Rear Facing Car Seat Invesigation

• Summer 2010Summer 2010• Location: Stark County Health DepartmentLocation: Stark County Health Department• Faculty Preceptor: Clair BourguetFaculty Preceptor: Clair Bourguet• Community Preceptor: Amanda KellyCommunity Preceptor: Amanda Kelly• Title: Health Educator-Injury Prevention Program Title: Health Educator-Injury Prevention Program

Coordinator-Safe Kids Stark Coordinator-Safe Kids Stark CountyCounty

• Competencies: A:4-10, C:3,7-9, D:3,5,6,8,10 Competencies: A:4-10, C:3,7-9, D:3,5,6,8,10 E:1,2,4,5 F:3,8, G:1-10, H:4,6-9, J:2,3,5,9-11, E:1,2,4,5 F:3,8, G:1-10, H:4,6-9, J:2,3,5,9-11, K:1-3,5, L:2,4,6,7K:1-3,5, L:2,4,6,7

• Initial interest was sparked by Bachelor’s degree Initial interest was sparked by Bachelor’s degree in Human Development and Family Studies and in Human Development and Family Studies and concentration in Family Life Educationconcentration in Family Life Education

• The concept of “extended rear facing” car seat The concept of “extended rear facing” car seat use was introduced to me after my daughter was use was introduced to me after my daughter was bornborn

• In 2007, a study published in In 2007, a study published in Injury Prevention Injury Prevention 1 1

concluded that: concluded that: -Rear facing car seats are more effective than -Rear facing car seats are more effective than

forward facing car seats in protecting restrained forward facing car seats in protecting restrained children aged 0-23 months. children aged 0-23 months.

-The benefit of rear facing car seats was also evident -The benefit of rear facing car seats was also evident when only children ages 12-23 months were when only children ages 12-23 months were included.included.

-Data showed that protection of rear facing in side -Data showed that protection of rear facing in side impact crashes was best.impact crashes was best.

-The authors recommend parents prolong the use of -The authors recommend parents prolong the use of rear facing car seats for best protection.rear facing car seats for best protection.

• In 2009, an article in the In 2009, an article in the British Medical JournalBritish Medical Journal22 made the recommendation that physicians made the recommendation that physicians should begin advising parents to rear face should begin advising parents to rear face children to the age of 4 based on a literature children to the age of 4 based on a literature review.review.

• In 2009, the American Academy of PediatricsIn 2009, the American Academy of Pediatrics33 published in its Parents Plus publication that:published in its Parents Plus publication that:

““Toddlers should remain rear-facing in a convertible car seatToddlers should remain rear-facing in a convertible car seat

until they have reached the maximum height and weightuntil they have reached the maximum height and weight

recommended for the model, or at least the age of 2.”recommended for the model, or at least the age of 2.”

• Finally, a study done by the NHTSAFinally, a study done by the NHTSA44 found that found that 21% of children under 12 months or 20lbs were 21% of children under 12 months or 20lbs were not rear facing as recommendednot rear facing as recommended

• Very little investigation into rear facing beyond Very little investigation into rear facing beyond 12 months12 months

• Use findings for social marketing campaignsUse findings for social marketing campaigns• Reduce injury and death in children 0-24 months Reduce injury and death in children 0-24 months

in motor vehicle crashesin motor vehicle crashes

• Estimate the level of rear and forward facing Estimate the level of rear and forward facing compliance in Stark Countycompliance in Stark County

• Examine the Theory of Planned Behavior and Examine the Theory of Planned Behavior and Health Belief Model relationship to car seat Health Belief Model relationship to car seat placement complianceplacement compliance

• Examine demographic factors that influence car Examine demographic factors that influence car seat placement complianceseat placement compliance

• Measures were developed using “Constructing a Measures were developed using “Constructing a TPB Questionnaire: Conceptual and TPB Questionnaire: Conceptual and Methodological Considerations” manualMethodological Considerations” manual

• Intention, subjective norms, perceived behavioral Intention, subjective norms, perceived behavioral control and intention all measured with Likert control and intention all measured with Likert scale statementsscale statements

• Attitude-measured with a semantic differential Attitude-measured with a semantic differential scale with oppositional adjectivesscale with oppositional adjectives

• Direct measures were used for all constructsDirect measures were used for all constructs

• Example scales:Example scales:Strongly Agree Neutral Strongly Disagree

I plan to place my child in a rear facing car seat position for 24 months (Intention)

1 2 3 4 5

My doctor wants me to rear face for 24 months (Social Norms)

1 2 3 4 5

Placing my child in a rear facing car seat position for 24 months is all my decision (PBC)

