Abstract
Objective
We modified the Child Safety Seat (CSS) Hassles Scale to characterize CSS hassles in a diverse population and test for associations between hassles and caregiver-reported child passenger safety behaviors.
Methods
Secondary analysis of a 2-site survey of caregivers seeking emergency care for their ≤10-year-old child in 2015. Caregivers answered questions regarding CSS hassles, child passenger safety behaviors, and demographics. Size-appropriate restraint use was defined by the American Academy of Pediatrics (AAP) 2011 Guidelines for Child Passenger Safety. We tested for associations between the number of hassles and adherence to AAP guidelines (including the consistent use of a size-appropriate CSS, travel in a back seat, and never traveling unrestrained).
Results
There were 238 caregivers included in analyses. Overall, caregivers endorsed a median of 5 hassles (IQR 2, 8). Half (50.8%) of caregivers endorsed child passenger safety behaviors that were nonadherent to AAP guidelines. Compared with caregivers reporting no hassles, there was an increased odds of not adhering to AAP child passenger safety guidelines for each additional hassle reported (aOR 1.11 95% CI 1.03, 1.19). In addition, a higher number of hassles was associated with the inconsistent use of a size-appropriate CSS (aOR 1.15 95% CI 1.06, 1.25) and as sometimes traveling unrestrained (aOR 1.13 95% CI 1.03, 1.23).
Conclusions
Caregivers who reported more CSS hassles were more likely to report behaviors that were not adherent to AAP guidelines. Addressing child safety seat hassles may provide solutions for nonadherence of AAP child passenger safety guidelines.
Keywords: Child restraint, hassles, adherence
Introduction
Injuries sustained in motor vehicle collisions (MVCs) are a leading cause of death for children 1 to 10 years old.1,2 There is extensive evidence that young children are best protected against severe injury and death in crashes when they use the recommended child safety seat (CSS) for their age and size.3–6 This evidence serves as the foundation for guidelines published by the American Academy of Pediatrics (AAP).7 Guideline-adherent child passenger safety behaviors, including consistent use of an age and size-appropriate CSS and sitting in a rear row of the vehicle, decline after a child’s first birthday and are less commonly observed among Black and Hispanic families and those with lower educational attainment and lower socioeconomic status.8–11 Disparities in restraint use translate into disparities in crash-related mortality.2 Suboptimal child passenger safety is associated with lack of knowledge but this does not fully explain the nonadherence to guidelines.12–15
Novel approaches are needed to identify at-risk families and promote guideline-adherent child passenger safety behaviors. Agran et al developed a 20-item Child Safety Seat Hassles Scale in a largely Spanish-speaking population of caregivers of 1- to 3-year-olds who violated child safety seat laws in California, and found that a high median frequency and intensity of perceived hassles were associated with inconsistent use.16 The Hassles Scale serves as a marker of inconvenience and the day-to-day challenges associated with regularly using a child passenger restraint system. It potentially has applicability in predicting inconsistent CSS use, but has not yet been studied in a diverse population. To build upon the work of Agran et al, we assess the self-reported intensity of the 20 hassle items in a racially and economically diverse population of caregivers of children 1 to 10 years old seeking care in two Michigan emergency departments (EDs). This study, conducted to inform hypotheses for future studies and new interventions to address suboptimal child restraint use, had two objectives: 1. To describe perceived CSS hassles in a diverse population and 2. To identify whether reported number of hassles is associated with adherence to AAP child passenger safety guidelines.
Methods
Study Design
We performed a secondary analysis of data collected May-September 2015 for pilot testing of an Emergency Department (ED) based child passenger safety intervention.17 Full details on recruitment and data collection for the pilot testing can be accessed in the original article.17
Setting
Data were collected from parents or caregivers seeking emergency care for children younger than 11 years old at Michigan Medicine (MM) C.S. Mott Children’s Hospital Emergency Department (ED) in Ann Arbor or the Hurley Medical Center (HMC) ED in Flint, Michigan. Since 2008, Michigan’s child passenger safety law has required children travel in car seats until age 4 and car seats or booster seats until age 8 or 57 inches tall, whichever comes first.
