The influence of parental education and other socio-economic factors on child car seat use

VPLIV IZOBRAZBE STARŠEV IN DRUGIH SOCIALNO-EKONOMSKIH DEJAVNIKOV NA UPORABO OTROŠKEGA AVTOMOBILSKEGA SEDEŽA

Mateja Rok Simon 1 , Aleš Korošec 1  and Marjan Bilban 2
  • 1 National Institute of Public Health, Centre for Health Research and Development, Trubarjeva 2, 1000 Ljubljana, Slovenia
  • 2 Institute of Occupational Safety, Chengdujska c. 25, 1260 Ljubljana-Polje, Slovenia
Mateja Rok Simon, Aleš Korošec and Marjan Bilban

Abstract

Introduction

The behaviour of parents in ensuring car passenger safety for their children is associated with socio-economic (SE) status of the family; however, the influence of parental education has rarely been researched and the findings are contradictory. The aim of the study was to clarify whether parental education influences the use of a child car seat during short rides.

Methods

A cross-sectional survey was carried out in outpatient clinics for children’s healthcare across Slovenia. 904 parents of 3-year-old children participated in the study; the response rate was 95.9%. A self-administered questionnaire was used. A binary multiple logistic regression was applied to assess the association between parental unsafe behaviour as dependent variable, and education and other SE factors as independent variables.

Results

14.6% of parents did not use a child car seat during short rides. Families where mother had low or college education had higher odds of the non-use of a child car seat than families where mother had a university education. Single-parent families and those who lived in areas with low or medium SE status also had higher odds of the non-use of a child car seat.

Conclusions

Low educational attainment influences parents’ behaviour regarding the non-use of a child car seat. Low parental education is not the only risk factor since some highly educated parents also have high odds of unsafe behaviour. All parents should therefore be included in individually tailored safety counselling programmes. SE inequalities could be further reduced with provision of free child car seats for eligible families.

1 Introduction

Injuries are the leading cause of death in children older than 1 year in Slovenia and other European countries, wherein preschool children are most vulnerable to traffic accidents (1). Despite the national mandatory child restrain use and scientific evidence that child safety car seat use is highly effective in reducing the risk of fatal and nonfatal injury during traffic collision (2, 3), in Slovenia, up to 20% of children younger than 12 years are not restrained (4).

High mortality and morbidity due to injuries are associated with poverty and material deprivation (5), which increase injury risks because children are exposed to a wider range of hazards due to poor safety of their living environment, while parents have less knowledge and time to implement safety measures and less means to buy safety devices (6). Until now, a relatively small number of studies was published on the relationship between parental safety practices and SE factors, such as low parental educational attainment, unemployment, a single-parent family, and living in poor areas. Some authors report that child safety car seat is used less frequently in families with low income (7, 8) and low parental educational attainment (9, 10), but most studies could not or did not try to prove the association with socio-economic (SE) factors (11-13). Very few studies analysed educational attainment in combination with other SE factors, despite the fact that it could influence parents’ ability for injury prevention in children. Parents with higher educational levels are more aware of potential dangers, they can seek out better information on injury prevention in children, and they have better intellectual abilities, more knowledge and greater motivation for intervention (10). We would expect that parental education positively influences their implementation of safety measures, but the findings so far are contradictory. Some authors report that parents with higher education levels use the child safety car seat more often (7, 10, 14), while other studies show that the use of a child car seat is not significantly different in families with lower educated mother (8, 11, 12), or it is even more frequent (15).

The aim of our study was to clarify whether parental education influences the use of child car seat and to assess the extent of its importance compared to other socio-economic factors. A self-administered questionnaire on safety practices was used in a cross-sectional area probability study sample of parents. The findings will contribute to the development of new programmes in the field of safety promotion and reduction of children’s health inequalities due to injuries.

