Résumé
La connaissance parentale des
harnais d’auto pour enfants et de leur utilisation
Anne W. Snowdon, Jan Polgar,
Linda Patrick et Lynette Stamler
Les traumatismes liés aux accidents de route constituent au Canada la principale
cause de décès et de blessures chez les enfants de moins de 14 ans, malgré l’im-
position de l’utilisation de dispositifs de retenue dans les véhicules. Un sondage a
été mené pour examiner le taux de connaissances et les perceptions de la popu-
lation parentale quant à l’utilisation de harnais d’auto pour enfants dans deux
communautés de la province d’Ontario. Des parents de poupons et d’enfants
âgés jusqu’à 9 ans ont été recrutés dans trois commissions scolaires urbaines et
rurales, dans des garderies et dans des hôpitaux. Un total de 1263 parents ont
donné de l’information sur l’utilisation de harnais d’auto pour 2 199 enfants.
L’analyse des données a révélé que seulement 68 % des enfants étaient assis dans
des sièges appropriés à leur poids. Notamment, au fur et à mesure que l’enfant
grandissait, le taux de non-utilisation de siège sécuritaire augmentait de façon
importante en raison d’un taux de transition précoce vers des sièges inadéquats
pour la grandeur et le poids de l’enfant. Les résultats ont également révélé que
les parents avaient des connaissances limitées concernant l’utilisation adéquate
des sièges de sécurité pour enfant et qu’ils recouraient fréquemment à des
sources d’information non professionnelles pour obtenir des renseignements sur
la sécurité dans un véhicule. Les auteures recommandent au personnel infirmier
de développer une stratégie globale et systématique visant à faire comprendre
aux familles les façons d’asseoir correctement un enfant dans un véhicule en
utilisant un siège de sécurité approprié à la grandeur, le poids et l’âge de l’enfant.
CJNR 2006,Vol. 38 N
o
2, 98–114
98
11-Snowdon 5/26/06 12:43 PM Page 98
Parents’ Knowledge about
and Use of Child Safety Systems
Anne W. Snowdon, Jan Polgar,
Linda Patrick, and Lynnette Stamler
Road crashes are the leading cause of death and injury in children under
14 years of age in Canada, despite mandatory use of vehicle restraints.A survey
design was used to examine parental knowledge and perceptions of the use of
safety systems for children in 2 communities in the province of Ontario. Parents
of children aged newborn to 9 years were recruited from 3 urban/rural school
boards and from daycare centres and hospitals.A total of 1,263 parents reported
on 2,199 children’s use of safety systems. Data analysis revealed that only 68% of
children used correct seats for their weight and that as the child advanced in age
the rate of misuse increased significantly due to high rates of premature transi-
tioning into safety seats inappropriate for the child’s height and weight.The
results also revealed that parents had limited knowledge concerning the correct
use of safety seats and frequently used non-professional sources of information
for vehicle safety information.The authors recommend that nurses develop a
comprehensive and systematic strategy to ensure that families understand how
to secure children in vehicles using the correct safety seat for the child’s height,
weight, and age.
Keywords: child safety, education program, intervention, car seat safety
Literature Review
Road crashes are the leading cause of death and serious injury for
Canadian children under the age of 14 years (Howard, Snowdon, &
McArthur, 2004; Safe Kids Canada, 2004). In Canada, approximately
two children die or are seriously injured every day as a result of road
crashes. In the United States, six children die and 673 are seriously
injured every day due to road crashes (National Highway Traffic Safety
Administration, 2004). Road crash injury is not limited to North
America; it is a growing global health challenge that claims the lives of
3,200 people every day worldwide and is estimated to result in life-
long disability in over 50 million people annually (World Health
Organization, 2004).Analysis of US crash data reveals that the risk of
death can be reduced by as much as 74% and serious injury by as much
as 67% with the correct use of child safety restraints (Weber, 2000;
Wegner & Girasek, 2003).The rate of accurate use of such restraints has
been reported as between 6% and 21% in American studies (Wegner &
CJNR 2006,Vol. 38 N
o
2, 98–114
© McGill University School of Nursing 99
11-Snowdon 5/26/06 12:43 PM Page 99
Girasek). Correct use requires that the safety seat be appropriate for the
child’s height, weight, and age; be accurately installed and positioned in
the vehicle; and be used every time a child is transported in the vehicle,
with the child securely fastened into it.