Data Collection
Caregivers were recruited on weekdays and weekends between 10am and 11pm, based on the order of arrival to the ED. Caregivers were approached after their child was placed in a treatment room. Trained research assistants used a standard script to review study procedures and obtained informed consent from eligible caregivers who were interested in participating. Survey responses were entered by participants on a study iPad using the Qualtrics survey platform (Provo, UT). Most caregivers were able to complete their survey responses in 10–15 minutes. Surveys were paused as needed for patient care. The Institutional Review Boards at the University of Michigan and HMC approved the study. Caregivers were given a $15 gift card for participation in the Emergency Department portion of the study.
Families were not approached if their child was critically ill or injured, if the child presented with concerns for child abuse, or if the admission process had already begun. Other exclusion criteria included caregivers <18-years-old, non-English-speaking caregivers, measured height of the child ≥57 inches (the height at which a child is expected to fit properly into an adult seat belt), or a child who required travel vest or wheelchair seating in vehicles. We excluded children younger than 1 year old (n=60) from this secondary analysis because the original Hassles Scale was developed for caregivers of 1 to 3 year olds. For the secondary analysis we did not include caregivers who reported their child usually used a seat belt (n=34) or when responses to any of the hassles questions were missing (n=7).
Variables
Caregivers were asked if their child ever used a CSS in their motor vehicle. If the caregiver indicated using a CSS, they were asked to select their most commonly used type from a number of sketched examples. We considered this to be the child’s usual CSS for subsequent questions. Caregivers were also asked if their child used any other type of CSS or had ever gone on a trip without being restrained.
To explore multiple factors related to difficulties or inconveniences associated with use of CSS, we used the 20 items from the Hassles Scale developed by Agran et al in 2006 (Appendix) and adapted response options by asking caregivers to rate the intensity of each hassle using a 4-point Likert scale (0 = not present, 1 = seldom, 2 = sometimes, 3 = often). The items were categorized as described in the original study of the Hassles Scale: child, crowding/inconvenience, busy, and multiple vehicles.16,18,19
Child factors include behaviors that make it challenging to use the CSS properly or keep the child in the CSS. Crowding/inconvenience factors are related to the inconvenience of using the CSS either due to CSS characteristics or other environmental characteristics. Busy factors are related to time commitments and/or time pressures that are not directly related to the CSS. Vehicle factors include having to change vehicles or move the CSS due to multiple cars or riding with others.16
Caregivers provided demographic data including their race/ethnicity, highest education level, and annual household income. Child age was categorized into 12–23 months, 2 through 4 years, and 5 through 10 years based on typical sizes of children and type and direction of child restraint. Child weight was measured for ED care. We considered children to be using a size-appropriate CSS using previously described methods.17 Briefly, we considered rear-facing CSS appropriate for children <35 pounds, forward-facing CSS appropriate for children 30–50 pounds, and booster seat appropriate for children 40–100 pounds. We allowed for overlap due to a lack of detailed information about the manufacturer specified weight limits of each child’s CSS. We considered child passenger safety behaviors to be guideline-adherent if the caregiver reported the child used a size-appropriate CSS on every trip, never travelled unrestrained, and always travelled in the back seat.
Analysis
We calculated descriptive statistics, including percentages, medians and interquartile ranges as appropriate. We performed qualitative comparisons of the types and distribution of hassles identified by guidline-adherent caregivers versus those identified by non-adherent caregivers. We determined the proportion of cargivers who ranked any hassle as problematic to any degree and compared across demographic charateristics using chi-square statistics. Counts of hassles were compared across demographic characteristics using Kruskal-Wallis rank sum tests for demographic characteristics with three or more categories and Wilcoxon rank sum tests for demographic characteristics that were dichotomous. We examined the hassles by caregiver race/ethnicity and nonadherence behaviors to assess for differences in the types of hassles (e.g., child, crowding/inconvenience) ranked in order from most to least commonly selected. We tested for the relationship between number of hassles and the individual and composite outcome measures of child passenger safety behaviors using logistic regression analysis with results presented as odds ratios and 95% confidence intervals (CI). We tested for the strength of the association in multiple variable logistic regression models adjusting for demographic characteristics of the caregiver (age category, race and ethnicity, educational attainment, annual household income, recruitment site, and child age category) with results presented as adjusted odds ratios and 95% CIs. We considered p<0.05 to be statistically significant. Analyses were conducted using Stata 15.1 (Stata Corp LLC, College Station, TX)
Results
Sample Characteristics
For the main study, there were 456 caregivers who met eligibility criteria and were approached; 347 (76.1%) consented to participate. Baseline surveys were completed by 339 caregivers, 238 of whom were eligible for this secondary analysis after excluding 60 children <1-year-old, 34 children who used seat belts only, and 7 caregivers whose hassle responses were incomplete. Figure 1 is a CONSORT diagram describing enrollments.