2 Methods

2.1 Study Design and Participants

An analytical cross-sectional survey was conducted in outpatient clinics for children’s healthcare across Slovenia. The study population comprised parents who brought their children for routine well-child visits at the age of three years. The sample was selected by the method of stratified area probability proportionate to size sampling (16) with the choice of 41 clusters with 23 persons. The questionnaire was completed by 904 parents; the response rate was 95.9%. 37 questionnaires (4.1%) were rejected due to child’s inadequate age, while 867 questionnaires were eligible for the analysis. Another 16 records were excluded from the final analysis, because families have not got a car. The average age of mothers was 33.0 years, while the average age of fathers was 35.7 years. Other socio-demographic characteristics of participant families are shown in Table 1.

Table 1

Socio-demographic characteristics of participant families.

Family characteristicsN(%)
Mother’s age (years)847
Less than 2919.8
30-3443.0
35 and more37.2
Father’s age (years)841
Less than 299.0
30-3434.2
35-3936.3
40 and more20.5
Mother’s education849
Vocational or less15.5
Secondary27.1
College27.1
University30.3
Father’s education842
Vocational or less29.0
Secondary30.8
College18.5
University21.7
Child sequence848
First child49.1
Second and following child50.9
Number of children848
One child27.8
Two or more72.2
Gender of the child850
Male51.4
Female48.6
Family type848
Both parents75.0
Parents and relatives22.1
Single-parent family2.9
Material welfare of the family844
Poor8.9
Medium81.6
Good9.5
Type of residence community842
Urban38.7
Suburban17.7
Rural43.6
SE status of area of residence850
Poor25.8
Medium17.9
Good56.3

2.2 Materials

A self-administered questionnaire was developed. Before starting data collection, 12 parents from one of the clinics participated in pilot testing. The final questionnaire was supplemented in accordance with the pilot testing findings and handed to 943 parents.

The questionnaire contained questions on safety practice and potential correlates. Safety practice regarding child car seat use was assessed with the following question: ‘How often is your child fastened in a child car seat during 5- to 10-minute rides?’ Answers were recorded to a dichotomous outcome (not using – never, less than half times, more than half times, using – always). Parents’ behaviour was defined as unsafe in cases when parents did not use a child car seat on every short ride, because a child is only safe when the child car seat is used, which is required by law in Slovenia. Potential correlates of safety practice were: socio-economic status assessed with maternal and paternal educational attainment (vocational or less, secondary, college, university), family type, material welfare of the family (self-assessed as poor – they cannot or can barely cover the usual needs with family income, including social benefits; medium – they cover the usual needs and possibly save some money; good – they easily save a part of the income and make investments), SE status of area of residence (quintiles of income tax base per capita in the municipality were defined as bad – the 1st and 2nd group with the lowest income tax; medium – the 3rd group; good – the 4th and 5th group) and the type of the residence community (self-assessed).

Family and child’s characteristics were defined with mother’s age, father’s age, gender of the child, child sequence, the number of children, parents’ knowledge on children’s injury prevention (poor – 1/3 of correct answers or less; good) and the source of information (reliable – books, medical staff; questionable – the Internet, magazines, TV; unreliable – friends, relatives, none). The motivational factors were defined on the basis of presumptions of Protection motivation theory (17). The four-point answer scale (‘low’ to ‘very high’) was used to measure parents’ perception of their children’s vulnerability, the severity of a child’s injury in a potential accident, safety measure efficacy and self-efficacy. Social norms were measured with the perceived expectations of significant others regarding the importance of safe behaviour (‘not so important’ to ‘very important’).

2.3 Procedure

In 41 paediatric outpatient study sample clinics, nurses invited parents who brought their three-year-old children for routine well-child visits in May and June 2013 to participate in the study. Parents, who gave their written consent for the participation in the study, filled in the questionnaire by themselves in the waiting room, while waiting for their child’s turn for a check-up. The data were gathered by self-administered questionnaires, accompanied by a cover letter, which explained the purposes of the study and why parents’ cooperation is important. In case both parents accompanied the child, they only filled in one questionnaire. Parallel answers given by the father and mother of the same child were not requested. Parents sealed up the completed questionnaire in an enclosed envelope and put it in a special box in the nurse’s office. The nurse opened the box only after the study data collection was over. In case parents did not wish to participate in the study, they marked the questionnaire accordingly and put it in the box. Parents were given full anonymity because the questionnaire did not include any personal data, which could identify them or their child. The participants did not receive any financial stimulation.