Issues of Use and Misuse
The primary goal of child safety seats is to protect the central nervous
system of children while travelling in vehicles (Weber, 2000). Restraints
in vehicles (seat belts, safety seats) are designed to limit and control the
body’s rate of deceleration during a crash, thus reducing the forces acting
on the body’s surface to minimize the differential motion between the
skeleton and the internal organs (Weber). Rapid deceleration of the body
and the impact of the vehicle’s structure on body surfaces are both asso-
ciated with severe injury during collisions. Safety seats are designed to
create a tight coupling of the restrained child and the crushing vehicle,
and to distribute the remaining load as widely as possible over the child’s
strongest anatomical structures (Weber). A child secured in a correctly
used safety seat is 2.7 times more likely to survive a crash without serious
injury than an unrestrained child (Berg, Cook,Vernon, & Dean., 2000;
Weber). Injuries associated with misuse of safety seats or premature use
of seat belts in young children include laceration or rupture of abdominal
organs (liver, spleen, bladder), spinal cord damage, and head injury
(Weber).
One of the most common types of misuse is premature transition
from child safety seats to seat belts, which often results in disabling or
fatal injury (Berg et al., 2000).A US study found that children between 2
and 5 years of age who used seat belts were 3.5 times more likely to
sustain significant injuries than children who used safety seats, and 4
times more likely to sustain significant head and abdominal injuries
(Winston, Durbin, Kallan, & Moll, 2000). In Canada, fewer than 28% of
children aged 4 to 9 years use booster seats (Safe Kids Canada, 2004;
Transport Canada, 1997); thus it is estimated that 1.8 million children in
Canada are at risk of serious injury due to the prevalence of premature
seat belt use.
Installation of safety seats in vehicles is a complex task that poses a
particular challenge for parents.A study of car-seat clinics conducted
throughout the province of Ontario found that four out of five safety
seats were installed or used incorrectly by parents (Ministry of
Transportation of Ontario, 2005). Common types of misuse include
safety seat straps fastened too loosely to the vehicle, incorrect use of
tether straps, incorrect use of locking clips or latches, harness straps
fastened too loosely over the child, and straps incorrectly positioned over
the child (Kohn, Chausmer, & Flood, 2000; Lane, Liu, & Newlin, 2002).
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 100
11-Snowdon 5/26/06 12:43 PM Page 100
Product manuals may also contribute to misuse, as their presentation
and vocabulary often exceed parents’ comprehension levels (Block,
Hanson, & Keane, 1998; Decina & Knoebel, 1997; Gaines, Layne, &
DeForest,1996;Wegner & Girasek, 2003).A recent US study of 107
manuals from 11 different manufacturers found that a grade 10 reading
level was required, on average, to fully comprehend the instructions
(Wegner & Girasek).
Non-use is another significant issue for child safety in vehicles.
Between 1998 and 2002 there were 402 child fatalities in vehicles in
Canada. In the majority of these cases (66% for infants, 50% for toddlers,
97% for school-aged children), the child was either unrestrained or
fastened in a seat belt (Chouinard & Hurley, 2005). Non-use of safety
seats or seat belts for children is estimated at 13% in Canada and 11.8%
in the United States (Chouinard & Hurley). In one US study, the
rationale used by parents for choosing not to use a child safety seat
included the child’s fussiness and discomfort, the inconvenience of using
the device, and needing the device for a younger child (Decina &
Knoebel, 1997).
Growth and Development
Rapid patterns of child growth and development also pose a challenge
to parents and caregivers with regard to accurate and effective use of
safety devices. Because of changes in children’s height, weight, and
cognitive development, parents must learn to instal and use a series of
different devices. For example, infants quadruple their weight in the first
2 years of life and then gain steadily at the rate of four to six pounds per
year until adolescence (Wong, 1999). Given the number and variety of
safety seats on the market, parents may have difficulty deciding when to
use which type of safety seat for each stage in their child’s growth and
development.
The risks associated with premature transition to seat belts in young
children are well documented (Safe Kids Canada, 2004;Winston et al.,
2000). Canadian and US studies have found that most parents do not
know that a seat belt offers less than optimal protection for a school-aged
child (Rivara et al., 2001; Safe Kids Canada). One study found that
parents believed booster seats were unsafe because they were not
anchored to the vehicle in the same way as child safety seats (Simpson,
Wren, Chalmers, & Stephenson, 2003). Other studies have found that
parents prematurely transition their children to seat belts, completely
unaware of the risks or believing they have made the right choice (Safe
Kids Canada; Simpson et al., 2003).
Parents’ knowledge and perceptions about safety seat use are not well
documented in Canada. In order to develop intervention programs for
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 101
11-Snowdon 5/26/06 12:43 PM Page 101
Canadian families to improve their children’s safety in vehicles, we need
greater insight into what parents know about vehicle safety systems and
how they use them.The purpose of this study was to examine parents’
knowledge about and use of safety systems for their children.The
research questions were: What are the patterns of safety seat use for children
(aged 0 to 12 years)? How does knowledge influence parents’ decisions to use
safety seats for their children? What sources of information do parents access
regarding vehicle safety for children?
