Has increasing the age for child passengers to wear child restraints improved the extent to which they are used? Results from an Australian focus group and survey study

WORKING LIFE STRESS, REHABILITATION COUNSELLING AND INCLUSION

Has increasing the age for child passengers to wear child restraints improved the extent to which they are used? Results from an Australian focus group and survey study

Alexia Janet Lennon*

Centre for Accident Research and Road Safety, Queensland University of Technology, Brisbane, Queensland, Australia

Abstract

Acknowledgement that many children in Australia travel in restraints that do not offer them the best protection has led to recent changes in legislation such that the type of restraint for children under 7 years is now specified. This paper reports the results of two studies (observational; focus group/ survey) carried out in the state of Queensland to evaluate the effectiveness of these changes to the legislation. Observations suggested that almost all of the children estimated as aged 0–12 years were restrained (95%). Analysis of the type of restraint used for target-aged children (0–6 year olds) suggests that the proportion using an age-appropriate restraint has increased by an estimated 7% since enactment of the legislation. However, around 1 in 4 children estimated as aged under 7 years were using restraints too large for good fit. Results from the survey and focus group suggested parents were supportive of the changes in legislation. Non-Indigenous parents agreed that the changes had been necessary, were effective at getting children into the right restraints, and were easy to understand as well as making it clear what restraint to use with children. Moreover, they did not see the legislation as too complicated or too hard to comply with. Indigenous parents who participated in a focus group also regarded the legislation as improving children's safety. However, they identified the cost of restraints as an important barrier to compliance. In summary, the legislation appears to have had a positive effect on compliance levels and on raising parental awareness of the need to restrain children in child-specific restraints for longer. However, it would seem that an important minority of parents transition their children into larger restraints too early for optimal protection. Intervention efforts should aim to better inform these parents about appropriate ages for transition, especially from forward facing child seats. This could potentially be through use of other important transitions that occur at the same age, such as starting school. The small proportion of parents who do not restrain their children at all are also an important community sector to target. Finally, obtaining restraints presents a significant barrier to compliance for parents on limited incomes and interventions are needed to address this.

Keywords: road safety; vehicle passengers; child restraints; evaluation; legislation

(Published: 20 March 2012)

Citation: Vulnerable Groups & Inclusion. DOI: 10.3402/vgi.v3i0.14975

©2012 A. J. Lennon. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


*Correspondence to: Alexia Janet Lennon, Centre for Accident Research and Road Safety, Queensland University of Technology, Brisbane, Queensland. Australia. Email: aj.lennon@qut.edu.au

 

Occupant injury comprises the largest proportion of child road crash trauma in most highly motorised countries. It is now well established that use of dedicated restraints for children is highly effective in reducing serious injuries and death to child passengers (Durbin, 2001; Henderson, Brown, & Paine, 1994; Mackay, 2001; NHTSA, 2009; Rice & Anderson, 2009; Starnes, 2005; Weber, 2000). However, there is also ample evidence that despite this demonstrated effectiveness, many parents still restrain their children in seatbelts or restraints that are too large and thus offer reduced protection (Bilston, Du, & Brown, 2011; Bilston, Finch, Hatfield, & Brown, 2008; Bingham, Eby, Hockanson, & Greenspan, 2006; Brown, Hatfield, Du, Finch, & Bilston, 2009; Edwards, Anderson, & Hutchinson, 2006; Koppel, Charlton, Fitzharris, Congiu, & Fildes, 2008; Rice, Anderson, & Lee, 2009). For this reason considerable research attention has been focused on understanding the contributing factors in relation to use and non-use of child restraints and the most effective ways of improving children's safety as car passengers.

Australia has been particularly active in the area of child occupant protection, with well regarded work being conducted to investigate the extent to which parents use dedicated restraints with their children and the psychosocial factors influencing this, as well as studies which examine the crash performance of restraints in both laboratory conditions and real world crashes (case review), (Brown & Bilston, 2006; Brown, McCaskill, Henderson, & Bilston, 2006; Edwards et al., 2006; Lennon, 2005, 2007).

In addition, legislators in Australia have been responsive to submissions and concerns amongst the medical and research communities in relation to better protecting child passengers. In 2009, the National Transport Commission (NTC), a body consisting of the Transport ministers from each of Australia's eight States and Territories, endorsed changes to the Australian Road Rules for children's restraint as passengers in motor vehicles. While the use of passenger restraints has been mandatory in Australia for almost four decades, for children the type of restraint was previously only specified for infants aged under 12 months. Although the majority of children are restrained when they travel, the various studies that report restraint type indicate that typically children are restrained in seatbelts once aged around 5 years old (Koppel, et al., 2008; Edwards et al., 2006; Lennon, 2005). The revised Road Rules now specify the type of restraint a child should use up to the age of 7 years. Thus babies under 6 months must be restrained in a rear-facing restraint, babies 6–12 months must use either a rear-facing restraint (if this still fits) or a forward-facing child seat, children over 12 months must be restrained in a forward-facing child seat until at least their 4th birthday, and children from 4 years must be restrained in a booster seat until at least 7 years old. In addition the revisions recognise the importance of rear seating for children and require that children under 7 years travel in the rear rather than front seat (NTC, 2008). In line with these recommendations, the different State and Territory governments (with the exception of the Northern Territory) have enacted legislation that incorporates the changes. There are also provisions within the legislation allowing for children to be moved into the next type of restraint if the child is physically too large for the restraint required for chronological age. The Queensland Government announced changes to the legislation in September 2009 and these came into effect in March 2010 (Department of Transport and Main Roads (TMR), 2011).