Figure 1:
CONSORT Flow Diagram
Characteristics of the study sample are shown in Table 1. Overall, most caregivers were mothers, 18–29 years old, non-Hispanic White, with an annual family income of <$25,000. When comparing the two sites, parents at HMC were younger, with more who identified as Black, non-Hispanic, with high School/GED or less education, lower family income, younger children and less protective child passenger safety behaviors.
Table 1:
Sample Characteristics by Hospital Site
|
Variables |
Total n=238 | % | MM n=132 | % | HMC n=106 | % |
|---|---|---|---|---|---|---|
| Relationship to Child | P=0.87 | |||||
| Mother | 210 | 88.2 | 117 | 88.6 | 93 | 87.7 |
| Father | 25 | 10.5 | 13 | 9.9 | 12 | 11.3 |
| Other | 3 | 1.3 | 2 | 1.5 | 1 | 1.3 |
| Parent Age | P=0.001 | |||||
| 18–29 | 112 | 47.1 | 48 | 37.8 | 64 | 62.1 |
| 30–39 | 95 | 39.9 | 62 | 48.8 | 33 | 32.0 |
| 40+ | 31 | 13.0 | 17 | 13.4 | 6 | 5.8 |
| Parent Race/Ethnicity | P<0.001 | |||||
| White, Non-Hispanic | 147 | 61.8 | 100 | 75.8 | 47 | 44.3 |
| Black, Non-Hispanic | 65 | 27.3 | 16 | 12.1 | 49 | 46.2 |
| Hispanic and other races | 26 | 10.9 | 16 | 12.1 | 10 | 9.4 |
| Parent Education Level | P<0.001 | |||||
| High school/GED or less | 105 | 49.2 | 43 | 32.6 | 62 | 58.5 |
| Associates degree or higher | 133 | 55.8 | 89 | 67.4 | 44 | 41.5 |
| Annual Family Income | P<0.001 | |||||
| <$25,000 | 136 | 57.1 | 40 | 30.3 | 62 | 58.5 |
| ≥ $25,000 | 102 | 42.9 | 92 | 69.7 | 44 | 41.5 |
| Child Gender | P=0.054 | |||||
| Male | 126 | 53.2 | 54 | 41.2 | 57 | 53.8 |
| Female | 111 | 46.8 | 77 | 58.8 | 49 | 46.2 |
| Child Age and Usual CSS Type | P<0.02 | |||||
| 1 year | 57 | 23.9 | 25 | 18.9 | 32 | 30.2 |
| Rear-facing (p=0.01) | 33 | 57.9 | 20 | 80.0 | 13 | 40.6 |
| Forward-facing | 22 | 38.6 | 5 | 20.0 | 17 | 53.1 |
| Booster | 2 | 3.5 | 0 | 0 | 2 | 6.2 |
| 2–4 years | 117 | 49.2 | 63 | 47.7 | 54 | 50.9 |
| Rear-facing (p=0.098) | 3 | 2.6 | 3 | 4.8 | 0 | 0 |
| Forward-facing | 87 | 74.4 | 49 | 77.8 | 38 | 70.4 |
| Booster | 27 | 23.1 | 11 | 17.5 | 16 | 29.6 |
| 5–10 years | 64 | 26.9 | 44 | 33.3 | 20 | 18.9 |
| Rear-facing (p=0.936) | 0 | 0 | ||||
| Forward-facing | 3 | 4.7 | 2 | 4.5 | 1 | 5.0 |
| Booster | 61 | 95.3 | 42 | 95.5 | 19 | 95.0 |
| Consistently uses one type of restraint (p<0.001) | 200 | 84.0 | 122 | 92.4 | 78 | 73.6 |
| Guideline nonadherent child passenger safety behaviors* (p<0.001) | 121 | 50.8 | 46 | 34.9 | 75 | 70.8 |
| Never use size appropriate CSS (p<0.001) | 67 | 28.2 | 24 | 18.2 | 43 | 40.6 |
| Not consistently using size appropriate CSS (p<0.001) | 38 | 16.0 | 10 | 7.6 | 28 | 26.4 |
| Have traveled unrestrained (p<0.001) | 31 | 13.0 | 5 | 3.8 | 21 | 20.2 |
| Allowed child to sit in the front seat (p=0.15) | 15 | 6.3 | 11 | 8.3 | 4 | 3.8 |
Composite Variable based on the presence of any of the behaviors, some caregivers reported more than one of the behaviors therefore the subitems do not total to 50.8%.