2.4 Data Analysis

Categorical variables were described with relative frequencies and continuous variables with mean ones. The association between unsafe behaviour as dependent variable and SE and other factors as independent variables was assessed using binary multiple logistic regression. Dummy variables were created for all observed independent variables in the analysis. The simple method was applied. Three models were fitted: SE factors (Model 1), adjusted for demographic factors (Model 2), and adjusted for demographic, motivational factors and social norms (Model 3). The Hosmer – Lemeshow test was used to perform the assessment of how well each model accounts for the outcome. For the comparison of three models, the likelihood ratio test was used, wherein Model 1 was a special case of Model 2, and Model 2 was a special case of Model 3. Further analyses were applied to investigate potential interaction effects (effect modification) among individual SE factors and between SE factors and motivational factors / social norms.

P-value ≥0.05 was considered as statistically significant. SPSS statistical package for Windows Version 21.0 was used for the analysis.

3 Results

14.6% of families did not always use a child car seat during short rides. In univariate analysis, families with mothers who had vocational, secondary and college education had significantly higher odds for unsafe behaviour regarding child car seat use compared to families with mothers with university education. The same applied for families with fathers who had vocational and secondary education compared to families with university-educated fathers, as well as for families living in areas with poor and medium SE status compared to families living in areas with good SE status. Other characteristics of participant families associated with unsafe behaviour are shown in Table 2.

After introducing multivariable analysis in Model 1, 2 and 3 (Table 3), the change in OR was substantial for several variables compared to univariate analysis. In Model 1, logistic regression analysis showed a significant association between the non-use of child car seat and vocational maternal education, college maternal education, and medium SE status of the area of residence. When the association between the outcome and SE factors was adjusted for demographic factors, motivational factors and social norms in Model 3, the association with single-parent family type and poor SE status of the area of residence became significant. We have tested potential interaction effects among individual SE factors, and between SE factors and motivational factors / social norms. There were no significant interactions; therefore, the change in ORs is likely to be attributed to confounding. Father’s education, material welfare of the family and the type of residential community were not significantly associated with the outcome in none of these three models. Other family characteristics associated with unsafe behaviour are shown in Table 3.

Model 3 showed the best fit to the data of all three analysed models. The inclusion of demographic factors into Model 2 increased the fit of Model 2 compared to Model 1, and further inclusion of motivational factors and social norms into Model 3 increased the fit of Model 3 compared to Model 2 (Table 3).

Table 2

Estimates of the prevalence of the non-use of a child car seat (Ntot=851), and results of invariable analysis of the association between the non-use of a child car seat and family factors.