Theoretical Context
The revised Health Promotion Model (HPM) was the theoretical basis
for the study (Pender, Murtaugh, & Parsons, 2002).Although this model
offers a theoretical context, it does not account for the unique way in
which parents interact with and on behalf of their children to achieve
health. One assumption of this study was that the choice of a vehicle
restraint for a child requires the dynamic and active involvement of an
adult, which in turn is influenced by multiple factors.The revised HPM
framework identifies a link between individual characteristics and expe-
riences that affect one’s behaviour-specific cognition and lead to a behav-
ioural outcome, described as a health-promoting behaviour. In this study,
the health-promoting behaviour of interest was parents’ use of safety seats
for their children.
Method
Design
Survey methodology was used to examine parents’ knowledge about and
use of safety seats for their children.This was the first phase in a program
of research to develop intervention strategies to support children’s safety
while travelling in vehicles.This survey phase was intended to provide
evidence to support the development of intervention programs that
promote children’s safety in vehicles.
Sample
The study was conducted in a large urban area in Southwestern Ontario
and in a smaller urban and rural area in Northern Ontario. Ethics
approval was obtained from the University of Windsor Research Ethics
Review Board, Nipissing University Ethics Board in North Bay, and the
ethics boards of three participating community hospitals. Permission to
access schoolchildren was granted by the directors of the school board
once ethics approval had been obtained from the universities.
In Southwestern Ontario, families of children aged 0 to 9 years were
accessed from an entire school board and its daycare programs (surveys
placed in children’s backpacks for Junior Kindergarten [JK] to grade 5)
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 102
11-Snowdon 5/26/06 12:43 PM Page 102
and from the obstetrical and pediatric units of two local hospitals. In
Northern Ontario, two school boards (JK to grade 5) and the obstetrical
unit of the local hospital were accessed using the same sampling strategy.
In school settings, surveys and completed consent forms were returned
to the researchers in self-addressed stamped envelopes or were collected
in classrooms. In hospital settings, research assistants approached parents
to obtain consent and then administered the survey to the parent, to
increase the rate of response and to ease the burden of survey comple-
tion. In total, 10,600 surveys were circulated; 1,263 were returned,
reporting on 2,199 children, which represents a response rate of 11.9%.
The demographics of the sample are described in Table 1.
This convenience sample is not representative of families in Ontario
since 90% were married (Ontario families = 75.2% married), 73.8% were
educated at the postsecondary level (Ontario = 54.9% educated at this
level), and 85.5% identified as Caucasian (Ontario visible minority popu-
lation = 19.0%) (Statistics Canada, 2001).
Instrument
The survey was designed to examine parents’ use of child restraint
systems (safety seats or seat belts), parents’ knowledge and decision-
making relative to safety seat use, and parents’ sources of information on
safety seats.The questions were developed based on instruments used in
car-seat clinics and on previous research identifying common patterns of
use and misuse.The questions were grouped according to type of safety
seat commonly used (rear-facing, forward-facing, booster, seat belt); use
of the seat, installation of the seat, and location of the seat in the vehicle;
and age, height, and weight of the child using the seat (the questions
were designed to elicit responses for up to three children in a family).
In this study,“correct use” was based on best practice guidelines (Safe
Kids Canada, 2004), defined as correct seat for the height and weight of
the child (i.e., rear-facing infant seat = < 12 months and < 20 lbs.;
forward-facing seat [preschool] = 20–39 lbs.; booster seat = 40–79 lbs.;
seat belt = > 80 lbs.), correct location of seat in the vehicle, and correct
fit of the child in the seat. Patterns of use of safety seats for up to three
children were examined relative to parents’ decision-making on choice
of safety seat and on transitioning the child to the next seat for his or her
height and weight.The questions employed a variety of strategies to elicit
clear and accurate information. Parents were asked to rate the importance
of their decision-making rationale on a five-point Likert scale. Pictures
of various styles of safety seat were included so that parents could readily
identify and more accurately report the seats they were currently using.
Short-answer and fill-in-the-blank questions were used so that parents
could add more description to the data.
