Interventions in Preschools to Increase the Use of Safety Restraints by Preschool Children

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Interventions

in Preschools

to Increase

the Use

of Safety

Restraints

by Preschool

Children

Jennifer

A. Bowman,

BSc (Hons),

Robert

W. Sanson-Fisher,

PhD,

and

Gloria

R. Webb, BA (Hons)

From the Department of Behavioral Sciences in Relation to Medicine, Faculty of Medicine, University of New Castle, New South Wales, Australla

ABSTRACT. Despite the proven safety value of wearing

vehicle safety restraints, people continue to travel with-out this protection. Legislation requiring the use of safety restraints has been implemented in several countries, including Australia, in an attempt to improve rates of restraint use. In Australia, legislation dramatically in-creased rates of adult restraint use, yet the rate of re-straint use by children remains comparatively low. One

of the main reasons for parents not restraining their child is the child’s dislike of wearing a restraint, with resultant disruptive behavior. This study compared two interven-tions implemented within preschools: a coercive interven-tion aimed at parents and an educational intervention aimed at preschool children. Measures of restraint use

were made by direct observation at preschools prior to

intervention and again immediately following the 2-week

interventions. The safety restraint use of children in the control and coercive intervention groups did not change

significantly as a result of intervention. Restraint use of

children in the educational intervention group increased

15 percentage points from 60.6% to 75.0%: a significant

increase of 25%. This novel intervention approach holds

promise as a means of increasing preschool children’s use of safety restraints. Pediatrics 1987;79:103-109; safety

restraint usage, preschool-aged children.

Motor vehicle accidents are the most common cause ofdeath ofAustralian children. Most children killed are passengers rather than cyclists or pedes-trians. In 1982, 52% of children younger than 5

years of age killed in motor vehicle accidents were passengers.’ Child morbidity as a result of traffic accidents is also high, and injuries are often severe. Children are particularly at risk for injury in traffic accidents due to their physical size and certain anatomical features.2

Received for publication Sept 3, 1985; accepted March 31, 1986. Reprint requests to (R.W.S.-F.) Behavioral Sciences in Relation to Medicine, University of Newcastle, New South Wales 2308, Australia

The situation is similarly grim in other developed nations and in recent years has begun to attract considerable attention from government agencies and research bodies. There are several ways in which motor vehicle travel could be made safer for all vehicle occupants, including children. For ex-ample, road conditions could be improved, speed limits lowered, and greater penalties imposed for drunk-driving and traffic violations.

Despite such measures, accidents will continue to occur, and we must consider how the effects of motor vehicle accidents can be lessened. A simple and effective means to reduce the incidence of death and injury resulting from traffic accidents, not re-quiring large expenditures of money, would be to increase the use of safety restraints. The effective-ness of safety restraints in reducing death and injury resulting from traffic accidents has been proven for adults7 and children.8’9

In many countries, including Australia, some de-gree of legislation regarding the use of safety re-straints already exists. However, the use of re-straints by children generally remains at a much lower level than adult use. Whereas 80% to 90% of Australian adults wear seat belts,’#{176}the rates for children are lower and vary with age. A study conducted in Sydney in 1981 found that 80.9% of children #{189}to 4 years of age were restrained, whereas only 42.5% of children between 4 and 7

years of age were restrained.” In 1983, the restraint

rates were 77.3% for children #{189}to 4 years of age

and 46.4% for children 4 to 7 years.’2 During the

1981-

to 1983-period, restraint use for the older age

group improved only slightly, and use for the younger group showed a disturbing decline.