NoatNot using a child car seat (%)Univariable analysis
OR (95% C.I.)P-value
Socio-economic factors
Mother’s education
University2577.01.00
College23018.73.05 (1.71-5.47)p=0.000
Secondary23013.92.15 (1.17-3.94)p=0.014
Vocational or less13223.54.08 (2.18-7.62)p=0.000
Father’s education
University1838.21.00
College15612.21.55 (0.76-3.17)p=0.226
Secondary25916.22.17 (1.16-4.04)p=0.015
Vocational or less24418.92.60 (1.40-4.83)p=0.002
Material welfare of the family
Good8011.31.00
Medium68914.71.36 (0.66-2.80)p=0.411
Poor7517.31.65 (0.66-4.13)p=0.281
Family type
Both parents63614.21.00
Parents and relatives18715.01.07 (0.68-1.69)p=0.778
Single-parent family2524.01.92 (0.75-4.93)p=0.177
SE status of area of resid.
Good47910.91.00
Medium15222.42.37 (1.47-3.82)p=0.000
Poor21917.41.72 (1.10-2.71)p=0.018
Type of residence community
Urban32613.51.00
Suburban14912.10.88 (0.49-1.58)p=0.671
Rural36716.31.25 (0.82-1.91)p=0.295
Demographic factors
Mother’s age
35 years and more31512.11.00
30-34 years36414.01.19 (0.76-1.86)p=0.454
do 29 years16820.21.85 (1.11-3.07)p=0.017
Father’s age
40 years and more17215.71.00
35-39 years3059.50.56 (0.32-0.99)p=0.046
30-34 years28818.41.21 (0.73-2.01)p=0.459
do 29 years7617.11.11 (0.54-2.29)p=0.781
Child sequence
First child41611.81.00
Second or latter43217.41.57 (1.07-2.32)p=0.022
Number of children
One child23614.11.00
Two or more61214.71.02(0.67-1.57)p=0.912
Gender of the child
Female14.34131.00
Male43714.91.05 (0.72-1.54)p=0.808
Knowledge
Good36912.51.00
Poor48216.21.36 (0.92-2.01)p=0.129
Information source
Books, med. staff37112.91.00
Internet, magazines, TV27217.61.43 (0.93-2.21)p=0.102
None, friends, relatives20213.41.03 (0.62-1.71)p=0.900
Motivational factors and social norms
Child vulnerability
High60714.21.00
Low23615.31.09 (0.72-1.66)p=0.687
Injury severity
Severe66911.21.00
Not severe16127.32.98 (1.95-4.54)p=0.000
Safety measure efficacy
Very effective73111.91.00
Not very effective11430.73.28 (2.08-5.18)p=0.000
Self-efficacy
Very self-effective2827.81.00
Not very selfeffective56517.92.57 (1.58-4.18)p=0.000
Social norms
Very important63711.61.00
Not very important20323.22.29 (1.53-3.44)p=0.000

Ntot . = total number of observations;

Noat = number of parents within the category

Table 3

Logistic regression models with odds ratios (OR) and 95% confidence intervals (95% C.I.) of the non-use of a child car seat according to socio-economic and other characteristics of a family.

Not using a child car seat
Model 1 OR (95% C.I.)Model 2 OR (95% C.I.)Model 3 OR (95% C.I.)
Socio-economic factors
Mother’s education
University1.001.001.00
College3.15 (1.62-6.09)***2.84 (1.43-5.65)**2.77 (1.31-5.83)**
Secondary1.89 (0.94-3.78)1.56 (0.76-3.21)1.40 (0.64-3.06)
Vocational or less3.63 (1.71-7.69)***3.34 (1.53-7.32)**3.91 (1.67-9.13)**
Father’s education
University1.001.001.00
College0.86 (0.39-1.90)0.82 (0.36-1.86)0.73 (0.30-1.79)
Secondary1.31 (0.65-2.64)1.28 (0.61-2.65)1.32 (0.60-2.89)
Vocational or less1.19 (0.57-2.50)1.02 (0.47-2.22)1.01 (0.44-2.29)
Material welfare of the family
Good1.001.001.00
Medium0.89 (0.41-1.90)0.84 (0.39-1.84)0.64 (0.28-1.46)
Poor0.84 (0.31-2.26)0.80 (0.28-2.26)0.51 (0.17-1.57)
Family type
Both parents1.001.001.00
Parents and relatives0.85 (0.52-1.40)0.83 (0.50-1.40)0.84 (0.48-1.49)
Single-parent family2.12 (0.78-5.77)2.59 (0.89-7.51)3.38 (1.09-10.52)*
SE status of area of resid.
Good1.001.001.00
Medium2.04 (1.22-3.39)**2.01 (1.18-3.41)**2.32 (1.30-4.15)**
Poor1.44 (0,89-2.33)1.54 (0.93-2.55)1.87 (1.07-3.23)*
Type of residence community
Urban1.001.001.00
Suburban0.72 (0.39-1.34)0.71 (0.37-1.35)0.64 (0.32-1.29)
Rural0.99 (0.62-1.57)0.88 (0.55-1.43)0.87 (0.52-1.47)
Demographic factors
Mother’s age
35 years and more1.001.00
30-34 years1.22 (0.70-2.14)1.05 (0.57-1.93)
do 29 years1.87 (0.89-3.93)1.66 (0.74-3.74)
Father’s age
40 years and more1.001.00
35-39 years0.53 (0.29-0.99)*0.62 (0.31-1.22)
30-34 years1.11 (0.57-2.15)1.51 (0.73-3.12)
do 29 years0.85 (0.33-2.20)0.85 (0.30-2.42)
Child sequence
First child1.001.00
Second or latter3.45 (1.76-6.77)***3.53 (1.73-7.23)***
Number of children
One child1.001,00
Two or more0.58 (0.29-1.17)0.58 (0.27-1.23)
Gender of the child
Female1,001,00
Male0.98 (0.64-1.49)0.97 (0.61-1.54)
Knowledge
Good1.001.00
Poor1.24 (0.81-1.92)1.10 (0.68-1.77)
Information source
Books, med. staff1.001.00
Internet, magazines, TV1.24 (0.76-2.01)1.21 (0.71-2.04)
None, friends, relatives0.80 (0.46-1.40)0.81 (0.44-1.49)
Motivational factors and social norms
Child vulnerability
High1.00
Low0.72 (0.42-1.24)
Injury severity
Severe1.00
Not severe2.35 (1.35-4.10)*
Safety measure efficacy
Very effective1.00
Not very effective2.59 (1.41-4.76)**
Self-efficacy
Very self-effective1,00
Not very self-effective1.69 (0.98-2.93)
Social norms
Very important1.00
Not very important1.72 (1.03-2.87)*
Hosmer Lemeshow goodness of fit testp=0.989p=0.572p=0.923
Likelihood ratio testp=0.000p=0.006 (Model 2 : Model 1)p=0.000 (Model 3 : Model 2)