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 103
11-Snowdon 5/26/06 12:43 PM Page 103
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 104
Table 1 Demographics of Sample
S.W. Ontario N. Ontario
Variable % (N) % (N)
Age (years)
< 18 .3 (6) 1 (4)
18–25 5.3 (93) 11 (46)
26–30 19.2 (340) 17.2 (72)
31–35 39.9 (707) 32.2 (135)
36–40 26.6 (471) 25.8 (108)
41–45 6.9 (123) 9.8 (41)
> 45 1.8 (31) 3.1 (13)
Sex
Female 90.5 (1,518) 87.5 (357)
Male 9.5 (159) 12.5 (51)
Marital Status
Married/common-law 87.8 (1,556) 75.4 (316)
Race
Caucasian 86.2 (1,495) 82.8 (342)
Native Canadian 5.7 (99) 13.1 (54)
Other 8.1 (141) 4.1 (17)
Region
Urban 72.8 (1,163) 65.5 (260)
Rural 27.2 (434) 34.5 (137)
Education
High school 25.6 (450) 28.9 (121)
College 33.6 (592) 43.2 (181)
University 29.4 (518) 21.5 (90)
Postgraduate 11.4 (200) 6.4 (27)
Income
< $25,000 7.8 (129) 21.3 (87)
$25,000–35,000 11.7 (194) 22.7 (93)
$36,000–45,000 11.8 (195) 14.7 (60)
$46,000–60,000 18 (298) 16.9 (69)
$61,000–80,000 21.8 (361) 12.2 (50)
> $80,000 28.9 (479) 12.2 (50)
Mean years of driving experience 16.57 15.93
11-Snowdon 5/26/06 12:43 PM Page 104
Content validity was supported in a series of pilot tests of the instru-
ment. Initially, the survey was administered to 120 undergraduate nursing
students.They were asked to identify questions that were difficult to
answer or to understand, and unclear or redundant questions were then
deleted.The survey was next administered to a different class of 100
undergraduate nursing students. On the basis of the second pilot test, the
survey was administered to a group of 25 parents of children under 9
years of age in the community who had been identified by the research
team.The number of questions in the survey ranged from 56 to 65,
depending on the number of children for which each participant
responded.
Data were entered into the SPSS statistical program and the initial
phases of the analysis focused on descriptive statistics to indicate the
demographic characteristics of the sample.The two communities were
compared using t tests and chi square to examine differences in demo-
graphics (income, education, age) and correct use of safety systems.There
were no significant differences between the two samples for correct use
of safety systems. However, when the samples were compared according
to age group and correct use, significant differences were found (Table 2).
In addition, there were no significant differences in the two samples
with regard to the parents’ ages (t = 0.354, df = 562, α = .723) or years
of driving experience (t = 1.775, df = 546, α = 0.076) but there were
significant differences in education levels (χ
2
= 36.313, df = 4, α < 0.001)
and income levels (χ
2
= 138.943, df = 5, α < 0.001). Over half of the
parents in Northern Ontario (58.7%) reported a family income of under
$45,000, but well over half of the parents (68.7%) in Southwestern
Ontario reported a family income of over $45,000. Education levels
differed less: 31.9% of parents in Northern Ontario were university-
educated, compared to 40.8% in Southwestern Ontario.
Results
The data provide a wide range of insights into parents’ knowledge about
and use of child safety seats.
Correct Use of Safety Seats
Overall, 74.3% (n = 1,586) of children in the study were seated in the
correct safety seat for their height and weight and their age.The rate of
correct use varied with the age of the child and the geographic location
of the family (Table 3). Infants in Northern Ontario were correctly
seated (87.5%, n = 56) much more often than those in Southwestern
Ontario (76.1%, n = 175). Preschool children (20–39 lbs.) were correctly
seated more often in Southwestern (76.7%) than in Northern Ontario
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 105
11-Snowdon 5/26/06 12:43 PM Page 105
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 106
Table 2 Chi-Square Results for Correct Use of Safety Seats
S.W. Ontario N. Ontario Degrees
Seat Correct Incorrect Correct Incorrect Chi-Square of Freedom Significance
Rear-facing 231 0 4 61 273.05 1 < 0.001*
Forward-facing 699 166 0 177 434.51 1 < 0.001*
Booster seat 502 119 0 156 356.3 1 < 0.001*
Seat belts only 50 0 15 1 3.173 1 0.242
* Significant at 0.0.
Table 3 Correct Use of Safety Seats
Rear-Facing Forward-Facing Booster Seat Belt Only Correct Use (%)
S.W. Ont. N. Ont. S.W. Ont. N. Ont. S.W. Ont. N. Ont. S.W. Ont. N. Ont. S.W. Ont. N. Ont.
Infants ≤12 months
0
–20 lbs 169 54 19100008998.0
21
–39 lbs 62 35710001428.5
Infants ≥13 months
0
–20 lbs 0 1520 0 0 0 67 67.0
Toddlers x = 3 years
21
–39 lbs 0 1 543 92 150 42 1 4 78 66.0
School-aged x = 6 years
40
–79 lbs 0 0 52 8 492 118 177 53 71 67.0
School-aged x = 8 yrs
80+ lbs 0 0 0 0 2 2 60 18 100 100.0
* Correct use appears in bold italics.
