Abstract
Objectives. To evaluate the effectiveness of parent-based child restraint system (CRS) education and hands-on CRS installation training.
Methods. We conducted a randomized trial with cluster sampling from May 2016 to January 2017 in 6 selected kindergarten classes in Shantou and Chaozhou, China. Parents were randomly assigned to receive 1 of the 3 study conditions: CRS education only, CRS education plus hands-on CRS installation training, or control (child electricity safety).
Results. Three months after the intervention, significantly higher CRS use was reported in the CRS education plus hands-on CRS installation training group than was reported in the control group (41.2% vs 18.5%; P = .011). However, no significant difference in CRS use was found between the CRS education only and the control groups (26.7% vs 18.5%; P = .33). The ratings on child passenger safety awareness increased significantly in both intervention groups but remained unchanged in the control group after the intervention.
Conclusions. The CRS education plus hands-on CRS installation training increased the use of child restraints, but the CRS education only condition did not. Both intervention methods helped to improve child passenger safety awareness.
Child restraint systems (CRSs) have been effective in reducing deaths and injuries in children in motor vehicle crashes.1,2 Numerous intervention efforts, including child passenger restraint laws, have been made in China to increase CRS use.3,4 Although China does not have a national law, 1 province (Shandong) and 3 cities (Shanghai, Hangzhou, and Shenzhen) have enacted child passenger restraint laws since 2015. Currently, the rates of CRS use in areas with the laws range from 16% to 27%, but the rates are lower than 1% in Shantou where such a law is lacking.5 The main reason for low CRS use was lack of parental awareness of CRSs. Recent evidence shows that education combined with free child safety seats led to an increase in CRS use among parents of newborns.6
We evaluated the effectiveness of parent-based CRS education with and without a hands-on CRS installation training program implemented in kindergarten classes. We hypothesized that CRS education would improve CRS use and that augmenting CRS education with hands-on CRS installation training would further improve the outcomes.
METHODS
We conducted a randomized trial with cluster sampling from May 2016 to January 2017. Six kindergarten classes were conveniently selected from the 2 medium- to small-sized cities located in eastern China: Shantou and Chaozhou. We then randomly assigned the selected kindergartens (3 from each city) into 1 of 3 study groups, with randomization occurring at the kindergarten level: CRS education only, CRS education plus hands-on CRS installation training, and control. All of the parents from the same kindergarten received the same study condition.
Eligible parents were those who (1) had a child aged 2 to 5 years, (2) were living in Shantou or Chaozhou for more than 6 months, (3) owned a car and had no CRS, and (4) had a valid driver’s license. Parents who had already bought a CRS or were unable to read or write were excluded. A total of 328 parents in the 6 kindergarten classes were invited to participate in the study. Of these, 177 parents who met the inclusion criteria were enrolled in the study). Of these, 52 were in the CRS education only group, 60 were in the CRS education plus hands-on CRS installation training group, and 65 were in the control group. Three months after the intervention, 27 parents were lost to follow-up. Of the 150 remaining parents who completed the follow-up, 45 were in the CRS education group, 51 were in the CRS education plus hands-on CRS installation training group, and 54 were in the control group.
Interventions
The CRS education only group received the following: (1) a pamphlet on child passenger safety and CRS legislation, (2) two 5-minute videos (1 displayed road traffic crash outcomes with and without the CRS, and another showed how to use a CRS correctly), and (3) a 30-minute lecture on child passenger safety.
The CRS education plus hands-on CRS installation training group received the CRS education described in the previous paragraph. In addition, parents received the following: (1) hands-on training on installation of a CRS conducted in a small group (3–4 parents per group) by 2 child passenger safety technicians trained in the study protocol and (2) a 3-month free trial of a CRS used in the parent’s own car.
The control group received a lecture about child electricity safety but no information on child passenger safety or CRS use.
Measures
We conducted a baseline survey before the intervention asking about child passenger safety awareness, CRS use, and demographics. We sent a WeChat link to the follow-up survey 3 months after the intervention to measure study outcomes on child passenger safety awareness and CRS use.
Data Analysis
We used the χ2 test to assess differences in child passenger safety awareness and CRS use before and after the intervention across the 3 groups, with an α level of .05. We analyzed the data with SPSS version 21.0 (IBM, Somers, NY).
RESULTS
The average age of parents was 33.7 years (range = 25–44), and the average age of children was 4.2 years (range = 2–5). Of the participating parents, 26.0% were men. More than half of the parents had attended some college or higher and had more than 5 years of driving experience. No significant differences in demographics were observed across the 3 study groups (Table 1).