4 Discussion

Our research on the behaviour of parents regarding the implementation of safety measures in families with young children confirmed the assumption that low (vocational) maternal education is significantly associated with the non-use of a child car seat during the short rides; however, the association with father’s low education was not significant.

Families with mothers with vocational education had higher odds of not using a car seat during short rides compared to families where mothers had a university degree, which is consistent with the findings of most authors (7, 9, 10, 14). At the same time, our results reveal significant differences between families with highly educated parents, since families where mothers had a college degree had higher odds of not using a car seat compared to families where mothers had a university degree. Parents with lower education level had significantly worse material status compared to parents with university education; they had less knowledge and were more likely to consult less reliable sources of information on child injury prevention, such as their relatives and friends, which is also reported by other studies (10, 14, 18). After controlling for material status and other factors in the model, it is obvious that other parents’ characteristics, which are related to education, also influence the nonuse of a car seat. E.g., parents with low education less frequently believe that child injuries are preventable (19); they have wrong beliefs about the invulnerability of their children (20) and are therefore not aware of the importance of ensuring child safety. The differences between families with less and highly educated mothers could be associated with other components of cultural capital, like embodied knowledge, cognitive abilities, skills and competencies (21), higher trust in one’s own efficiency for solving problems and stronger motivation (22) of mothers with university degrees.

Family type was also an important factor for the non-use of a child car seat. Single-parent families had higher odds of not using a car seat than families with both parents, which is consistent with the results of some authors (23), while most of them could not prove this premise (7, 8, 10). Authors report that poor implementation of safety measures in single-parent families is associated mainly with their worse material status (23, 24) and their inability to purchase an expensive child car seat (7, 14). However, our results did not confirm this assumption, because family type was significant despite controlling for material status and other factors. This is probably due to the combination of material and social dimension of deprivation (25).Therefore, the behaviour of single-parent families may be influenced by their weak social networks, which does not offer single mothers enough instrumental support from relatives and friends in terms of child care, child transportation and financial or informational assistance (26). Social isolation could also have a negative influence on the opportunity to borrow a car seat, which is a common way to acquire expensive safety equipment in low-income Slovenian families (27).