Below, this paper reports the results of an evaluation of the new Queensland legislation, conducted in 2011, approximately 18 months after the new laws came into effect in the State. The main aim of the evaluation was to examine the extent of compliance, that is, the extent to which child passengers were appropriately restrained for age (as specified under the legislation). In addition, there was an interest in gauging the level of parental support for the changes as well as their understanding of the purpose for these, and to examine parental perceptions of the ease of complying and potential barriers to compliance. Knowledge about the barriers or difficulties parents experience in using restraints or complying with the new requirements can be used to inform any future changes or improvements to the legislation to improve its effectiveness. Moreover, better information about how the legislation has affected parents is expected to provide a basis to plan non-legislative interventions such as community, educational or behavioural interventions with parents/carers and other stakeholder groups. In addition, it will allow identification of the most effective aspects of the legislation and those areas in need of extra attention to improve the effectiveness/compliance.

The evaluation consisted of an observational study, intercept interviews with non-Indigenous parents, a focus group with Indigenous parents and a brief telephone interview with representatives from organisations that work with parents or children aged under 7 years. The focus of this paper is primarily on the parent experiences though the observational study is also described in brief.

THE IMPORTANCE OF RESTRAINT DESIGN AND FIT

Because children are different from adults both in stature and in some critical aspects of anatomy (such as skeletal strength and development), restraints that are designed for adults, such as seatbelts, do not offer the same level of protection for children. Thus effective child restraints take into account the special needs of children and are designed accordingly. Restraints work by distributing the forces during a crash over the child's strongest body components, by reducing the extent to which the child's body makes contact with the vehicle interior (AS/NZS 1754:2010) and by reducing the amount of crash force that is transferred to the passenger. An important principle of protection involves maximising the child's “ride down” during a crash. To achieve this, the child must be fastened as tightly as possible to the vehicle via the restraint as this maximises the distance over which the wearer comes to a stop (Bilston, Brown, & Kelly, 2005). Thus, the protective effect of a child restraint is crucially dependant on its correct installation in the vehicle as well as proper harnessing of the child into the restraint. In addition, retention of the child in the restraint is enhanced by using the most appropriate sized restraint for the child (Charlton, Fildes, Laemmle, Koppel, Fechner & Moore, 2005).

Restrained children involved in crashes typically receive injuries that are only minor in nature (Agran, Anderson, & Winn, 1997; Brown, Griffiths, & Paine, 2002; Brown, Bilston, McCaskill, & Henderson, 2005). However, the most common injuries occur to the head (Newgard & Jolly, 1998), usually as a result of contact with the vehicle interior (Henderson et al., 1994), and it is these that are likely to result in serious injury or death. Thus, it is important that restraints effectively prevent or limit the degree to which the wearer's head and body come into contact with the inner vehicle structures under crash forces (Henderson, Charlton, Pronk, & Scully, 2003). In Australia, the design and performance requirements of all child restraints are regulated by, and must be approved to, an Australian Standard, in this case, AS/NZS1754:2010—Child Restraint Systems for Use in Motor Vehicles.

A number of different child restraint types are available, each designed to suit a specific child age range and developmental stage. They can be broadly grouped into rearward-facing restraints suitable for infants, forward-facing restraints suited to toddlers, and booster seats for older children. In Australia, rearward-facing restraints (or infant carriers) are designed to suit infants from birth up to 6–12 months of age (birth to 9 or 12 kgs, depending on the specifications of the particular restraint). These are available as single mode use (e.g. infant capsules) or dual mode/“convertible” restraints which can be used in rearward-facing mode for children aged between 6 and 12 months (up to 12 kgs) and then “converted” to face forward for older, larger babies and toddlers. Forward-facing toddler restraints are designed to be used with children who have outgrown the rear-facing restraint (6–12 months of age) until the child is at least 4 years of age (currently from 8–18 kgs) (AS/NZS1754:2010; RTA, 2011). Both rear and forward facing seats have an inbuilt six-point harness system. The restraint is designed to be held into the vehicle by the vehicle's lap/sash belt, which is passed through the restraint frame. In addition, top tether straps, which are attached to an anchor point (the position and performance of which is governed by vehicle design rules), are required in Australia (Griffiths, Brown, & Kelly, 2009). Figure 1 illustrates each of these restraint types.


Fig 1

Figure 1.  Examples of restraints available on the Australian market and suitable for children under 4 years. Baby capsule (left) is mounted facing the rear of the vehicle and suits children from birth to approximately 6 months or 12 months old. Convertible (dual mode) child restraint (center). This restraint can be used with newborns in rear-facing mode and then ‘‘converted’’ to face forward once a child is able to hold his/her neck up. In forward facing mode the restraint suits children until approximately 4 years old. Note the active head restraint ‘‘cushions’’ for side impact protection. Forward-facing child seat (right) is a single mode restraint suitable for children who have outgrown the rear-facing infant restraint. This type of restraint suits children to approximately 4 years old.