The predominant caregiver-reported usual CSS was a forward-facing car seat. There were 67 caregivers (28.2%) who indicated that they were never using a size-appropriate CSS based on their child’s age and measured size. Inconsistent use of a size-appropriate CSS was reported by 38 caregivers (16%). Travel with an unrestrained child on at least some trips was reported by 31 caregivers (13%) and 15 caregivers (6.3%) had let their child sit in the front seat. Caregiver-reported child passenger safety behaviors were considered nonadherent to AAP guidelines for 121 caregivers (50.8%), including 46 caregivers (34.9%) from MM and 75 caregivers (70.8%) from HMC.
Figure 2 provides a visual comparison of the types of hassles identified by caregivers who were categorized as having guideline-adherent child passenger safety behaviors to those with at least 1 guideline-nonadherent child passenger safety behavior. Of note, the types of hassles identified most frequently by both groups are very similar, and include child factors (such as the child being bored or uncomfortable and not liking riding in CSS), busy factors (such as the multiple trips being made in a day), and the child not liking being restrained on long trips.
Figure 2:
Comparison of Hassles in Parents with Non-Adherent and Adherent Behaviors
Table 2 presents the proportion of caregivers who identified any hassle across site, self-reported demographic and child passenger safety behavior characteristics, revealing a statistically significant difference only in patient race/ethnicity. Table 3 presents the median count of hassles identified. Overall, caregivers endorsed a median of 5 hassles (IQR 2, 8). The median hassles count was significantly higher for non-Hispanic Black caregivers than for caregivers of other races as well as among caregivers who reported annual household income <$25,000 and those recruited at HMC. There was no difference based on caregiver education or type of CSS.
Table 2:
Proportion of Caregivers Identifying Any Hassles by Caregiver/Child Characteristics
| Any Hassle | |||
|---|---|---|---|
| % | p-value | ||
| Parent race/ethnicity | Non-Hispanic, White | 85.0 | 0.02 |
| Non-Hispanic, Black | 95.4 | ||
| Hispanic and other races | 76.9 | ||
| Annual family income | <$25,000 | 91.2 | 0.12 |
| >=$25,000 | 83.8 | ||
| Parent education attainment | High school or less | 88.6 | 0.56 |
| Associates degree or more | 85.7 | ||
| Child age category | 1 year | 92.9 | 0.23 |
| 2–4 years | 86.3 | ||
| 5–10 years | 82.8 | ||
| Child restraint type | Rear-facing car seat | 91.7 | 0.25 |
| Forward-facing car seat | 89.3 | ||
| Booster seat | 82.2 | ||
| Site | Michigan Medicine | 87.4 | 0.794 |
| Hurley Medical Center | 88.3 | ||
Table 3:
Median Count of Hassles by Caregiver/Child Characteristics
| Count of Hassles | |||
|---|---|---|---|
| Median (IQR) | p-value | ||
| Parent race/ethnicity | Non-Hispanic, White | 4 (2, 7) | 0.005 |
| Non-Hispanic, Black | 6 (3, 10) | ||
| Hispanic and other races | 4 (1, 8) | ||
| Annual family income | <$25,000 | 5 (2, 9) | 0.048 |
| >=$25,000 | 4 (2, 7) | ||
| Parent education attainment | High school or less | 4 (2, 7) | 0.84 |
| Associates degree or more | 5 (2, 8) | ||
| Child age category | 1 year | 5 (3, 7) | 0.086 |
| 2–4 years | 5 (2, 9) | ||
| 5–10 years | 4 (1, 6) | ||
| Child restraint type | Rear-facing car seat | 5 (3, 7.5) | 0.394 |
| Forward-facing car seat | 5 (2, 9) | ||
| Booster seat | 4 (1, 7) | ||
| Site | Michigan Medicine | 4 (2, 7) | 0.032 |
| Hurley Medical Center | 5 (2, 9) | ||