11-Snowdon 5/26/06 12:43 PM Page 106
(66.2%). In the school-aged population, use of booster seats was 70.1%
in Southwestern and 66.7% in Northern Ontario.Thus, the Northern
community had a very high rate of correct use for infants but a lower
rate of correct use in all of the other age groups with the exception of
the children over 80 pounds using seat belts.
Transition of Children in Safety Seats
Parents were asked the age at which they transitioned their child to the
current safety seat and the factors on which they based this decision.
Figure 1 illustrates the rate at which parents transitioned their infant from
a rear-facing to a forward-facing seat. Premature transition of infants
began at 4 months, and by 9 to 12 months the majority of infants (78%)
were in a forward-facing seat. Parents identified the child’s “fit” in the
safety seat and the child’s weight as the most important factors in the
decision to transition to a forward-facing seat; age was not a factor in the
decision.
The second clearly apparent transition was that from a safety seat to
a seat belt. Figure 2 illustrates parents’ timing of this transition. Families
reported using seat belts when their children were as young as 3 years,
after which age the use of seat belts increased rapidly, with half of
all children in the study using seat belts by the age of 7. Correct use of
seat belts requires that the occupant be at least 80 pounds and 57 inches
tall (Safe Kids Canada, 2004).Although age is not the main criterion,
most booster seat laws in Ontario and Quebec identify 8 years as the
minimum age for seat belts (Safe Kids Canada).
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 107
Figure 1 Use of Rear-Facing Safety Seats in Infants
Up to 12 Months (n = 296)
100
80
60
40
20
0
0–3 4–8 9–12
Age (months)
Percentage
100
70.6
22.8
11-Snowdon 5/26/06 12:43 PM Page 107
Parental Knowledge
Parents were asked to rate the importance of a number of factors in the
decision to purchase a safety seat for their child or to transition their
child from one safety seat to another. It was assumed that parents’
knowledge influenced their decisions regarding safety seats.A Likert scale
was used for this purpose.The most important factor in choosing a new
safety seat was the “fit” of the child in the seat (mean rating = 4.27),
followed by the child’s weight (mean rating = 4.24).Age was not consid-
ered important (mean rating = 2.73), nor was the child’s resistance (mean
rating = 2.70).
Patterns of Safety Seat Use in Families
In the majority of families, both parents worked and therefore required
others to transport their child in a vehicle as part of the family routine.
The survey included items on strategies used by parents to ensure their
child’s safety in vehicles other than their own. Most parents (77%, n =
670) reported transferring the child’s own safety seat to the other vehicle
and routinely instructing the other driver regarding its use for their
child.The most common group of other drivers transporting the child
were grandparents (84%, n = 778), followed by “other family members”
(41%).
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 108
Figure 2 Premature Use of Seat Belts in Children Aged 3 to 11
100
80
60
40
20
0
34567891011
Age (years)
Percentage
1.7
7.1
16.0
31.0
49.6
61.0
81.0
100 100
Percentage of children using a seat belt.
Percentage of children meeting the 80-lb. weight requirement for safely using a seat belt.
11-Snowdon 5/26/06 12:43 PM Page 108
Location of Safety Seat in the Vehicle
Regarding placement of the child in the vehicle, the majority of children
(96%, n = 1,179) were correctly placed in the rear seat.There was little
variation in parents’ use of rear seating for their children when it was
examined according to the age of the child.
Challenges of Safety Seat Installation
The majority of parents (86%, n = 1,069) reported “little or no diffi-
culty” (scored on a 5-point Likert scale) with installing the safety seat in
their vehicle. However, the study did not observe for accuracy regarding
installation of the seat. Seventy-eight percent (n = 947) of the parents
reported that the instruction manual packaged with the safety seat was
clear and easy to follow, 17% (n = 201) reported that it was moderately
easy to follow, while 5% (n = 63) reported that it was unclear and not
easy to follow.
Safety Seat Purchase
Ninety-six percent of parents stated they had purchased a new safety seat.
The factors influencing parents’ choice of safety seat were ease of use
(74%, n = 911), affordability (37%, n = 450), and aesthetics (22%, n =
269).
Sources of Information
Parents were asked to describe the sources of information they routinely
accessed to support use of safety seats for their children. Sixty-five
percent (n = 787) indicated that finding information was “easy,” 23% (n
= 272) that it was moderately easy, and 12% (n = 137) that it was not
easy.The majority of parents used pamphlets and magazines as their
primary source of information (n = 766, 63%), followed by friends and
family (n = 382, 32%). Health-care professionals and car-seat clinics were
not common sources of information.