For older children between the ages 4 and 7 years, belt-positioning booster seats were developed to lift or “boost” the child into a position that allows an adult seatbelt to fit adequately and thus offer a similar level of crash protection from the belt as that afforded to an adult (Kahane, 2004). Until recently, booster seats were available with either a high back or as a backless “cushion” (see Figure 2 and were approved for child weights between 14 and 26 kgs. More recently, with the acknowledgement that some children aged 4 to 7 years fall beyond this weight range, and the recognition of flaws in previous designs (Griffiths et al., 2009) new designs and categories of booster seats are becoming available on the Australian market. In particular larger booster seats and convertible booster seats which combine the features of forward-facing restraints and booster seats are expected to be become widely available from 2012. Figure 2 displays examples of safety seats suitable for older children. Booster seats can also be used with an “H” harness (4–point harness) which allows the use of the booster seat in vehicle positions with lap-only belts (e.g. centre rear seats). The backless booster seat has been removed from the most recent Australian Standard (AS/NZS1754:2010), as it does not provide any protection from side impacts. It is expected that booster cushions will disappear from Australian retailers by 2012 (Lumley, 2011).


Fig 2

Figure 2.  Examples of restraints available on the Australian market and suitable for children aged 4–7 years. Larger high-backed ‘‘convertible’’ booster seat with top tether (left). This restraint is dual mode combining the forward facing child seat (using the in-built harness and top tether) and booster seat functions by removing the harness and using the vehicle seatbelt or an add-on child H harness instead. Thus this restraint suits children from approximately 6 months old until the child is tall enough to use a seatbelt (around 8–10 years). High-backed booster seat (second left), single mode, no top tether (lighter seat weight) suitable once the child outgrows the forward-facing child seat until the child is tall enough to use the seatbelt. It is designed for use with the vehicle seatbelt or an add-on child H harness (passed through the slots on the seat back). Note the absence of an anti-submaring clip. Larger high-backed adjustable height booster seat with top tether (third left). This restraint is also single mode and used with the vehicle seatbelt or an add-on child H harness. However the adjustable height allows use with taller children who have outgrown the forwardfacing child seat but are still not tall enough to allow good seatbelt fit. Note the anti-submarining device (clip on the seat), guides for lap portion of the seatbelt, and slots for add-on H harness (if used). Backless booster ‘‘cushion’’ with sash belt guide (now removed from AS/NZS 1754:2010) (right).

EFFECTIVENESS OF CHILD RESTRAINTS

Dedicated child restraints have been found to be very effective in reducing the risk of injury. US based research has suggested that infant and toddler restraints may reduce the risk of fatality by 71% for children under 1 year old and 54% for children 1–4 years old when used in passenger cars (NHTSA, 2009). For non-fatal injury, analyses of the US National Automotive Sampling System Crashworthiness Data System data for the period 1988–2003 revealed that rear-facing child restraints were highly effective in reducing the risk of serious injury (defined as scores of ≥ 9 on the Injury Severity Scale) for children aged under 1 year, with effectiveness calculated as 97%, and those aged 12–23 months (effectiveness of 86%). Forward-facing child seats were also effective, but at a lower level, with effectiveness calculated as 94% and 69% for under 1 year olds and 12–23 month olds respectively (Henary et al., 2007). Similarly, analyses of US insurance-based crash data suggests that forward-facing child seats reduce the risk of serious injury (defined as injury scores of ≥ 2 on the Abbreviated Injury Scale) to children aged 1–4 years by 78% when compared to wearing a seatbelt (Arbogast, Durbin, Cornejo, Kallan, & Winston, 2004). The relative paucity of Australian fatality figures for children in this type of restraint together with the requirement for using top tethers means that comparable Australian calculations are unavailable. However, in terms of preventing injury, Australian dynamic testing has indicated that forward-facing restraints with top tethers are extremely effective at limiting forward head excursion (and thus the head strikes that result in the more serious injuries) under various restraint configurations (Lumley, 1997), as well as withstanding severe crash forces that might otherwise result in serious injury to the child's neck or chest (Henderson et al., 1994). This has led experts in the area to conclude that forward-facing restraints, when used in the Australian context, are very effective at providing protection against injury.

In-depth Australian case reviews of crash-involved children to examine restraint performance under real-world conditions have revealed that dedicated restraints are highly protective (Brown et al., 2005; Henderson, 1993). However, these same studies found that use of the right sized restraint and rear seating for children, that is, optimal restraint, was uncommon: despite high levels of restraint usage (over 90%) among the case children, most (87%) were sub-optimally restrained either through being placed in a seatbelt or restraint that was too big, or through occupying front seat positions. The elevated risks to children from being placed in restraints that are too big for them were highlighted over 10 years ago (Winston, Durbin, Kallan, & Moll, 2000). More recently US research has found that 3–4 year old children restrained in booster seats rather than more age-appropriate forward-facing child seats are at as much as 27% elevated risk of both non-disabling and fatal injuries (Sivinski, 2010). For slightly older children, Australian and US-based research suggests that premature graduation to adult seatbelts is even more prevalent and problematic in terms of injury outcome (Koppel et al., 2008; Winston et al., 2000). For children aged 4–8 years, using a seatbelt rather than a booster seat may elevate the risk of injury by as much as 3.5 times and the risk of head trauma by as much as 4.2 times (Durbin, Kallan, & Winston, 2005; Winston et al., 2000). A recent analysis of insurance records for crash involved 4–8 year olds in the US (Arbogast, Jermakian, Kallan, & Durbin, 2009) suggests that use of booster seats in age-appropriate children is very effective in reducing the overall risk of serious injury (defined as injury scores of ≥ 2 on the Abbreviated Injury Scale). This study found an overall reduction of 45% in injury risk for children using booster seats. Importantly, analyses were adjusted for several confounding variables (such as vehicle age, impact direction, driver being the parent or not) and included a greater proportion of older children (6–8 years) in the study sample. Thus both research and intervention efforts have moved to a focus on optimal restraint in more recent times.