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re-strained.’3’5 Restraint use is especially poor for children older than 3 or 4 years of age.’’8 An American study, examining the health and safety behaviors of preschool children and their mothers, found that wearing seat belts was the least practiced of all children’s health and safety behaviors.’9

To gain some understanding of why children’s use of safety restraints remains so low, we need to consider the attitudes of parents to child restraint

use and the sociodemographic variables associated with it. Parents’ income, educational level, and occupation have been consistently related to chil-dren’s restraint use. High socioeconomic status is associated with higher rates of restraint use by children.’3”8’2#{176}25 Several studies have also related parents’ locus of control and restraint use to chil-dren’s restraint use.’3”5’21’23’ There is no apparent relationship between a family’s traffic accident his-tory and child restraint use.’3”5’23

Reasons given by parents for not restraining their children are generally related to the dissatisfaction and discomfort of the child and parental inconven-ience.’3”8’24’ Lack of knowledge on the part of parents regarding the safety value of restraints, legislation regarding the use of restraints, or the types of restraints available is not usually given as a major reason for nonrestraint of children.

An earlier study by the present authors, dealing with the psychosocial factors affecting parents’ use of restraints for their children, revealed several other significant relationships. Married parents and parents who did not smoke were more likely to restrain their children. Children traveling longer distances to preschool were more likely to be re-strained, and the type of safety restraint available in a vehicle was also related to use. Parents’ per-ceptions of their ability to influence the likelihood of their child being involved or injured in an acci-dent appeared to be related to restraint use with their children; few other attitudinal or belief factors were related to use. However, the issues of chil-dren’s dislike of using restraints and possible re-sultant behavioral problems were not addressed in the survey.

It is not difficult to see a connection between the reduction in restraint use that occurs as children reach the age of 3 or 4 years and the finding that the chief reasons for the nonuse of restraints by children are their dislike of being restrained and parents’ perception of their discomfort. Children of preschool age are inquisitive and active and are not likely to be receptive to a safety restraint if it inhibits their view of the world. Children younger than this age are not likely to object strongly to wearing a restraint; children of 3 or 4 years, how-ever, may test parental authority by refusing to

wear restraints. In the earlier study, the statement, “I always put my preschool child in a restraint, no matter how much s/he resists,” elicited significantly different responses from parents of restrained and unrestrained children. Those who agreed with the statement were generally parents whose child was using a restraint. Parents may decide not to insist on restraining a child to avoid conflict (G. R. Webb, R. W. Sanson-Fisher, and J. A. Bowman, unpub-lished results).

One study found that poor safety attitudes of mothers were associated with several variables, in-cluding the child’s age. Mothers of children less than 3 years of age believed, as well as providing crash protection, restraints helped control the child’s behavior and increased comfort and enjoy-ment of the trip. Mothers of children 3 years and older, however, saw few benefits of children’s re-straint use, apart from their value in crash protec-tion, and usage problems were perceived as high. Safety restraints were thought to be uncomfortably restrictive for the child and likely to cause irritation or distress.18 The validity of such beliefs may be questioned, because there is some evidence that even children 3 and 4 years of age display less disruptive behavior when restrained in a child seat.26

Other possible reasons for the infrequent use of restraints by preschool-aged children may be: the parents’ perception that the restraint device is no longer needed when the child can sit unaided, the child’s failure to progress to wearing an adult seat belt after being displaced from a restraint device by a younger sibling, or the ability of some children to undo restraints.’7

Intervention programs designed to increase child restraint use have used various methods. These have included the education of mothers by medical staff in hospitals or private practices,8’23’27#{176} mass media campaigns,3’ and coercive programs incor-porating police enforcement of legislation.’6

All interventions have focused on increasing the knowledge and awareness of parents concerning child restraint devices and their safety value. Some success has been achieved in interventions con-ducted with mothers prenatally or immediately postnatally. However, the duration of the effects are not known. No intervention has made a signif-icant difference in the low level of restraint use by children in the age group of approximately 3 to 8 years.

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beneficial to educate children to be more accepting of safety restraints and to promote their voluntary use of restraints. To date, there has been no inter-vention targeted at children, with the aim of mod-ifying the child’s -behavior.

