidents similar to those of successful countries such as the Netherlands and Australia.
Studies have revealed using safety seats could reduce the risk of mortality among infants and children aged 1–4 and 4–7 years old by 70%, 54–80% (26) and 59%, respectively (25). In other words, using safety seats reduces death and injuries among children (6).
Our results showed behaviors of sitting in the front seat, sitting on the lap of the front passenger, standing in the back seat and sticking hands and other body parts out of the window significantly decreased among children by 64.8%, 32.4%, 38% and 84% in the intervention group in the second stage compared to the first stage, respectively (vs. 27%, 23%, 7% and 30.6% in the control group, respectively). Children sitting in the front seats alone or on others’ lap could be ejected in case of severe braking or accidents due to their physiological condition such as lower height and weight and high head weight compared to the body size. Thus, the possibility of head injury exposes them to the risk of death and more injury (27). Moreover, children sitting in the front seats are injured even in low-speed accidents due to air bag inflation (28). When the child sits on the lap of the front passenger, they are more likely to be ejected in case of braking or accidents. Moreover, the airbag may inflate and injure the child. The child is placed between the passenger and airbag and suffers more damage. Studies have shown 36% of children are killed in traffic accidents as passengers, mostly in middle- and high-income countries because they are at higher risk due to sitting in front or back seats without using a safety seat (4). The present study showed more than 80% of children were used to sit in the front seat at the beginning of the study. Although it is clearly stated in Iran’s traffic laws that children under the age of 12 years old should not sit in front seats (29), this law is not currently implemented. Therefore, the police should take specific measures for violators (29). Moreover, various organizations such as education, police, insurance, etc. should cooperate to prevent children from sitting in front seats and standing in the car (2).
Barriers to using the booster seat at the interpersonal level of SEM model were examined. The results showed the frequency of barriers to booster seat use significantly decreased in the intervention group after intervention. Parents’ lack of knowledge of booster seat (more than 80% of parents in the intervention group in the first phase) was among these barriers. In line with this finding, Khademi et al. conducted a research in another city of Iran and found that more than 88% of parents did not know the appropriate seat for their child’s age and weight (1). Although the majority of children used safety seats in Australia, almost half of the parents were not aware of how to use safety seats correctly and the appropriate age for using adult seat belts rather than safety seats (26). Parents’ unfamiliarity with the law of using the booster seat, limited space in the car, parents’ lack of attention to buying the booster seat, taking a lot of time to buckle the seat belt and uncomfortable feeling for the child in the booster seat were other barriers to booster seat use, which significantly decreased in the intervention group in the second phase. Therefore, the studied intervention could reduce the barriers to booster seat use probably as a result of group discussion among parents in the group. The booster seat expensive price was another barrier. Some parents did not know the booster seat price at the beginning and realized its high price after intervention. Various solutions were presented in group discussions among parents, e.g., people could jointly collect some amount of money for buying the booster seat and give it as the present at birthday parties, instead of giving a cheap gift to the child. In the present study, the frequency of children’s unsafe behaviors in the intervention group significantly decreased in the second phase. It could be said that SEM-based intervention could change children’s behavior at multiple levels. In the studied intervention, a specific educational program was implemented at interpersonal and interpersonal levels. This process could cause behavioral interactions between parents and children. Moreover, encouraging children to perform safe behaviors in virtual groups, providing social support and performing the intervention at intrapersonal level simultaneously could play a major role in promoting safe behaviors. Therefore, SEM-based teaching at different levels was effective in changing the frequency of unsafe behaviors.
The COVID-19 outbreak was among the limitations of the current study, which prevented interventions at the environmental level. It was probably one of the reasons why the current study could not increase the frequency of booster use. If the schools were open and researchers could introduce the booster seat in person in the school environment, the frequency of using the booster seat could increase. Studies have shown interventions at different levels of ecological model could cause synergistic effects of the desired behavior (12, 13, 24, 30). Lack of stores selling booster seats was another limitation of the study. Lack of access to centers selling booster seats as well as its high price were among the major barriers to its use. Although there was discussion in virtual groups about places to buy booster seats, its expensive price was among the important points in environmental interventions and having access to it. Booster seats are available to families in different countries worldwide. In some countries, there is a safety seat lending center that lends this device to families who could not afford it. In some others, subsidies are given for purchasing booster seats (6). Studies have demonstrated distributing this device is among the efficient ways for increasing the frequency of booster seat use in low-income societies (10). Such centers should be established in our country to increase children’s access to booster seats and its application. Studies have shown the frequency of healthy behaviors in the environment causes more people to do them (12, 32, 31–33, 34).
Another limitation of the present study was that unsafe behaviors decreased in the control group because the intervention was virtually performed on SHAD network. Parents and teachers sent messages on different virtual networks such as Instagram and WhatsApp and this issue caused contamination bias. One of the strengths of the present study was that this study investigated the frequency of using booster seats and educating children, teachers and parents about this device for the first time in Iran using SEM at different levels.