Engineering intervention to increase the level of optimal restraint has taken the form of enhancements to the design of restraints for the Australian market and the requirements for their testing. These are intended to facilitate correct installation of restraints, reduce misuse and encourage choice of the most appropriate restraint for age. Such enhancements include the use of age-based (rather than weight-based) restraint categories (incorporated into the most recent revision of the Australian Standard AS/NZS1754:2010), visual indicators on products (e.g. seatbelt path and shoulder height markings) and new instructions and information about restraint devices.

Two other enhancements to the AS/NZS1754:2010 are worth noting. The first of these is changes to the side impact test requirements for restraints such that larger crash test dummies must be used (simulating the maximum child age for the restraint type) with a dynamic test door that is better able to simulate real-life crash conditions. This is expected to result in better head protection for children at the upper end of the size range for restraints. The second is the provision of the much-needed larger booster seat (Type F) for those older children in the restraint “gap” because they are too short for adult belts but exceed the weight limits of the smaller booster seats specified under previous Standards.

Educational intervention has targeted parents and attempted to raise awareness of the dangers of moving children into larger restraints too soon. However, these attempts have been largely locally-based rather than national. As a result it is unclear how effective they have been.

As mentioned previously, legislation has also been used to draw parents’ attention to using the most appropriate restraint for age with children and to encourage safer seating positions.

THE CURRENT STUDY

The revised legislation for the restraint of child passengers came into effect in March 2010 in Queensland. In April 2011, The Queensland Injury Prevention Council, in conjunction with the Department of Transport and Main Roads, Queensland, commissioned the Centre for Accident Research and Road Safety, Queensland to conduct an evaluation of the impact of the legislation. The evaluation, consisting of three studies, was carried out during May–September of 2011. The results of the observational study (Study 1) have been described elsewhere and so will only be summarised briefly here before moving on to describe and discuss the results of the parent interviews and focus group (Study 2) in detail.

WHAT EFFECT HAS THE LEGISLATION HAD ON THE SEATING POSITIONS AND TYPES OF RESTRAINTS USED WITH CHILD PASSENGERS IN QUEENSLAND?

Road-side observations of child passengers (aged 0–12 years) in four major population centres in Queensland (Brisbane, Sunshine Coast, Mackay, Townsville) included a total of 1922 vehicles carrying 2791 children. Only vehicles with a rear seat and no adult front seat passengers were included in the sample. In order to ensure the greatest level of child passenger traffic, sites for observations were located mostly around places that children are most likely to be travelling, such as primary schools (junior or elementary schools) and shopping centres. The observations were conducted at times that suited child travel patterns, such as immediately prior to the start of the school day or during the finish times in the afternoons. Trained observers were instructed to record the number of children in the vehicle, the seating position (front, rear) and type of restraint each wore (rear-facing infant restraint; forward facing child seat; booster seat; child “H” harness; seatbelt; unrestrained), and to estimate each child's age group, based on seated height (0–2 years; 3–6 years; 7–12 years). Interested readers can find a more detailed description of the methodology in the report of the evaluation (see Lennon, Darvell, Edmonston, Biggs & Shaw, 2011).

Overall, the majority of the vehicles observed (63%) had only one child passenger. In the main, these children were seated in the rear seat (68% of vehicles observed), which is an encouraging result. Restraint usage rates were high, with over 95% of the children observed in some type of restraint.

For the child sample (2791 children), just over half (1426, 51%) were estimated as aged 0–6 years and therefore within the target age range for the legislation. Almost all of these target-aged children were travelling in the rear seat (1348, 95%) as required under the revised legislation and were using a dedicated child restraint (73%) rather than a seatbelt or travelling unrestrained. In terms of the types of restraints worn, the majority were using a forward facing child seat (45%), followed by booster seats (26%), and seatbelts (20%). A small proportion of children were in rear-facing infant restraints (3%) and around 4% were clearly unrestrained. For a small proportion, the child was not clearly unrestrained, but the type of restraint could not be seen (e.g. lap-only belt) and these were coded “Unknown” (2%).

Children's restraint status was coded “Appropriate” if the child was wearing the type specified under the legislation for the estimated age of the child and was seated in the rear seat. Otherwise restraint status was coded ”Inappropriate” (“unknown” was omitted from this calculation). On this basis, 75% of the 0–6 year olds were appropriately restrained under the requirements of the legislation.

An important focus of this research was to determine whether the changes to the legislation had a positive effect on the extent to which children travelled in the appropriate restraint for age. In 2005, an observational study using similar methods was conducted in Brisbane, the capital city of Queensland (Lennon, 2005). That study found that over 8% of children estimated as aged 0–6 years were travelling in the front seats of vehicles. Overall, 66% of the 0–6 year olds were using a dedicated child restraint, 25% were restrained in a seatbelt and 3% were unrestrained (6% “unknown”). Taking the use of a dedicated restraint as a proxy for using the appropriate restraint for the child's age (though this will overestimate the true level of appropriate restraint since in the previous study those children who were using a booster seat but were still at an age where a forward facing restraint should be used cannot be distinguished) these figures suggest that around 70% of the 0–6 year olds were appropriately restrained (“unknown” excluded). When compared with the results of the current study, it appears that proportion of 0–6 year old children restrained appropriately for age has improved, though modestly. These gains appear to have been due to reductions in the proportion of children travelling in the front seat and in the proportion using a seatbelt.