The purpose of this study was to implement and compare the effectiveness of two interventions to increase the safety restraint use of preschool chIl-dren. Preschool children were selected as targets for the interventions for several reasons: the partic-ularly low levels of restraint use among this age group, the availability of subjects, and the suitabil-ity of preschool environments for the implementa-tion of such interventions.

One intervention was a coercive strategy aimed at parents and was in this sense a traditional type of approach. The parents ofpreschool children were threatened with possible fines for noncompliance with child restraint legislation. The threat was is-sued in the form of posters, reminder cards, and letters from the police.

The second intervention was designed to address two problems: children’s resistance to the use of restraints and passive acceptance by children of being unrestrained. It was an educational interven-tion for preschool children rather than their par-ents. Children were taught by their teachers to become “seat belt conscious” and to insist on wear-ing a restraint when traveling in the car. If not restrained by parents, children were taught to per-sist until the parents did take action to ensure that they were suitably restrained. Children were, in a sense, modifiers of their parents’ behavior.

It was hypothesized that the educational inter-vention would increase safety restraint use by pre-school children significantly. The coercive inter-vention, directed at parents, was expected to be less effective in increasing restraint use. A slight im-provement was expected, because a police enforce-ment campaigir had been found to have some effect in a previous study.’6 The rate of restraint use for vehicle occupants other than preschool children was also recorded, to determine whether the effects of interventions were extended to other passengers. The group, “other vehicle occupants,” included adults, infants, and all children not attending pre-school.

METhODS

Sample

The subjects for this study were children attend-ing 45 preschools within Newcastle and the sur-rounding area. Preschool children are typically 3,

4,

or 5 years of age. Preschools were selected ran-domly from the telephone directory. All preschool

personnel who were approached, with one excep-tion, agreed to take part in the study.

Restraint status was recorded for 740 preschool children and 916 other vehicle occupants before the interventions were implemented and for 751 pre-school children and 1,011 other vehicle occupants immediately after the interventions. The increase in sample numbers for the postintervention obser-vations may be a result of observers becoming more proficient at their task and thus observing more cars and more children.

Observation

of Restraint

Use

Restraint use rates were determined using an observational method (G. R. Webb et a!, unpub-lished data). Observers were recruited and trained in the observation technique at preschools not used in the study. Observer training included familiar-izing observers with the various types of child re-straints available and practicing the use of the observation schedule.

Information about restraint status was recorded separately for preschool children and for any others in the vehicle, including the driver. Observers were instructed to be as accurate as possible. If unsure of the restraint status of a passenger, observers were instructed to record the status as unknown. Taxicabs, trucks, and minibuses with other than a standard car seating arrangement were excluded. Observers were asked to record restraint informa-tion for as many suitable vehicles as possible.

Vehicle occupants were recorded as being re-strained only if they were using a restraint suitable for their age and if it was correctly worn. Belts that were obviously loose or twisted were considered to provide inadequate protection to the wearer, who was recorded as being unrestrained. Children whose restraint devices were not anchored securely to the car, or who were not firmly secured within the restraint itself, were recorded as being unrestrained.

The reliability of observers was checked by corn-parison with a calibrator, using the x index of eernent.’ All were found to be reliable, with an average K value of .82.

The Study-Three

Stages

The assistance and cooperation of preschool di-rectors and the police were solicited. The educa-tional and coercive interventions were developed in consultation with a preschool director and police officers, respectively. The study was conducted in three stages.

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For each preschool, percentage restraint use was calculated separately for preschool children and for all other vehicle occupants. Preschools were as-signed randomly to a control or intervention group, after matching for restraint usage. This ensured that no group was biased with a disproportionate number of high or low restraint rates. Fifteen pre-schools were assigned to each of the control, edu-cational intervention, and coercive intervention groups.

Intervention. Interventions were implemented si-multaneously during a 2-week period. Immediately following the observations, research assistants vis-ited the preschools in the two intervention groups to deliver and explain the use of the intervention materials. Preschools were visited twice during the 2-week intervention to ensure that interventions were being implemented correctly.