Table 4 summarizes the association of a hassles count with nonadherent child passenger safety behaviors. Each increase in the count of hassles above no hassles was associated with an increased odds of inconsistent use of size appropriate CSS (OR 1.18 95% 95% CI 1.09, 1.27), sometimes traveling unrestrained (OR 1.16 95% CI 1.07, 1.26), and being nonadherent to AAP guidelines (OR 1.13 95% CI 1.06, 1.20). These associations remained after adjustment for age of the child, age of the parent, parent race/ethnicity, parent education, household income, and recruitment site. In this adjusted analysis, recruitment site was found to be statistically significant, with an increased odds of non-guideline adherent behaviors (OR 3.02 CI 1.63, 5.58), never using a size-appropriate CSS (OR 2.42 CI 1.17, 5.00), inconsistent use of the size approporiate CSS (OR 4.06 CI 1.63, 10.13), and riding unrestrained (OR 6.71 CI 2.03, 22.12) in caregivers from HMC.
Table 4:
Unadjusted and Adjusted Associations of Hassles Count and Nonadherent Child Passenger Safety Behaviors
| Composite of Specific Behaviors | Specific Nonadherent Child Paseenger Safety Behaviors | ||||
|---|---|---|---|---|---|
|
|
Not guideline adherent* | Never use size-appropriate CSS | Inconsistent use of size appropriate CSS | Front seat OR |
Unrsestrained OR |
| Unadjusted Logistic Regression | OR (95% CI) | OR (95% CI) | OR (95% CI) | (95% CI) | (95% CI) |
| Count of Hassles** | 1.01 (0.95, 1.07) | 1.18 (1.09, 1.27) | 1.06 (0.96, 1.18) | 1.16 (1.07, 1.26) | |
| Adjusted Logistic Regression | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) |
| Count of Hassles** | 1.10 (1.02, 1.18) | 0.97 (0.90, 1.05) | 1.14 (1.05, 1.24) | 1.05 (0.93, 1.19) | 1.11 (1.01, 1.22) |
| Child Age | |||||
| 1 year | Ref | Ref | Ref | Dropped due to collinearity | Ref |
| 2–4 years | 1.55 (0.75, 3.20) | 1.42 (0.69, 2.95) | 1.12 (0.44, 2.80) | 2.09 (0.65, 6.76) | |
| 5–10 years | 0.87 (0.37, 2.05) | 0.24 (0.07, 0.82) | 0.56 (0.17, 1.89) | 1.68 (0.39, 7.26) | |
| Parent Age | |||||
| 18–29 | Ref | Ref | Ref | Ref | Ref |
| 30–39 | 0.77 (0.39, 1.55) | 0.27 (0.12, 0.62) | 3.24 (1.17, 8.94) | 4.19 (0.97, 18.2) | 2.38 (0.75 7.54) |
| 40+ | 1.10 (0.37, 3.31) | 0.24 (0.05, 1.20) | 4.59 (0.98, 21.40) | 3.85 (0.54, 27.45) | 2.53 (0.39, 16.31) |
| Parent Race/Ethnicity | |||||
| White, Non-Hispanic | Ref | Ref | Ref | Ref | Ref |
| Black, Non-Hispanic, Hispanic, or Other Races | 1.83 (0.95, 3.52) | 1.36 (0.64, 2.90) | 1.49 (0.59, 3.74) | 1.53 (0.41 5.71) | 2.40 (0.82, 7.00) |
| Parent Education Level | |||||
| High school/GED or less | Ref | Ref | Ref | Ref | Ref |
| Associates degree or higher | 0.86 (0.44, 1.66) | 1.76 (0.82, 3.78) | 0.52 (0.21, 1.28) | 0.60 (0.15 2.32) | 0.62 (0.22, 1.72) |
| Annual Family Income | |||||
| <$25,000 | Ref | Ref | Ref | Ref | Ref |
| ≥ $25,000 | 0.80 (0.41, 1.55) | 1.27 (0.61, 2.90) | 0.82 (0.33, 2.02) | 1.29 (0.31, 5.38) | 1.01 (0.36, 2.78) |
| Site | |||||
| Michigan Medicine | Ref | Ref | Ref | Ref | Ref |
| Hurley Medical Center | 3.02 (1.63, 5.58) | 2.42 (1.17, 5.00) | 4.06 (1.63, 10.13) | 0.51 (0.14, 1.87) | 6.71 (2.03, 22.12) |
Composite outcome consists of the presence of any of the four specific nonadherent behaviors (Size-appropriate restraint, consistent use of restraint, sitting in a rear seat, never riding unrestrained)
Count of hassles measures the incremental impact of each hassle with zero hassles as the reference group.
Discussion