PARENT VIEWS OF, AND SUPPORT FOR, THE CHANGES TO THE LEGISLATION

An aim of this evaluation was to gauge the extent to which parents understood the reasons for the changes in the legislation, knew what those changes were, the ease or difficulty they perceived in complying, and their support for the changes. Views in relation to these issues were sought from both Indigenous and non-Indigenous parents in Queensland.

Non-Indigenous parents

For non-Indigenous parents, a brief interview schedule (<10 minutes duration) was administered verbally by trained research officers. Eligibility criteria were that the parents had children aged under 7 years living with them and that they drove those child(ren) at least once per week in a passenger vehicle. Permission to approach parents was granted by shopping centres in the same cities as those that were used for the observational study (Brisbane, Sunshine Coast, Mackay, and Townsville). Initial interview questions focused on the types of restraints that parents used with each of their children aged 7 years and younger.

Interviewers were instructed to record responses for up to four children in the target age range for each family. To assist parents in identifying which types of restraints they used, parents were shown photographs of each of the six different types of child restraint available on the Australian market at the time (rear facing infant restraint, forward-facing child seat, high backed booster seat, backless booster seat, H harness, seatbelt) each with a child wearing the restraint (with the exception of the backless booster seat) as well as unoccupied. Later questions asked parents whether they were aware that the law had changed recently, and if so, how they had found out about these changes, what they thought the main changes had been, and what the reason was for making the changes. Parents were also asked whether they now did anything different in restraining their children as a result of the changes in the law. An additional interest in this study was to identify any barriers to using appropriate restraints with children and parental support for the changes. To assess these, parents were asked to rate their level of agreement (1 = “Strongly disagree” to 5 = “Strongly agree”) with 11 statements related to child restraints or the legislation. A complete list of these items is given in Table II.

RESULTS

In all, 490 parents, predominantly mothers (89.6%) responded to the interview. Data on response rate was not collected as although the number of direct refusals was very low, most “refusals” were actually in the form of deliberately avoiding contact with the researcher (mostly through shaking one's head while walking quickly past) and thus not only would eligible potential participants have been unaware of the purpose of the study, the researchers could not determine how many of these “refusals” were actually from eligible parents. A large proportion of the participants indicated that they were full time parents (44.3%) probably reflecting the type of location used for recruitment. Most (89%) had at least high school (secondary school) education (40% reported having completed a university degree or higher level of education). Almost half (46.1%) indicated that family income was AU$91,000 or more, with a further 37.8% reporting family income as between AU$51,000 and $90,000. Thus only 15.9% of the parents were on low family incomes. The majority of parents (78.0%) reported that they were “Frequently” the person who drove their children and that typically this involved 1–2 trips per day (54.1% of parents) or three or more trips (31.6%) with only 14.3% of parents typically driving their children less than once per day. The majority of the parents reported having only one or two children under the age of 7 years living with them (241, 49.2%, 226, 46.1% respectively). In total, parents gave responses for 769 children under the age of 7 years.

Table I shows the breakdown of reported restraint type by age of the child (as reported by parents). As can be seen, most of the children were using the appropriate restraint for age as specified under the legislation. The italicised figures in the table highlight those children reported as using a restraint other than the one specified for age. Thus around 9% of the children were not appropriately restrained under the requirements of the new legislation. In order to examine restraint use more closely, children were given a code of “Appropriate” if they were reported as restrained in a restraint of the required type for the child's age. Otherwise, the restraint type was coded “Inappropriate”. Data on appropriateness of restraint type was then analysed according to grouped child age, with age groupings corresponding to those for the types of restraint for age, that is: 0–6 mths, 7 mths–under 2 years, 2–under 4 years, and 4–under 7 years. Chi square tests for differences between these age groups revealed that children aged 7mths–under 2 years were significantly more likely, and children aged 2–under 4 years were significantly less likely to be appropriately restrained for age than the other age groups (χ2 (3)=81.492, p<.001, Cramer's V for effect size φc=.33).In particular, 42 children aged 3 to 4 years were using booster seats instead of forward facing child seats.


Table I. Types of restraints parents (n = 490) reported using with their under 7 year old children (n = 769) (by age group of child).
Restraint type and number (%) of children reported as using them
Child's age Rear facing Forward facing childseat Booster seat Seatbelt H Harness Total
0–6 mths 76 (89.4) 9 (10.6) 85 (100)
7–< 12 mths 10 (9.5) 86 (90.5) 96 (100)
1– < 2 years 2 (2.1) 92 (95.8) 2 (2.1) 96 (100)
2– < 3 years 97 (83.6) 19 (16.4) 116 (100)
3– < 4years 95 (69.3) 42 (30.7) 137 (100)
4– < 5years 40 (36.0) 71 (64.0) 111 (100)
5– < 6 years 11 (16.4) 54 (80.6) 1 (1.5) 1 (1.5) 67 (100)
6– < 7 years 3 (4.9) 52 (85.2) 3 (4.9) 3 (4.9) 61 (100)
Total 433 240 4 4 769