TABLE 1—
Outcomes and Demographics of Parents and Children Among 3 Groups in a Parent-Based Intervention to Improve Child Restraint System (CRS) Use: Shantou and Chaozhou, China, May 2016–January 2017
| Items | CRS Education Only (n = 45), No. (%) | CRS Education Plus Hands-on CRS Installation Training (n = 51), No. (%) | Control (n = 54), No. (%) | P |
| Intervention outcomes | ||||
| CRS use | .035a,b | |||
| Yes | 12 (26.7) | 21 (41.2) | 10 (18.5) | |
| No | 33 (73.3) | 30 (58.8) | 44 (81.5) | |
| Child passenger safety awarenessc | ||||
| Preintervention | (54.1) | (54.3) | (54.3) | |
| Postintervention | (80.7) | (86.3) | (69.8) | |
| Differenced | (26.7) | (32.0) | (15.4) | |
| Demographics | ||||
| Parent gender | .93 | |||
| Male | 11 (24.4) | 13 (25.5) | 15 (27.8) | |
| Female | 34 (75.6) | 38 (74.5) | 39 (72.2) | |
| Parent age, y | .10 | |||
| ≤ 35 | 27 (60.0) | 39 (76.5) | 42 (77.8) | |
| > 35 | 18 (40.0) | 12 (23.5) | 12 (22.2) | |
| Parent education level | .40 | |||
| ≤ high school | 22 (48.9) | 20 (39.2) | 28 (51.9) | |
| ≥ college | 23 (51.1) | 31 (60.8) | 26 (48.1) | |
| Family monthly income, yuan | .08 | |||
| ≤ 5000 | 10 (22.2) | 16 (31.4) | 7 (13.0) | |
| > 5000 | 35 (77.8) | 35 (68.6) | 47 (87.0) | |
| No. of children in family | .28 | |||
| 1 | 22 (48.9) | 22 (43.1) | 18 (33.3) | |
| ≥ 2 | 23 (51.1) | 29 (56.9) | 36 (66.7) | |
| Child gender | .28 | |||
| Male | 20 (44.4) | 31 (60.8) | 29 (53.7) | |
| Female | 25 (55.6) | 20 (39.2) | 25 (46.3) | |
| Child age, y | .39 | |||
| ≤ 4 | 28 (62.2) | 38 (74.5) | 35 (64.8) | |
| > 4 | 17 (37.8) | 13 (25.5) | 19 (35.2) | |
CRS education only group was not statistically significant (P = .33) compared with the control group.
CRS education plus hands-on CRS installation training group was statistically significant (P = .011) compared with the control group.
This was based on percentage of the correct responses to the 4 child passenger safety items.
Differences in rating before and after intervention.
Three months after the intervention, a significant difference in CRS use occurred across the 3 intervention groups (Table 1). Specifically, a significantly higher proportion of CRS use was observed among parents in the CRS education plus hands-on CRS installation training group than in the control group (41.2% vs 18.5%; P = .011). However, no significant difference in CRS use was observed between the CRS education only and control groups (26.7% vs 18.5%; P = .33). Child passenger safety awareness in both intervention groups was increased after the intervention as compared with the control group.
DISCUSSION
This research documented that the CRS education plus hands-on CRS installation training increased the use of child restraints 3 months after the intervention; the CRS education only condition improved knowledge and attitudes but did not increase CRS use. CRS use is low in China and only 1% in Shantou; even in cities with legislation, such as Shanghai and Shenzhen, CRS use is 16% to 27%.5 By contrast, in Australia and the United States, the CRS use was 90% and 86%, respectively.7 When children are secured in a correctly installed, age-appropriate CRS, they are far less likely to be seriously injured in crashes.8 Given that China currently has more than 285 million vehicles and no national CRS use requirement, it is vital to implement effective interventions to increase CRS awareness and use to improve child passenger safety.
Our results demonstrated that education alone did not help increase CRS use are consistent with our previous findings that parents of newborns who received the education combined with free child safety seats were significantly more likely to use CRSs after an intervention compared with parents who received education only.6 These results suggest that education plus hands-on interventions might be essential in improving CRS use and should be implemented widely in China to prevent child passenger injuries.
Existing studies suggested that demographics are associated with CRS use. Specifically, child safety car seats are used less frequently in families with low income9,10 and low parental educational attainment.5,11 In this intervention study, distribution of demographic characteristics were balanced in the 3 groups, so confounding factors were well adjusted, and the research results were more reliable.
This study had some limitations. The self-report method used to assess the intervention effect may have led to reporting bias. Child passenger safety awareness and CRS use were measured only in the short term (i.e., 3 months). Thus, future studies must assess the long-term effect of the intervention. Despite the limitations, this study showed that CRS education plus hands-on CRS installation training increased CRS use but that education alone did not. A combination of both methods helped improve CRS use and child passenger safety.
ACKNOWLEDGMENTS
All authors express appreciation for the support of the sample-selected participants and all the investigators.
HUMAN PARTICIPANT PROTECTION
The study, conducted from May 2016 to January 2017, was in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Shantou University Medical College (Code: SUMC-2015-38).
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