Postinteruention Observation. Immediately fol-lowing the interventions, observations were made again at the preschools. Observations were con-ducted on the same day of the week as the prein-tervention observations had been made. The sam-ple of children observed was thus basically homo-geneous for pre- and postintervention observations. Percentage restraint use was calculated separately for preschool children and for other vehicle occu-pants for each preschool.

Interventions

Coercive. The coercive intervention was aimed specifically at parents and used threats of random police checks and fines to attempt to increase chil-dren’s restraint use. The intervention was carried out on the same day of the week as the preinterven-tion observation, so that the children observed (and their parents) were the targets for the intervention. Letters from the Chief Inspector of Police in the Newcastle District were handed individually to par-ents by the preschool director. The letters were distributed on the appropriate day in the first week of intervention.

The letter outlined legislation concerning the wearing of safety restraints by children. It warned parents that police would be conducting random checks in the area and that parents whose children were not adequately restrained would be fined. In fact, police were not conducting checks but had agreed to include the warning in the letter to mag-nify parents’ perceptions of threat. The letter also included information regarding the types of child restraints available and their approximate cost. An accompanying pamphlet supplied general informa-tion regarding the use of child restraints.

Posters and reminder cards, with the same warn-ing of police cheeks and possible fines, were also

used. Each preschool was supplied with three pos-ters, which were displayed prominently. Reminder cards were pinned to the children’s clothing or placed in their lunch boxes on the intervention days in both weeks.

Educational. The educational intervention was aimed at the preschool children, with the intent that the children be taught to “educate” their par-ents. It was hoped that the children would modify parental behavior with regard to child restraint use.

Like the coercive intervention, the educational intervention was intended primarily for children attending preschool on the particular day of the week that observations had been made. However, preschool directors were given the choice of imple-menting the educational intervention for all chil-dren attending the preschool if they desired. In the latter case, it was emphasized that the intervention should be implemented especially thoroughly for the observed children.

The intervention was presented to preschool di-rectors in kit form, which included the intervention material and a detailed explanation of its use. The intervention had two aims. The primary aim was to teach children verbal responses appropriate to situations in which they, or others traveling in the vehicle, were not using safety restraints. Children were taught to insist that they be restrained and to persist in the face of initial parental inaction. The secondary aim of the educational intervention was to teach children about the importance of always wearing restraints and to familiarize them with their use. The material supplied to preschools in-cludeth copies of six different drawings featuring cartoon characters; two brief.songs, written to well-known tunes; a rubber stamp, which read “Seat Belt Safety”; and two modified lap seat belts, which were fitted to preschool chairs. Suggestions were made for ways in which the supplied materials might be used, but it was left to the individual preschool teachers to create their own programs.

RESULTS

AND

DISCUSSION

Preschool-Aged

Children

t Tests were calculated for the control, coercive, and educational groups to compare the pre- and postintervention restraint use. For preschools in the educational intervention group, the t test

mdi-cates a significant increase in restraint use, P =

.009, from 60.6% to 75.0%. Small, nonsignificant increases in restraint use occurred for preschools in both the coercive and control groups. These results are summarized in Table 1.

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TABLE 1. Safety Restraint Use in Cars by Preschool

Children

Control Intervention Groups

Group .

Coercive Educational

Preintervention

No. surveyed 221 260 259

% restrained 59.9 59.9 60.6

Postintervention

% restrained 60.3 62.8 75.0

P value .93 .62 .009

postintervention observation and nested under in-tervention group. Results indicate a significant main effect of pre/postintervention observation (F

= 6.88, P = .0121) and a significant interaction

effect between intervention group and pre/postin-tervention observation (F = 3.64, P =

.0348).

The significant interaction suggests that signifi-cant change in restraint use had occurred for some intervention groups and not others. A Tukey post hoc analysis confirmed the ttest finding that safety restraint use had increased significantly for the educational intervention group only (d = 11.67, df =

42).