The association between the non-use of a child car seat and material status of a family was not significant, even though authors report that the non-use of a child car seat is more frequent in low-income families, since car seats are expensive and families with lower SE status have difficulties buying them (7, 8, 14). The lack of disparity in child restraint use due to different material statuses of familiesis likely to be a reflection of a good social policy in Slovenia, which may improve poor families’ financial abilities to buy child car seats. We also assume that families buy child car seats despite their poor material statuses, or they borrow them from relatives or friends, because this is a necessary prerequisite for following the traffic safety regulation.

Families living in areas with poor and medium SE status had higher odds of not using a child car seat compared to families living in areas with good SE status, which is also reported by other authors (28, 29). Our study confirmed an independent influence of the area SE status, therefore the differences in unsafe behaviour between areas are not only the result of geographical clustering of families with similar characteristics, as claimed by some authors (30). We assume that families who live in poor areas have less opportunities to borrow child car seats because the ‘demand’ is higher than the ‘offer.’ It is also possible that risky behaviour of parents is influenced merely by living in the environment with poor ‘culture of safety’ and thus those parents are not aware of childhood injury risks (10). In such an environment, people generally believe that injuries can rarely be prevented because they are the result of an unfortunate coincidence. In areas with medium SE status, which were predominantly rural, parents’ behaviour might be influenced also by other factors, related to area of residence. E.g., lower seat belt usage was reported in areas with low population density (31) and in areas where drivers had a lower perceived risk of being ticketed (32).

The strength of the study is in high parental responsiveness, which greatly reduces bias due to the self-selection of respondents and corresponding difference reduction in odds of parental unsafe behaviour. The study did not involve the data collection on non-participant parents, therefore we were not able to assess the difference between them and participants; however, educational structures of mothers from the study and from Birth registry (33) are very similar, which indicates good representativeness of the sample. By using multivariable analysis in three models, we were able to show that adding demographic factors, motivational factors and social norms to the basic model of SE factors has improved each model’s fit to data. Potential interaction effects among individual SE factors and between SE factors and motivational factors/social norms were not significant; therefore, the change in odds ratios in the models is likely to be attributed to confounding variables. These findings revealed the importance of examining motivational factors and social norms as determinants of parents’ behaviour regarding the use of child safety equipment.

The study has some limitations. First, the sample included a small number of single-parent families (3%) compared to the proportion of single women (18%) noted in the Birth registry (33). In the study, we asked with whom the child lived, therefore it is possible that a certain share of single mothers answered that the child and herself were staying with her parents or other relatives – in extended family. We also assume that the status of single women could change in the three-year period after the child was born, and that they possibly lived with partners at the time of the research. Nonetheless, it is realistic to expect that women in single-parent families bring their children to preventive well-child visits less frequently compared to parents from other family types, because of higher work overload and lack of help due to weak social networks (34). Second, a self-administered questionnaire was used, therefore parents might give socially desirable responses about the implementation of safety measures, which could cause some bias due to the misclassification of the outcome, and reduce the differences in unsafe behaviour. Despite that, we decided to use a selfadministered questionnaire, because it ensures better anonymity compared to a personal interview, and thus the respondents are more open about socially undesirable behaviours, even though the questions are about sensitive or threatening health care practices (35). In addition to that, the questionnaire did not include any personal data, which would allow for the identification of the child or parents. Studies so far found a high degree of consistency between self-reported safety practices and actual observations (36), and the prevalence of the non-use of a child car seat in our study was very similar to child restraint use measure on Slovenian roads (4).Therefore, we assume that self-reported data in our study are reliable enough. Third, we were unable to prove the independent influence of child’s vulnerability on car seat use. It is possible that some parents did not quite understand the question on the risk of their child to be injured in a car crash, which was asked hypothetically, if a child would not be restrained in a car seat during a car ride. If parents who did use a car seat missed this, they might assess that the risk for their child’s injury was small, which could lead to the reduction of differences in car seat use.