In addition to examining whether children were appropriately restrained, an assessment was made of the parent's reported restraint practices. Parents’ practices were categorised as “Appropriate” if all their children aged under 7 were reported as using the type of restraint specified under the legislation. Otherwise, parental practice was categorised as “Inappropriate”. On this basis, 415 (85%) of the parents were deemed to have “Appropriate” restraint practices, leaving only 75 (15%) of parents who reported that at least one of their children was restrained in an inappropriate restraint for age. While this result suggests a very high level of compliance with the legislation, more detailed analyses revealed a statistically significant difference in the level of appropriate parental practices on the basis of location. Parents in the city of Mackay were more likely to have at least one child under 7 years old inappropriately restrained than parents in the other cities, while parents on the Sunshine Coast were less likely to do so (χ2 (4)=25.01, p<.001, Cramer's V for effect size φc=.23)

Awareness of, and attitudes towards, the new legislation

In terms of awareness, 410 of the 490 parents (84%) indicated that they knew that the legislation had changed. The most common source for having learned about the changes was through television (35%) followed by “friends or family” (13%). Those parents who indicated they were aware the legislation had changed were asked what they thought the purpose had been. Encouragingly, improved safety was the main reason given by most parents (357, 87%), with a further 19 (5%) parents mentioning inadequacies in the previous legislation (e.g. “seatbelts not enough”, “premature graduation”). This suggests that over 90% of parents perceived the changes to the law as being about better protecting children. Only 11 (3%) parents said they didn't know and only one parent gave a response mentioning financial gain as a reason. The other responses given were more idiosyncratic (e.g. “submarining”, “update the legislation”), but it is noteworthy that there were no irrelevant responses.

In relation to their understanding of what the changes had been, parents’ responses were less encouraging. Key words in parents’ verbatim responses to questions were coded into mutually exclusive categories based on whether the details parents gave were complete and accurate or not. There were no parents who gave a complete and accurate summary of the new requirements. However, about one third of the parents (132, 32%) seemed to be aware of the main requirement that children needed to be restrained in a dedicated restraint until they were older. Around half of these parents (77, 18.6% overall) correctly identified the age for this as until at least 7 years, while others did not specify an age and some gave other (incorrect) ages. Some parents (10.4%) correctly gave the details of the requirements for specific ages of children only. In almost 40% (161) of cases, it was not clear from the response whether the parent's knowledge was accurate (e.g. “Age limits on seats and different seats”, “Age increase”) and these were coded as partially complete but uncertain accuracy. There were 63 parents (15.3%) who supplied apparently incorrect information (e.g. “H harness compulsory”) and 28 (6.8%) who indicated that they didn't know.

Parents’ responses to the attitudinal items are displayed in Table II. Responses have been collapsed into three categories: Agree (where parents endorsed responses of “Strongly agree” or “Agree”), Disagree (responses of “Strongly disagree” or “Disagree”) and Neither agree nor disagree (where response were at the mid-point of the response options). As can be seen, the majority of parents agreed that the new law was easy to understand (70.5% agreed), made it clear what restraint type to use (78.5% agreed) and was effective at getting children into the right restraints (75.4% agreed). In addition, they did not agree that the law too complicated (82.8% disagreed) or was too hard (87.9% disagreed) or expensive (73.7% disagreed) for them to comply to comply with. Moreover a very high proportion indicated that they believed they had all that was needed to comply (94.7% agreed). Taken together, these results suggest that parents had a positive overall view of the legislation, an interpretation supported by the high level of parents agreeing that the new law was necessary (79.9%) and low level of agreement (15%) that children had been using the right restraints prior to the changes.


Table II. Parent responses (n = 410) to attitudinal items in relation to the child restraint legislation and to relative safety of age-appropriate restraints.
To what extent do you agree or disagree with the following statements(response options: 1 = “Strongly disagree to 5 = “Strongly agree” Disagree Neither agree nor disagree Agree
Most children were wearing the right restraint so there was no need to change the law 237 (57.8) 111 (27.0) 62 (15.1)
The new law is easy to understand 44 (10.7) 77 (18.8) 289 (70.5)
The new law is too hard for me to comply with 360 (87.9) 39 (9.4) 11 (2.7)
The new law is too complicated 339 (82.8) 50 (12.3) 20 (4.8)
The new law makes it clear what I need to use with my children 31 (7.6) 57 (13.9) 322 (78.5)
I have done what I need to do in order to comply with the new law 2 (0.5) 20 (4.9) 387 (94.7)
The new law is effective at getting children into the right restraints 26 (6.3) 75 (18.2) 309 (75.4)
Overall, I think we needed the new law 18 (4.4) 65 (15.8) 327 (79.8)
It has been expensive for me to comply with the new law 302 (73.7) 46 (11.2) 62 (15.1)
A child seat is safer than a booster seat for children 2–4 yrs 9 (2.2) 18 (4.3) 383 (93.4)
Children aged 5–7 years are just as safe in a seatbelt as they are in a booster seat 329 (80.2) 45 (10.9) 36 (8.8)

Using the variable created to examine the appropriateness of parental restraint practices (that is, “Appropriate” versus “Inappropriate”) a more detailed analysis of responses to the attitudinal statements was conducted in order to see whether parents who were restraining their children appropriately had different attitudes. No differences were found on this basis for any of the statements, suggesting that parents who were not complying with the legislation (for at least one child) were just as likely as those who were complying to hold positive views of the legislation and the ease of compliance.