The postintervention restraint use of children in the educational group was significantly different at P = .05 from all other pre- and postintervention

measures. The educational intervention, designed specifically for children rather than their parents, was effective in increasing the safety restraint use of preschool children. An increase of 25% occurred for children in the educational intervention group after only a brief 2-week intervention.

The failure of the coercive intervention to in-crease restraint use can be understood when it is recognized that coercion does not address the prob-lem of children who dislike being restrained and refuse to wear safety restraints. Although one other study did find a police enforcement campaign to be effective,16 there are differences between that study and this that may explain the discrepant findings. Chief among these differences is that, in the present study, the threat of police enforcement was appar-ent, not real. Police were no more visible than usual and were not especially checking on the restraint

use of children. If the threat had been manifest, the coercive intervention may have had greater impact. The level of police enforcement required to increase restraint use is an issue that needs to be investi-gated.

The unchanged level of restraint use for children in the control group was expected. It provides evi-dence that no other factors were operating to in-crease restraint use. There is every reason to as-sume that the increase in restraint use by children

in the educational group was a direct result of the intervention.

Other

Vehicle

Occupants

t tests were calculated to compare pre- and post-intervention restraint use in the three intervention groups for all vehicle occupants other than pre-school children. No significant changes were found. The results are summarized in Table 2. They sug-gest that the effects of interventions did not extend to other vehicle occupants, as hypothesized.

Although not quite significant, the increase in restraint use from 77.9% to 85.2% in the coercive group suggests an interesting trend. It implies that the coercive intervention may have some effect on the restraint use of others, whereas it had none on the use of preschool children. This would be

con-sistent with the argument that the barriers to re-straint use are different for adults and children. The coercive intervention may have provided suf-ficient incentive for adults to restrain themselves but not enough for adults to insist that seat belts be worn by children who dislike wearing them. This issue remains largely speculative, however, because the other vehicle occupants group included not only adults but all children and infants other than pre-school children. If restraint use had been recorded separately for adults or drivers, the trend observed may have been significant.

Given the failure oflegislation to make an impact on safety restraint use by young children, it appears reasonable to implement education for children rather than their parents. If children become “seat belt conscious” to the extent that they become ardent advocates for their own safety, then one of the major barriers to child restraint use may have been removed. The potential effectiveness of this approach has been demonstrated in the present research. The length of time for which the inter-vention effect persists should be examined, as it seems likely that “booster” interventions may be needed to maintain the increased level of restraint use.

TABLE 2. Safety Restraint Use in Cars by Other Ve-hide Occupants

Control Intervention Groups Group

Coercive Educational

Preintervention

% restrained 80.9 77.9 78.6 Postintervention

% restrained 79.1 85.2 84.6

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Educational interventions for children are likely to be most effective when they are introduced while the child is young. It has been recognized that health education in general must begin early in life, preferably in preschool.’9

The potential for conducting interventions in educational institutions has not been appreciated fully. There is enormous scope for implementing health and safety programs, including safety re-straint interventions, at all levels of schooling,2’ with preschools representing an untapped resource for health risk behavior intervention. For safety restraint intervention, preschools may be especially appropriate locations, because children of preschool age are among the most poorly protected. Pre-schools could provide annual opportunities for in-tervention with new attenders. Preschool children may be especially receptive to safety restraint pro-grams implemented by their teachers, who repre-sent familiar yet authoritative figures.

Conclusion

The effectiveness of educating preschool children about the need to wear safety restraints has been demonstrated. The educational intervention was effective in modifying children’s active resistance to use of restraints and passive acceptance of non-use. The children became modifiers oftheir parents’ behavior. Preschools were found to be an untapped valuable resource for such interventions.

However, to obtain optimal results, a child re-straint campaign should simultaneously provide in-formation to parents. There are still some miscon-ceptions concerning the use of safety restraints that need to be addressed by parent education pro-grams.’3”8 Also, the problem of misuse of safety restraints and the importance ofcorrectly installing and fitting restraint devices must be stressed through parent education programs. More can be done to save children’s lives by increasing the use of safety restraints.