1 2 3 4 5

Easy (Attitude) 1 2 3 4 5 Hard

Important (Attitude)

1 2 3 4 5 Not Important

• For the sake of time and space I was able to For the sake of time and space I was able to obtain information on:obtain information on:

-perceived -perceived susceptibilitysusceptibility of a car accident of a car accident

-perceived -perceived severityseverity of injury in a car accident of injury in a car accident

-perceived -perceived benefitsbenefits of rear facing car seat placement of rear facing car seat placement

• Example scales:Example scales:

Strongly Agree Neutral Strongly Disagree

Getting into a car accident is a real possibility (Susceptibility)

1 2 3 4 5

My child could get badly injured if in a car accident (Severity)

1 2 3 4 5

My child is safe when in a rear facing car seat position (Benefits) 1 2 3 4 5

• Survey was administered at:Survey was administered at:• Safe Kids Day Stark County-4Safe Kids Day Stark County-4• Stark County HD WIC Program-67Stark County HD WIC Program-67• Alliance City WIC Office-18Alliance City WIC Office-18• Stark Louisville WIC-6Stark Louisville WIC-6• A Wonder World-Learning Center-11A Wonder World-Learning Center-11• Early Childhood Resource Center-4Early Childhood Resource Center-4• Total of 110 surveysTotal of 110 surveys

• Survey was administered to parents or caregivers Survey was administered to parents or caregivers with children under 24 monthswith children under 24 months

• 2 page paper survey2 page paper survey• Majority of participants filled out while waiting in Majority of participants filled out while waiting in

WIC officeWIC office• Average time to complete was 5-10 minutesAverage time to complete was 5-10 minutes• No identifying information collectedNo identifying information collected

• 94% were mothers94% were mothers• 77% were between the ages of 20-34 years 77% were between the ages of 20-34 years

(M=28)(M=28)• 89% of the respondents identify as Caucasian89% of the respondents identify as Caucasian• 36% report the highest education level obtained 36% report the highest education level obtained

was a high school diplomawas a high school diploma• 44% reported working either part or full time44% reported working either part or full time• 31% report being stay at home caregivers31% report being stay at home caregivers• 21% report being students21% report being students

• 57% had an income of less than $25,00057% had an income of less than $25,000• 21% had an income of $25,000-$50,00021% had an income of $25,000-$50,000• 36% were single, 38% were married, and 23% 36% were single, 38% were married, and 23%

were in a relationship but not marriedwere in a relationship but not married• 47% had 1 child, 32% had 2 children47% had 1 child, 32% had 2 children

• 32% of respondents got information about car 32% of respondents got information about car seat placement from professionals such as seat placement from professionals such as physicians, hospitals, or the fire departmentphysicians, hospitals, or the fire department

• 25% got information from the car seat manual or 25% got information from the car seat manual or booksbooks

• 12% got information from family or friends12% got information from family or friends• 11% got information from the internet/online11% got information from the internet/online• 75% report that a physician had not 75% report that a physician had not

recommended rear facing for 24 monthsrecommended rear facing for 24 months

Complier Type

Frequency Percent

Non Complier 8 7.3

Forward Complier

30 27.3

Rear Complier 58 52.7

Super Complier 8 7.3

Total 104 94.5

Missing 6 5.5

Total 110 100.0

• 62.7% were under 12 months old and 37.7% were 62.7% were under 12 months old and 37.7% were over 12 months oldover 12 months old

• 58.2% were 20lbs or below and 37.3% were 58.2% were 20lbs or below and 37.3% were greater than 20lbsgreater than 20lbs

• 62.7% were placed rear facing, 36.7% were 62.7% were placed rear facing, 36.7% were forward facingforward facing

• 40.7% of children ride in the car 7 days per week 40.7% of children ride in the car 7 days per week on averageon average

Table 1. Descriptive Statistics for TPB Study Measures

Mean SD Range

Attitude 2.16 1.0 1-5

Subjective Norms 3.36 1.15 1-5

Perceived Control 2.46 1.24 1-5

Intention 2.87 1.31 1-5

Table 2. Correlation Analysis of Theory of Planned Behavior Variables

Variable Attitude Subjective Norm Perceived Control Intention

Attitude 1.00

Subjective Norm .58* 1.00

Perceived Control .75* .66* 1.00

Intention .78* .76* .80* 1.00

*is significant at .01 level (2-tailed)