Indigenous parents

Queensland's Indigenous population comprises only a small proportion of that of the State (estimated as 160,000 people and less than 4% of population, ABS, 2006 data; Australian Indigenous Health Infonet, 2010). However, injury is major cause of morbidity and mortality for Indigenous Australians, and transport-related injury is responsible for 35% of all injury-related Indigenous deaths, a rate almost three times higher than for non-Indigenous Australians (AIHW, 2008). For Indigenous injury-related hospitalisations, transport-related injury comprises 10%. In Queensland, improving knowledge about Indigenous injury is hampered by a number of factors, including the remoteness of the communities in which a large proportion of the Indigenous population lives (26% compared to 2% of non-Indigenous population).

For these reasons, it was deemed important to include Indigenous parents in this study even though it was acknowledged that this part of the study could only be very preliminary and exploratory in nature.

With funding from the Australian Federal Government's Indigenous Road Safety Grant Scheme in 2009, the Department of Transport and Main Roads (TMR) in partnership with the Centre for Accident Research and Road Safety began an Indigenous road safety trial. As part of this trial, a part-time Indigenous Project Officer position, based in the community of Woorabinda, was created. Work with the community on road safety has been on-going, and in relation to child restraints has included a focus on educating parents in the use of restraints with children and the establishment of a hire scheme to allow parents to obtain restraints more readily. The Project Officer, herself Indigenous, together with the Regional Manager, TMR agreed to act as local facilitators for the study and to invite the community to participate. As child restraints were already an identified community priority in Woorabinda, there was ready agreement from the community.

The local facilitators elected to use a focus group (yarn up) to collect data as this method is more culturally consistent with the Indigenous “oral tradition” and avoids comprehension problems that arise as a result of language and numeracy differences. Qualitative methods such as focus groups are also more appropriate to the exploratory stages of investigation. To align the discussion with the same areas of focus as the non-Indigenous interviews, the facilitators chose four “yarning topics” to guide the focus group discussion: support for the new child restraint requirements; understanding of the new requirements; compliance with these; perceived barriers to compliance; and possible opportunities for external agency support to increase compliance.

A single focus group was conducted at the Woorabinda Daycare Centre, a familiar and relatively informal environment that parents were used to accessing, and therefore, likely to be non-threatening. Discussions were not audio or video-recorded in order to maintain participants’ sense of ease. However, in order to capture the key themes and issues discussed under each of the four yarning topics, the facilitators took notes including verbatim comments from participants. In accordance with the eligibility criteria, all participants (n=11) had children under seven years of age in their care and self-reported driving a passenger vehicle at least one day per week. Once notes from the session had been written up, the summary of themes was shown to participants to allow verification that themes were an accurate reflection of the discussion and to correct any misrepresentation. Direct quotes are given in support of some points below. In keeping with preserving anonymity, speakers have not been identified.

FINDINGS

Given the strong role that family plays in Indigenous community life and the younger demographic profile in most Indigenous communities, it was not surprising that there was unanimous support for any initiative that “… makes kids safe”. The group indicated that they “… strongly support the new child restraint rules”, as illustrated by one parent:

The painted sign on the way in to the joint [the community] says—“Our children are our future”—That's how we think in Woorie. We have lots of kids and want them to grow up and be safe. Buckling them up in the car is one way to do that.

Parents thought that understanding of the requirements of the new legislation for parents in the community was only “about average” but was better than it had been, due to the increased education from the Indigenous Project Officer. The hire scheme was valued and seen as a way of improving availability and had “raised the profile of road safety in Woorie” and meant “more kids are buckled up”. When asked to estimate local compliance (Facilitator: “how many do the right thing all the time?”), the group thought “… about half of our mob [people]— maybe more … It's more sincei[Project Officer's name] came along”.

A number of barriers to greater levels of compliance were identified by the Indigenous parents. Chief among these appeared to be the cost of restraints, which is high for a parent on income support:

Most of us around here are on [income support] so we can't afford the boosters and stuff …so some people don't use ‘em. The hire scheme has at least given us a few new ones to use.

This issue was exacerbated by the (incorrect) belief that second hand restraints were illegal to use. While using second hand restraints is not a recommended practice, because of the risk of the restraint having been involved in a crash, it is not illegal provided the restraint is still one of those approved under the Australian Standard.

A second problematic belief was that short trips are safer than longer ones, and thus restraints aren't needed on shorter trips, as articulated by one parent:

I make sure I've got the kids in the right restraints if I'm heading to Rocky [long trip] … I don't worry about it if I'm just driving around Woorie [short trip].

Parents said that they found the promotional material that was used to provide guidance on the appropriate selection of restraints was confusing and they called for clarity on this, especially for children who were very small or very large for age.

In addition, barriers related to vehicles were also mentioned. The lower levels of vehicle ownership (and therefore increased sharing of vehicles) was perceived as leading to problems. Each vehicle might be used by several people in a day and changing the type of child restraints for each use was perceived as difficult. Retrofitting of the anchor bolts needed for top tethered restraints was also identified as a barrier, particularly for older vehicles and utility trucks, which are common vehicles in Indigenous communities. Finally, the lack of qualified restraint installers was perceived as another barrier to greater use of restraints.

DISCUSSION

Results from both the observational and the parent interview studies suggest that the legislation has had a positive effect on the proportion of 0–6 year old children restrained in age-appropriate restraints (compared to the figures from the earlier published observational study). However, while the road-side observations would indicate a modest increase (5–7%) in the proportion of target-aged children travelling in age-appropriate restraints, the parent reports suggest a much higher benefit, with over 90% of 0–6 year olds reported as restrained in age-appropriate restraints. It is likely that the real level is closer to that of the observational study as self-selection bias in the recruitment of the parents to the interview study is likely to have resulted in overrepresentation of more compliant parents (note for instance that there were no children reported as travelling unrestrained in the parent reports while 4–6% of children overall were categorised as unrestrained in the observations). In the interviews parents may also have been more likely to report greater levels of compliance than was accurate due to social desirability and self-report biases.