Discussion
The rate of correct use of child safety seats found in this study (74%) is
generally consistent with rates found in Canadian national surveys
(Chouinard & Hurley, 2005).The most surprising finding was a very
high rate of reported use of booster seats for school-aged children (70.1%
in Southwestern Ontario, 66.7% in Northern Ontario).Although an
entire school board was sampled in Southwestern Ontario (JK to grade
5), it is possible that parents who were knowledgeable about safety seat
use self-selected more than parents who were less knowledgeable and
that a random sampling approach would have yielded different results.
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 109
11-Snowdon 5/26/06 12:43 PM Page 109
A study of booster seat use that was conducted in the same Southwestern
Ontario community 1 year earlier and that accessed children through
after-school “latchkey” programs in the same school board region found
that only 40% (n = 105) of children used booster seats.The present
findings need to be validated with more rigorous sampling approaches.
Another compelling finding was the pattern of premature transition
of children to seat belts or to other safety seats.The majority of research
to date has relied solely on a cross-sectional sampling approach as well as
observation and self-report (Chouinard & Hurley, 2005; Safe Kids
Canada, 2004; Simpson et al., 2003).The retrospective approach used in
the present study elicited valuable insights into how and when parents
make decisions regarding safety seat transition. Many of the parents
mistakenly believed that “fit” and weight are the most important factors
in safety seat transitioning; they were unaware that, for infants, age is a
critical marker for transitioning. Parental knowledge about the correct
age and the correct height and weight at which to transition children has
been reported as very limited due to confusion about these factors;
however, work in this area has focused primarily on the US booster seat
population (Rivara et al., 2001) rather than on the premature transi-
tioning of infants.An American roadside survey found that only 54% of
infants under 1 year of age were properly restrained (Staunton et al.,
2005). Public awareness through prenatal classes and education of new
parents has been successful in supporting the use of rear-facing safety
seats for newborn babies. However, parents need more detailed infor-
mation on how and when to transition children beyond the newborn
period.
Similarly, premature seat belt use was evident in the present study,
with half of the children using seat belts at age 7 (Figure 2).This finding
is consistent with the results of US studies, which report that 40% to 80%
of 5 to 8-year-old children use seat belts (Staunton et al., 2005;Winston
et al., 2000). In one of the studies, police roadblocks were used to ensure
obligatory participation in the observation, which reported only 1% of
children using the correct safety seat (Staunton et al.).This use of road-
blocks may lead to a more reliable estimate of safety seat use than the
voluntary participation used in most observational research.The most
recent Transport Canada survey (1997) used “drive by” observation of
safety seat use at intersections; the accuracy of these national data may
therefore be limited. More rigorous methods for observing actual safety
seat use in Canadian families are clearly needed. In the United States,
premature use of seat belts for children has been widely studied (Ebel,
Koepsell, Bennett, & Rivara, 2003; Rivara et al., 2001;Winston &
Durbin, 1999;Winston et al., 2000), with seat belt use found to begin at
age 2 and to be very common by age 5. In the present study, similarly,
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 110
11-Snowdon 5/26/06 12:43 PM Page 110
seat belt use began as young as age 3 and increased dramatically as the
children approached the age of 6.
Another important finding of the present study was the sources of
information used by parents to support the proper use of child safety
seats. Parents reported relying heavily on “instructions on the box” and
family and friends, rather than physicians, nurses, or safety seat experts.
Lack of access to consistent and accurate information may be a major
contributing factor in the misuse of safety seats in Canadian families. It
may also reflect the lack of school-based education for children and lack
of vehicle safety information for parents, whose reliance on friends,
neighbours, and family members contributes to the perpetuation of
misinformation throughout communities. In a recent study, only 16% of
parents reported ever being asked about child seat safety by their primary
care provider (family physician, pediatrician, nurse practitioner)
(Lemoine, Lemoine, & Cyr, 2006).Thus, car seat safety may not be
viewed as a primary care issue, despite the fact that riding in a vehicle is
the most dangerous activity a child can engage in (McKay, 2003).Why
do health professionals not raise the issue of car seat safety with families?
If they have not received training or education in effective use of child
safety seats, they may not be aware of children’s risk of injury. Educational
programs might consider addressing injury prevention more directly, so
that professionals can adequately counsel families and help to prevent the
spread of misinformation.
This study also found that the drivers (other than parents) to most
frequently transport children in vehicles were grandparents.This finding
raises a number of issues. Grandparents are not likely to have had experi-
ence with safety seats for their own children, since even seat belts were
not made mandatory by law until 1977 in Canada.There are no
published studies of grandparents’ knowledge and use of safety systems
for children travelling in vehicles. Future research could examine grand-
parents’ knowledge and use of child safety systems and consider tailored
intervention programs that reflect the learning needs of older adults who
routinely provide care for children in vehicles.This particular area of
research will become increasingly important as Canada’s population ages
and grandparents assume more active roles in transporting children.