Table Regression Analysis Predicting Intent to Rear Face for 24 Months

Variable R2 B beta sig

Attitude .571 .332 .267 .002

Subjective Norms .564 .341 .311 .000

Perceived Control .611 .429 .414 .000

Total .765 .000

N=81

Theory of Planned Behavior Comparison of Means Table

N Mean95% Confidence Interval for Mean

Beta Sig.Lower Bound Upper Bound

Intention Mean

Non Complier 6 4.3333 3.6979 4.9688

-.520 .000Forward Complier 28 3.7679 3.3856 4.1501

Rear Complier 58 2.4655 2.1474 2.7836Super Complier 8 2.0625 1.1031 3.0219

Total 100 2.9100 2.6495 3.1705

Attitude Mean

Non Complier 5 3.2500 1.9514 4.5486


Rear Complier 53 1.9104 1.6747 2.1460Super Complier 7 2.2500 .9558 3.5442

Total 87 2.1580 1.9429 2.3732

Norms Mean

Non Complier 6 4.5000 3.8841 5.1159


Rear Complier 55 2.8727 2.5918 3.1537Super Complier 7 2.9524 2.2093 3.6954

Total 93 3.2867 3.0545 3.5190

PBC Mean

Non Complier 5 3.3000 2.0126 4.5874


Rear Complier 51 2.0784 1.7711 2.3857Super Complier 7 1.9286 .7825 3.0747

Total 85 2.4765 2.2087 2.7442

Table. Regression Analysis Predicting Behavior and Health Belief Model Constructs

Variable R2 B beta sig

Perceived Susceptibility .009 -.067 -.088 .364

Perceived Severity .012 -.073 -.096 .272

Benefits .012 -.055 -.076 .300

Total .034

N=81

N Mean

95% Confidence Interval for Mean

Sig.Lower Bound Upper Bound

Susceptibility

Non Complier 6 2.2500 .6671 3.8329

Forward Complier 28 2.1964 1.9106 2.4822

Rear Complier 57 2.0351 1.7652 2.3050

Super Complier 8 1.9375 1.0596 2.8154

Total 99 2.0859 1.8921 2.2796 .836

Perceived Severity

Non Complier 5 2.6000 1.4894 3.7106


Rear Complier 58 2.0776 1.8160 2.3391

Super Complier 8 2.1875 1.2679 3.1071

Total 99 2.1717 1.9779 2.3656 .599

Benefits

Non Complier 6 2.5833 1.4139 3.7527


Rear Complier 52 2.4135 2.1524 2.6746

Super Complier 8 2.4375 1.5885 3.2865

Total 92 2.5217 2.3113 2.7322 .584

Cross tabulation

Complier

TotalNon

ComplierForward Complier

Rear Complier

Super Complier

Where do you get information about car seat placement?

doctors/hospitals/fire dept/trained personnel

1 (.03) 7 (.22) 22 (.69) 2 (.29) 32

family/friends/social groups

0 (.0) 3 (.30) 6 (.60) 1 (.10) 10

manual/book/magazines/professional literature

3 (.11) 8 (.30) 13 (.48) 3 (.11) 27

online/internet 1 (.11) 1 (.11) 6 (.67) 1 (.11) 9

other 1 (.20) 0 (.0) 4 (.80) 0 (.0) 5

Total 6 19 51 7 83

Cross tabulation

Complier

TotalNon


Rear Complier

Super Complier

Where do you get information about car seat placement?

doctors/hospitals/fire dept/trained personnel

1 (.03) 7 (.22) 22 (.69) 2 (.29) 32

family/friends/social groups

0 (.0) 3 (.30) 6 (.60) 1 (.10) 10

manual/book/magazines/professional literature

3 (.11) 8 (.30) 13 (.48) 3 (.11) 27

online/internet 1 (.11) 1 (.11) 6 (.67) 1 (.11) 9

other 1 (.20) 0 (.0) 4 (.80) 0 (.0) 5

Total 6 19 51 7 83

Cross tabulation

Complier

TotalNon


Rear Complier

Super Complier

Has your healthcare provider recommended you place your child in a rear facing car seat position for 24 months?

Yes 2 (.09) 0 (.0) 19 (.83) 2 (.09) 23

No 6 (.08) 28 (.36) 38 (.49) 6 (.08) 78

Total 8 28 57 8 101

Cross tabulation

Complier

TotalNon


Rear Complier

Super Complier

Has your healthcare provider recommended you place your child in a rear facing car seat position for 24 months?