The study findings about the impact of SE factors on parents’ safeguarding behaviour will contribute to a more effective design and implementation of child passenger safety interventions in Slovenia and other comparable countries. Despite the fact that since 1998, we have a law on the mandatory use of safety seats for children’s car transportation in Slovenia, our results show that 15% of parents decide not to use child car seat during short rides, wherein parents’ low education is not the only SE risk factor. Highly educated parents and single parents also have higher odds of unsafe behaviour. This is the reason why we need to introduce a new counselling programme for all parents during routine well-child visits (37). We assume that parents underestimate the danger of collision during rides near home, and by this they also underestimate the severity of child’s injuries and the effectiveness of a safety car seat, as shown in our results. Therefore, information for the parents should be primarily aimed at clarifying the facts on child passenger injury risk and the effectiveness of the child car seat. For less educated parents, individually tailored injury prevention counselling is recommended, which would be designed according to individual’s needs and characteristics, and thus parents will be more motivated and likely to use the car seat even during short rides (38). The most successful programmes include the combination of education and hands-on training on how to properly use the child car seat (39, 40), and they could be implemented during routine well-child visits (37). The advantage of integrating such programmes into well-child care is that they can reach all families, including the ones that may not be using a car seat and therefore do not seek counselling by themselves (37). Inequalities due to unsafe behaviour associated with financial incapacity and social isolation could be further reduced with the provision and installation of free child car seats (40, 41) for eligible families receiving public assistance and single-parent families.

Motivational factors have a great impact on singleparent families’ decision to use the car seat. Thus, further research is needed to understand the facilitators and barriers for parents’ safe behaviour, which would significantly contribute to designing more effective child passenger safety promotion interventions for vulnerable families. Some other determinants of parents’ behaviour, such as perceived risk of being ticketed, descriptive social norms, availability and accessibility of safety equipment, should be examined too.

5 Conclusion

Low (vocational) maternal education attainment is associated with unsafe parents’ behaviour regarding the use of a child car seat during short rides. However, low maternal education is not the only SE risk factor, since families with college-educated mothers, single parents and families living in areas with poor and medium SE status are associated with the non-use of a child car seat too. In general, the prevalence of the child car seat use is low, thus counselling programmes in combination with hands-on training on how to properly install and use child car seat should be introduced for all parents in the framework of well-child care. Information for the parents should have an emphasis on the facts regarding child passenger injury risk and on the effectiveness of a car seat. Inequalities due to unsafe behaviour associated with low education, financial incapacity and social isolation could be reduced with individually tailored counselling and provision of free child car seats for eligible families and single-parent families.

Acknowledgements

The authors express gratitude to the parents and employees of outpatient clinics for children’s healthcare across Slovenia for successful cooperation in the survey.

Conflicts Of Interest

The authors declare that no conflicts of interest exist.

Funding

The study was financed by the National Institute of Public Health.

Ethical Approval

Received from the National Medical Ethics Committee of the Republic of Slovenia (No. 82/11/12).

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    Laflamme L, Hasselberg M, Burrows S. 20 years of research on socioeconomic inequality and children’s unintentional injuries - understanding the cause-specific evidence at hand. Int J Pediatr 2010; pii 819687.

    • PubMed
    • Export Citation
  • 6

    Towner E, Dowswell T, Emington G, Burkes M, Towner J. Injuries in children aged 0-14 years and inequalities. London: Health Development Agency, 2005.

  • 7

    Schluter PJ, Paterson J. Vehicle child restraint usage for Pacific children aged 6 weeks to 4 years: findings from the Pacific Islands Families study. Accid Anal Prev 2010; 42: 2075-81.

    • Crossref
    • PubMed
    • Export Citation
  • 8

    Yanchar NL, Kirkland SA, LeBlanc JC, Langille DB. Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia – a population–based study. Accid Anal Prev 2012; 45: 326-33.

    • Crossref
    • PubMed
    • Export Citation
  • 9

    Chen X, Yang J, Peek-Asa C, McGehee DV, Li L. Parents’ knowledge, attitude and use of child restraints, Shantou, China. Am J Prev Med 2014; 46: 85-8.

    • Crossref
    • PubMed
    • Export Citation
  • 10

    Snowdon AW, Hussein AA, Ahmed SE. Children at risk: predictors of car safety seat misuse in Ontario. Accid Anal Prev 2008; 40: 1418-23.