There are two limitations to the study.The preponderance of
Caucasian respondents is not representative of the diversity of Canadian
urban populations; while the Northern Ontario site contributed some
aboriginal participants, these were too few in number to allow for a
strong comparative analysis. In addition, the use of self-report surveys
may have resulted in a selection bias on the part of parents, which could
mean that the findings represent a “best case scenario” regarding correct
use of safety seats in Canadian families.
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 111
11-Snowdon 5/26/06 12:43 PM Page 111
Implications for Nursing Practice
Nurses clearly have an extraordinary opportunity to take a leadership
role, nationally and internationally, in championing injury-prevention
initiatives for children travelling in vehicles. Every year in Canada, the
equivalent of three classrooms full of elementary schoolchildren never
reach grade 5 due to fatalities in vehicles (Safe Kids Canada, 2004).The
development of a comprehensive strategy to prevent death and serious
injury in Canadian families is long overdue. Such a strategy would
engage nurses in community agencies, ambulatory care, obstetrics, and
pediatrics to ensure that parents and children have the knowledge and
skills necessary to travel safely in vehicles. Just as height, weight, and
allergy and immunization status are assessed throughout childhood using
a standardized approach, so too should safety seat use be screened and
assessed. Nurse practitioners, nurses in school health programs, pediatric
nurses, and emergency room nurses should be conducting routine safety
seat assessment for all children and providing consistent, accurate infor-
mation to families on a routine basis.
Interdisciplinary and cross-sector partnerships are needed in order to
achieve the 70% reduction in fatalities and 67% reduction in serious
injuries among Canadian children reported as achievable in the current
research (National Highway Traffic Safety Administration, 2004).
Partnerships with school boards, police/fire services, and educators would
be a unique and critically important means for nurses to influence in-
class health and safety education in primary schools.Teachers and parent
councils could partner with nurses to facilitate the implementation of
programs that teach children and parents about the correct use of safety
seats, as schoolchildren experience higher rates of death and serious
injury than any other age group (Chouinard & Hurley, 2005). Such
cross-sector partnerships would be an ideal opportunity for nurses to
build on community education programs for families with infants and
toddlers and extend safety education into schools, to ensure that all
children travel safely in vehicles. Cross-sector strategic partnerships may
also position nurses to more directly influence policy, such as federal
booster seat legislation.
There is no question that vehicle safety programs, in order to provide
a comprehensive, national approach to education that supports effective
use of safety seats in Canadian families, need the involvement of profes-
sionals from education, health, police services, and even the private sector
(i.e., the auto industry). Nursing is the ideal discipline, with its wealth of
knowledge and experience in health promotion, to conquer road crashes
as the leading cause of death among Canadian children.Theoretical
development of injury prevention research for children travelling in
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 112
11-Snowdon 5/26/06 12:43 PM Page 112
vehicles has not been addressed in the health literature.The present
findings may represent a first step in identifying some of the conceptual
underpinnings of injury prevention in this important area of health
promotion research in Canada.
References
Berg, M., Cook, L. H.,Vernon, D., & Dean, M. (2000). Effect of seating position
and restraint use on injuries to children in motor vehicle crashes. Pediatrics,
105(4), 831– 835.
Block, D., Hanson,T., & Keane,A. (1998). Child safety seat misuse: Home
visiting assessment and intervention. Public Health Nursing, 15(4), 250–256.
Chouinard,A., & Hurley, R. (2005, June 6–9). Towards the development of a national
child restraint survey. Paper presented at 15th Canadian Multidisciplinary
Road Safety Conference, Fredericton, New Brunswick.
Decina, L., & Knoebel, K. (1997). Child safety seat misuse patterns in four states.
Accident, 29(1), 125–132.
Ebel, B. E., Koepsell,T. D., Bennett, E. E., & Rivara, F. P. (2003). Use of child
booster seats in motor vehicles following a community campaign: A
controlled trial. Journal of the American Medical Association, 289(7), 879–884.
Gaines, S., Layne, B., & DeForest, M. (1996). Promoting automobile safety for
young children. American Journal of Maternal/Child Nursing, 21, 148–151.
Howard, A., Snowdon, A., & MacArthur, C. (2004). Removing barriers to
booster seat use in Canada. Paediatrics and Child Health, 9(5), 295–297.
Kohn, M., Chausmer, K., & Flood, M. H. (2000).Anticipatory guidance about
child safety misuse: Lessons from safety seat “check-ups.” Archives of Pediatrics
and Adolescent Medicine, 154(6), 606.
Lane,W. G., Liu, G. C., & Newlin, E. (2002).The association between hands-on
instruction and proper child safety seat installation. Pediatrics, 106(4), 924.