Yes 2 (.09) 0 (.0) 19 (.83) 2 (.09) 23

No 6 (.08) 28 (.36) 38 (.49) 6 (.08) 78

Total 8 28 57 8 101

Cross tabulation

Complier

TotalNon ComplierForward Complier Rear Complier

Super Complier

Highest level of education attained

Some high school

1 (.09) 3 (.27) 7 (.64) 0 (0) 11

High school diploma or

GED5 (.14) 8 (.22) 22 (.60) 2 (.05) 37

Some college 2 (.05) 11 (.27) 26 (.63) 2 (.05) 41

College graduate

0 (.0) 6 (.43) 4 (.29) 4 (.29) 14

Total8 28 59 8 103

Cross tabulation

Complier

TotalNon ComplierForward Complier Rear Complier

Super Complier

Highest level of education attained

Some high school

1 (.09) 3 (.27) 7 (.64) 0 (0) 11

High school diploma or

GED5 (.14) 8 (.22) 22 (.60) 2 (.05) 37

Some college 2 (.05) 11 (.27) 26 (.63) 2 (.05) 41

College graduate

0 (.0) 6 (.43) 4 (.29) 4 (.29) 14

Total8 28 59 8 103

Cross tabulation

Complier

TotalNon


Rear Complier

Super Complier

What is your family income level?

Less than $25,000 7 (.12) 16 (.26) 37 (.61) 1 (.02) 61

$25,000-$50,000 0 (.0) 8 (.38) 11 (.52) 2 (.10) 21

$50,000-$75,000 0 (.0) 0 (.0) 4 (.80) 1 (.20) 5

$75,000-$100,000 0 (.0) 3 (.60) 1 (.20) 1 (.20) 5

$100,000 and above 0 (.0) 2 (.40) 1 (.20) 2 (.40) 5

Total 7 29 54 7 97

Cross tabulation

Complier

TotalNon


Rear Complier

Super Complier

What is your family income level?

Less than $25,000 7 (.12) 16 (.26) 37 (.61) 1 (.02) 61

$25,000-$50,000 0 (.0) 8 (.38) 11 (.52) 2 (.10) 21

$50,000-$75,000 0 (.0) 0 (.0) 4 (.80) 1 (.20) 5

$75,000-$100,000 0 (.0) 3 (.60) 1 (.20) 1 (.20) 5

$100,000 and above 0 (.0) 2 (.40) 1 (.20) 2 (.40) 5

Total 7 29 54 7 97

• Rate of compliance at 87%.Rate of compliance at 87%.• Rate of non compliance is 7%Rate of non compliance is 7%• Theory of Planned behavior demonstrated high Theory of Planned behavior demonstrated high

predictive value for both intention and actual predictive value for both intention and actual behaviorbehavior

• HBM lacked significance, possibly due incomplete HBM lacked significance, possibly due incomplete measuresmeasures

• More investigation is needed for HBMMore investigation is needed for HBM

• Doctors, hospitals, fire depts. ,and trained Doctors, hospitals, fire depts. ,and trained individuals are important places for rear compliers individuals are important places for rear compliers to get informationto get information

• Keep reinforcing rear facing, especially to 24 Keep reinforcing rear facing, especially to 24 monthsmonths

• Verbal messages may be more effective for non Verbal messages may be more effective for non complierscompliers

• Target low education and low income populationsTarget low education and low income populations

• Was not able to obtain adequate information on Was not able to obtain adequate information on HBM for proper analysisHBM for proper analysis

• Self report questionnaireSelf report questionnaire

è Henary B, Sherwood C, Crandall J, et al. Car safely seats for children: Henary B, Sherwood C, Crandall J, et al. Car safely seats for children: rear facing for best protection. rear facing for best protection. Injury PreventionInjury Prevention [serial online]. [serial online]. December 2007;13(6):398-402. Available from: Academic Search December 2007;13(6):398-402. Available from: Academic Search Complete, Ipswich, MA. Accessed July 20, 2010.Complete, Ipswich, MA. Accessed July 20, 2010.

h Watson E, Monteiro M. Advise use of rear facing child car seats for Watson E, Monteiro M. Advise use of rear facing child car seats for children under 4 years old. children under 4 years old. BMJ: British Medical JournalBMJ: British Medical Journal [serial online]. [serial online]. June 20, 2009;338(7709):1496-1497. Available from: Academic Search June 20, 2009;338(7709):1496-1497. Available from: Academic Search Complete, Ipswich, MA. Accessed July 20, 2010.Complete, Ipswich, MA. Accessed July 20, 2010.

h O’Keefe L. What to consider when positioning car seats for toddlers. O’Keefe L. What to consider when positioning car seats for toddlers. AAP NewsAAP News. April 2009:30(12). April 2009:30(12)

1 Study: Parents moving kids out of car seats too soon. Study: Parents moving kids out of car seats too soon. Safety & HealthSafety & Health [serial online]. October 2, 2009;6.[serial online]. October 2, 2009;6.

Health & Medicine

Rear Facing Car Seat Invesigation