ACKNOWLEDGMENTS

This work was supported by funds from the Child Accident Prevention Foundation of Australia and the Health Commission ofNew South Wales Hospital Health Promotion Programme.

Valuable assistance was lent by the Traffic Accident Research Unit, a division of the Traffic Authority of New South Wales; the New South Wales Police Department; the National Roads and Motorists’ Association, and all participating preschool directors and teachers.

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Hospitals) Australia, 1982, ABS catalogue No. 9405.0.

Can-berra, Australian Bureau of Statistics, 1983

2. Avery JG: The safety of children in cars. Practitioner

1980;224:816-821

3. Henderson M, Wood R: Compulsory wearing of seat belts in New South Wales, Australia: An evaluation of its effect on vehicle occupant deaths in the first year. Med J Aust

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1976;66:451-456

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Wales, 1970 to 1981, Traffic Accident Research Unit

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11. Fleming DM: The Use of Restraints by Children in

Auto-mobiles-1981. Sydney, National Roads and Motorists’

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inAutomobiles-1983 (Preliminary Report). Sydney, National Roads and

Motorists’ Association, 1983

13. Neumann CG, Neumann AK, Cockrell ME, et al: Factors

associated with child use of automobile restraining devices: Knowledge, attitudes and practice. Am J Dis Child

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Am J Dis Child 1976;130:1311-1317

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Nurs Res 1980;29:281-284

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Sydney, National Roads and Motorists’ Association, 1981

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pre-school children in cars. Arch Dis Child 1982;57:549-560 18. Freedman K, Lukin J: Occupant Protection for Children. A

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28. Christophersen ER, Sullivan MA: Increasing the protection media campaign. Paper presented to the American

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AMERICAN

ACADEMY

OF PEDIATRICS

RESIDENCY

FELLOWSHIPS

STIPULATIONS

To enable young physicians to complete their pediatric training, the American Academy of Pediatrics will grant a small number of fellowships of $500 and

$3,000

each to pediatric interns and residents for the year beginning July 1.

Candidates must meet the following requirements: 1. Be legal residents of the United States or Canada;

2. Have completed, or will have completed by July 1, a qualifying approved internship (P1-0) or have completed a P1-i program, and have made a definite commitment for a first year pediatric residency (P1-i or P1-2) acceptable to the American Board of Pediatrics; or

3. Be pediatric residents (P1-i, P1-2, or P1-3) in a training program and have made a definite commitment for another year of residency in a program acceptable to the American Board of Pediatrics;

4. Have real need of financial assistance; and

5. Support their application with a letter from the Chief of Service substan-tiating the above requirements; if a change in residency training program is contemplated (ie, moving to another institution), a letter from the chief of this service certifying acceptance to this program will also be necessary.

The fellowships have been provided through grants to the American Academy of Pediatrics by Mead Johnson Nutritional Division, Gerber Products Company, and the McNeil Consumer Products Company.

Although the fellowship awards are intended primarily for the support of first and second year pediatric residents, it is also recognized that some physicians may desire a third or fourth year of pediatric residency. Up to 25% of the fellowships may be awarded to persons in this category. Consideration will be given to geographic spread of awards, and preference will be exhibited for well-qualified but smaller training centers which perhaps have fewer resources for residents in training than do some of the larger centers.

The Committee on Residency Fellowships of the American Academy of Pediatrics will make final decision on the granting of the Awards. Those interested in applying may write to Jean D. Lockhart, MD, Department of Maternal, Child and Adolescent Health, American Academy of Pediatrics, 141 Northwest Point Rd, Elk Grove Village, IL 60007, for application forms.

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1987;79;103

Pediatrics

Jennifer A. Bowman, Robert W. Sanson-Fisher and Gloria R. Webb

Children