Lemoine, M.-H., Lemoine, C., & Cyr, C. (2006). Pediatric primary care quality
and accessibility: Parents’ perspective. Pediatrics and Child Health, 11(1),
25–28.
McKay, M. (2003). Children in cars — keeping them safe at every age.
Contemporary Pediatrics, 20(9), 65–78.
Ministry of Transportation of Ontario. (2005). Safe and secure: Choosing the right
car seat for your child. Retrieved March 5, 2006, from http://www.
mto.gov.on.ca/english/safety/carseat/choose.htm
National Highway Traffic Safety Administration. (2004). Misuse of child restraints.
(DOT HS 809 671.) Retrieved March 2, 2006, from www.nhtsa. dot.gov.
Pender, N., Murtaugh, C., & Parsons, M. A. (2002). Health promotion in nursing
practice (4th ed.). Upper Saddle River, NJ: Prentice-Hall.
Rivara, F. P., Bennett, E., Crispin, B., Kruger, K., Ebel, B., & Sarewitz,A. (2001).
Booster seats for child passengers: Lessons for increasing their use. Injury
Prevention, 7, 210–213.
Safe Kids Canada. (2004). Booster seat use in Canada:A national challenge. Toronto:
Author. Retrieved March 7, 2006, from http://www.sickkids.ca/SKC
ForParents/custom/EnglishReport_BoosterSeats.pdf
Parents’ Knowledge about and Use of Child Safety Systems
CJNR 2006,Vol. 38 N
o
2 113
11-Snowdon 5/26/06 12:43 PM Page 113
Simpson, J. C.,Wren, J., Chalmers, D. J., & Stephenson, S. C. R. (2003).
Examining child restraint use and barriers to their use: Lessons from a pilot
study. Injury Prevention, 9, 326–331.
Statistics Canada. (2001). Community profiles. Retrieved February 28, 2006, from
http://www12.statcan.ca/english/profil01/CP01/Details/Page.cfm?Lang=
E&Geol=PR&Code1=3
Staunton, C., Davidson, S., Kegler, S., Dawson, L., Powell, K., & Dellinger,A.
(2005). Critical gaps in child passenger safety practices, surveillance, and
legislation: Georgia, 2001. Pediatrics, 115, 372–379.
Transport Canada. (1997). Child restraint use in Canada: 1997 survey data. TP2436,
Road Safety Leaflet #CL 9804 E. [Brochure]. Retrieved February 26, 2006,
from http://www.tc.gc.ca/roadsafety/tp2436/c19804/menue.htm
Weber, K. (2000). Crash protection for child passengers:A review of best
practice. UMTRI Research Review, 31(3), 1–27.
Wegner, M.V., & Girasek, D. C. (2003). How readable are child safety seat instal-
lation instructions? Pediatrics, 111(3), 588–591.
Winston, F. K., & Durbin, D. R. (1999). BUCKLE UP! is not enough:
Enhancing the protection of the restrained child. Journal of the American
Medical Association, 281, 2070–2072.
Winston, F. K., Durbin, D. R., Kallan, M. J., & Moll, E. K. (2000).The danger of
premature graduation to seat belts for young children. Pediatrics, 105(6),
1179–1183.
Wong, D. (1999). Whaley and Wong’s nursing care of infants and children (6th ed.).
St. Louis: Mosby.
World Health Organization. (2004). World report on road traffic injury prevention.
Retrieved March 8, 2006, from http://www.who.int/world-health-
day/2004/infomaterials/world_report/en/index.html
Authors’ Note
This project was sponsored by Daimler Chrysler Canada and AUTO21,
University of Windsor.
Comments or queries may be directed to Dr.Anne Snowdon, Faculty
of Nursing, University of Windsor, 401 Sunset Avenue,Windsor, Ontario
N9B 3P4 Canada.Telephone: 519-253-3000, ext. 4812. Fax: 519-973-
7084. E-mail: asnowdon@cogeco.ca
Anne W. Snowdon, RN, PhD, is Associate Professor and Theme A Coordinator,
AUTO21, Faculty of Nursing, University of Windsor, Ontario, Canada. Jan
Polgar, PhD, OT Reg, is Associate Professor and Graduate Chair, School of
Occupational Therapy, Faculty of Health Sciences, University of Western Ontario,
London, Ontario. Linda Patrick, RN, PhD, is Assistant Professor, Faculty of
Nursing, University of Windsor. Lynnette Stamler, RN, PhD, is Associate
Professor, College of Nursing, University of Saskatchewan, Saskatoon, Canada.
Anne W. Snowdon, Jan Polgar, Linda Patrick, and Lynnette Stamler
CJNR 2006,Vol. 38 N
o
2 114
11-Snowdon 5/26/06 12:43 PM Page 114