In this study of more than 200 families from diverse backgrounds, we described perceived CSS hassles and tested for associations between the number of hassles identified and CSS patterns of use in a more diverse population than previously studied. Consistent with our hypothesis, perceived hassles by caregivers were associated with adherence to guidelines for CSS use. For each increase of 1 hassle, the odds of nonadherence increased by 1.13.
We found that the most common hassles identified by caregivers were child-associated and busy factors, regardless of adherence to AAP guidelines. Similarly, in the Agran study, child factors and busy factors were most often identified as highest intensity regardless of child passenger safety behavior.16 The similarities in types of hassles identified across groups provides data on which to base targeted interventions.
We found an association between a higher number of identified hassles and specific guideline non-adherent child passenger safety behaviors such as inconsistent use of a size appropriate CSS and travelling unrestrained. This was similar to the original application of the Hassles Scale by Agran et al in primarily Spanish-speaking parents of children recommended to use forward-facing CSS.16 Studies on the issue of premature transitions out of a size-appropriate CSS have identified multiple contributing factors, including education, risk perception, and parenting style.13,18,20 There was not a significant association found between number of hassles and never using a size appropriate CSS or allowing the child to travel in the front seat. An increased number of hassles may impact certain child passenger safety behaviors such as always traveling in a size appropriate CSS, and may not impact others such as the decision to allow a child to sit in the front seat, or to never use a size appropriate CSS. Previous qualitative literature on parental perceptions of barriers to children sitting in the rear seat of the vehicle found that parents were generally aware of the risk of sitting in the front seat, and most often identified social pressures, inconsistent enforcement of a rear seating only rule among family members, and sitting in the front seat as a treat and when taking a short trip, none of which are directly related to the specific hassles evaluated in this study.21 This finding requires further study, as it is still unclear if and how much knowledge level and perception of CSS hassles are interrelated.
Non-Hispanic Black caregivers identified a higher median number of hassles than non-Hispanic White and Hispanic caregivers. In multivariable models, race was not found to be significant however recruitment site was. This is likely the result of unmeasured differences in the populations of caregivers presenting with their children to these Emergency Departments in different communities with potentially different stressors and social norms. These results suggest a potentially fruitful area of research to address multifactorial nature of racial and socioeconomic disparities in CSS use, children traveling unrestrained, and associated mortality caused by motor vehicle crashes.
This study has implications for future public health interventions. It is possible that caregivers may be more forthcoming about child passenger safety hassles than they are about consistent use of the recommended CSS This information could be easily gathered from families during clinical encounters or when obtaining services from community agencies dedicated to the health and well being of children. This is potentially an opportunity for implementation in clinical practice as a screening tool for increased risk of suboptimal child passenger safety behaviors.