For both studies, children in the 2–4 year age group appear the most likely to be travelling in restraints that are too big. One interpretation of the parent interview results is that parents are moving 3 year olds into booster seats prematurely either because they are unaware that under the new legislation, the type of restraint required is based on the child's age (and forward facing restraints should be used until the child is at least 4 years), or because of a mistaken belief that the child has outgrown the forward facing seat, in which case the legislation allows for use of a booster seat. A belief that the child is too big for the restraint has been found to be the most common reason parents gave for non-use of a child restraint (prior to the legal requirements to do so) in previous Australian studies (Koppel, Charlton, Fitzharris, Congiu & Fildes, 2008; Edwards et al., 2006). Whilst it might be true that some 3 year old children will be too big for the forward facing restraint, growth charts (as based on the US Centers for Disease Control growth charts, see Kuczmarski, Ogden, Guo, et al., 2002) suggest that only 3% of 3 year olds would be expected to have outgrown this type of restraint (based on the weight, and assuming that height is proportional to weight). The implications for intervention are that educational and promotional efforts need to target parents of children in the critical 2–5 years age group and to focus on promoting the aged-based criteria so that parents may be less likely to change the restraint too soon. These could be linked to children's introduction to school as the majority of children in Queensland now commence school somewhere between the 4th and 5th birthday (the “prep” year). Educational materials could also target staff of child care centres for pre-school aged children and encourage them to emphasise the need for children to remain in forward facing restraints until at least 4 years old. It might be expected over time that the age-based criteria for transition to different types of restraints will become more familiar to parents and that compliance levels will improve as a result.

It is encouraging that parents appeared to value the changes in the legislation and correctly perceived them to be intended to improve children's safety. While non-Indigenous parents did not seem to regard the financial outlay involved in appropriately restraining their children as an issue, Indigenous parents cited this as an important barrier. The Queensland Ambulance Service operates an accessible and affordable hire scheme for rear-facing infant restraints in Queensland (and similar schemes are in place in much of Australia). However, such a scheme is not available for other types of restraint. Due to the length of time that forward facing restraints and booster seats are used by a child (typically at 2–3 years under the new legislation), hire schemes may not represent the best way forward to increase the levels of use with appropriate-aged children. It may be more effective to establish schemes that assist disadvantaged parents with purchasing and installing suitable restraints.

Non-Indigenous parent responses to the attitudinal questions on the relative safety of child seats and booster seats for age-appropriate children suggest that there is still some work to be done to increase parental acceptance of booster seats as a safety device. The introduction on the local market of larger booster seats suitable for older, heavier children may assist this.

Overall, it appears that changing the legislation has been well accepted by parents and has improved the extent to which children targeted by it are travelling in age-appropriate restraints. This evaluation did not address optimal restraint for children aged 7–12 years, though this is an important issue. One potential negative side-effect of the new legislation is that parents will interpret the legislation to mean that an adult seatbelt is the required or the most appropriate restraint for a child who has reached his or her 7th birthday. However, a large proportion of children under 11 years old are still too short for good belt fit and would be better protected by remaining in a booster seat until they are at least 145 cm tall. With the apparent high acceptance of the current amendments to the legislation it may be that parents will develop habits of retaining children in dedicated restraints until a later age and that social norms will also alter accordingly. Legislation can be helpful in this regard, particularly where it is enacted in an environment of high voluntary compliance (as has been the case in Australia) and may thus be perceived as causing only minor inconvenience.

LIMITATIONS

This evaluation has several limitations that should be borne in mind when considering the findings. The most important of these is that, for both studies, there is no objective measure of whether the child restraints were being used correctly, that is, in the manner intended by the manufacturer. Incorrect use (e.g. failing to attach the restraint to the vehicle properly) can lead to serious reductions in the protection offered by a restraint, and hence the improvements in children's safety suggested by these results is tempered by the extent to which they are being installed and used properly. The observations consisted primarily of school-related travel and thus the restraint patterns observed may not accurately represent parental restraint practices for other types of trip. In addition, children's ages were estimates based on seated height and these may not have been accurate, resulting in over or under estimating the proportions of children in each type of restraint and the levels of appropriate restraint. Unfortunately, the methodology used does not allow for calculating the extent to which the results were affected by this.

For the parent interviews, the usual limitations introduced by use of self-report measures apply here. There was evidence that the sample was more representative of compliant parents than of those parents who might be less informed about restraints or more inclined to take a casual approach to their children's restraint, and it is these parents who are arguably those who might most benefit from intervention.

Lastly, the qualitative and exploratory nature of the focus group conducted with Indigenous parents only allows for more general issues to be identified. Further exploration is needed to provide a more comprehensive picture of the views for Indigenous parents more generally.

ACKNOWLEDGEMENTS

This research was supported by a grant from the Queensland Injury Prevention Council and from the Department of Transport and Main Roads, Queensland. Thanks are due to Millie Darvell, Lauren Shaw, and Sarah Biggs for their assistance. Colin Edmonston and Kylie Major-Oakley, TMR, kindly provided support and assistance with the work with the Woorabinda Community.

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About The Author

Alexia Janet Lennon
Centre for Accident Research and Road Safety, Queensland, Queensland University of Technology
Australia

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