Limitations
Our study has several limitations. First, self-reported CSS use is subject to social desirability bias, which could underestimate the magnitude of inconsistent restraint use. In addition, we can not be certain that our sample is truly representative of all caregivers, including the spouses/partners of the participating caregivers. However, we have previously demonstrated that caregiver-reported child restraint use was consistent with observed restraint use in the EDs included in this study.17 We are reassured that the reported nonadherence is approximately the same as nonadherent behaviors noted in studies where CSS use was evaluated by certified car seat technicians.17,22,23 Second, we do not have information about the manufacturer specified weight and height limits of the restraints that families have used in the past or were using for their children. Third, we did not collect information on behavioral or developmental challenges that families may face when traveling with their children or using CSS. Fourth, the 20 hassle items do not apply to all child ages/developmental stages or restraint systems causing us to exclude the <1 year olds, children with neurodevelopmental issues requiring specialized CSS, and seat belt restrained populations. This is an area for future research and development of hassles representative of those circumstances. In addition, the hassles questions were asked with regard to the restraint the caregiver reported using most often for their child. We did not collect data on hassles that were present when using a more protective restraint and may have been factors in a family’s decision to prematurely transition from a forward-facing CSS to a booster seat, for example. There is also a potential that the population of caregivers who seek ED care for their children is not fully representative of the general population. Another generalizability consideration is that car travel is common in southeast Michigan, where this study was conducted, due to a limited public transportation system and our findings may not apply to areas or populations more reliant on public transporation. In addition, we studied only 2 sites, however the demographics of the sites are very different, thus contributing to broader generalizability of our results.
Conclusions
A higher number of child passenger safety hassles identified by caregivers is associated with being nonadherent to AAP child passenger safety guidelines. Hassles may represent addressable difficulties with the consistent use of recommended CSS for children that are separate and unrelated to lack of education or knowledge that have been the focus of prior child passenger safety programs. Further studies are needed to evaluate how best to use child safety seat hassles for the identification of suboptimal CSS behaviors and to inform targeted i
What’s New:
A higher number of hassles is associated with inconsistent child restraint use, unrestrained travel, and nonadherence to child restraint guidelines among a diverse group of caregivers of children 1 to 10 years old who use child safety seats.
Funding Source:
Ms. Winkels was supported by the University of Michigan Medical School Summer Biomedical Research Program; Dr. Macy received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23 HD070913). The funding source had no involvement in the study design, collection and analysis of data, or writing of the manuscript.
Abbreviations:
- ED
Emergency Department
- HMC
Hurley Medical Center
- AAP
American Academy of Pediatrics
- MM
Michigan Medicine
- IQR
interquartile range
- CSS
Child safety seat
APPENDIX
Child Safety Seat Hassles Scale Questions
| How much of a problem is each situation for you when {child’s name} is in {his/her} {usual restraint}? [Not at all/Just a little bit/Somewhat/A big problem] | |
|---|---|
| 1 | {Child} resists riding in the {usual restraint} |
| 2 | {Child} gets bored or uncomfortable in the {usual restraint} |
| 3 | {Child} gets out of the {usual restraint} when the vehicle is moving |
| 4 | {Child} needs to be attended to while riding in the car |
| 5 | {Child} does not like riding in the {usual restraint} |
| 6 | I have to make multiple stops on a trip |
| 7 | It is difficult to get child ready for outings on time |
| 8 | I have to drive too many people in the vehicle |
| 9 | The {usual restraint} takes up too much room in the vehicle |
| 10 | I’m in a hurry and sometimes forget to check if everyone is buckled |
| 11 | I have to run extra errands just for children |
| 12 | {Child} doesn’t like to be restrained on long trips |
| 13 | It takes too long to get child in the {usual restraint} |
| 14 | {Child} does not listen/will not obey without being nagged |
| 15 | {Child} is sleeping when ready to begin a trip |
| 16 | {Child} and I need to get a ride with someone else |
| 17 | I have to move the {usual restraint} from one vehicle to another |
| 18 | There is a change in the car in which child rides in |
| 19 | I must make multiple trips in a day |
| 20 | {Child} wants to ride like other children |
Footnotes
Financial Disclosure: Authors have indicated they have no financial relationships relevant to this article to disclose.
Conflict of Interest: Authors have indicated they have no potential conflicts of interest to disclose.
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