    • Crossref
    • PubMed
    • Export Citation
  • 11

    Macy ML, Cunningham RM, Resnicow K, Freed GL. Disparities in ageappropriate child passenger restraint use among children aged 1 to 12 years. Pediatrics 2014; 133: 262-71.

    • Crossref
    • Export Citation
  • 12

    Keay L, Hunter K, Brown J, Bilston LE, Simpson JM, Stevenson M. et al. Child restaint use in low socio-economic areas of urban Sydney during transition to new legislation. Accid Anal Prev 2013; 50: 984-91.

    • Crossref
    • Export Citation
  • 13

    Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Too small for seatbelt: predictors of booster seat use by child passengers. Pediatrics 2003; 111: 323-7.

    • Crossref
    • Export Citation
  • 14

    O’Neil J, Daniels DM, Talty JL, Bull MJ. Seat belt misuse among children transported in belt-positioning booster seats. Accid Anal Prev 2009; 41: 425-9.

    • Crossref
    • PubMed
    • Export Citation
  • 15

    Kakefuda I, Yamanaka T, Stallones L, Motomora Y, Nishida Y. Child restraint seat use behavior and attitude among Japanese mothers. Accid Anal Prev 2008; 40: 1234-43.

    • Crossref
    • PubMed
    • Export Citation
  • 16

    Lemeshow S, Robinson D. Surveys to measure programme coverage and impact: A review of the methodology used by the Expanded Programme on Immunization. World Health Stat Q 1985; 38: 65-75.

    • PubMed
    • Export Citation
  • 17

    Rogers RW. Cognitive and physiological processes in fear appeals and attitude change: a revised theory of protection motivation. In: Cacioppo JT, Petty RE, editors. Social psychophysiology. New York: Guilford, 1983: 153-76.

  • 18

    Koppel S, Muir C, Budd L, Devlin A, Oxley J, Charlton JL, Newstead S. Parents’ attitudes, knowledge and behaviours relating to safe child occupant travel. Accid Anal Prev 2013; 51: 18-26.

    • Crossref
    • PubMed
    • Export Citation
  • 19

    Girasek DC. Public beliefs about the preventability of unintentional injury deaths. Accid Anal Prev 2001; 33: 455-65.

    • Crossref
    • PubMed
    • Export Citation
  • 20

    Will KE. Child passenger safety and the immunity fallacy: why what we are doing is not working. Accid Anal Prev 2005; 37: 947-55.

    • Crossref
    • PubMed
    • Export Citation
  • 21

    Kamin T, Kolar A, Steiner PM. The role of cultural capital in producing good health: a propensity score study. Zdr Varst 2013; 52: 108-18.

  • 22

    Leganger A, Kraft P. Control constructs: do they mediate the relation between educational attainment and health behaviour? J Health Psychol 2003; 8: 361-72.

    • Crossref
    • PubMed
    • Export Citation
  • 23

    Ueland O, Kraft P. Safety measures taken by Norwegian mothers. Inj Prev 1996; 2: 197-201.

    • Crossref
    • PubMed
    • Export Citation
  • 24

    Weitoft GR, Haglund B, Hjern A, Rosen M. Mortality, severe morbidity, and injury among long-term lone mothers in Sweden. Int J Epidemiol 2002; 31: 573-80.

    • Crossref
    • PubMed
    • Export Citation
  • 25

    Leskošek V. Social determinants of health: the indicators for measuring the impact of poverty on health. Zdr Varst 2012; 51: 21-32.

  • 26

    Leininger LJ, Ryan RM, Kalil A. Low-income mothers’ social support and children’s injuries. Soc Sci Med 2009; 68: 2113-21.

    • Crossref
    • PubMed
    • Export Citation
  • 27

    Rok-Simon M. Stališča staršev novorojenčkov glede uporabe avtomobilskega sedeža. Zdr Varst 2004; 43: 19-28.

  • 28

    Brixey S, Guse CE, Meurer J. Booster seat use in inner-city day care center population. Traffic Inj Prev 2008; 9: 238-42.

    • Crossref
    • PubMed
    • Export Citation
  • 29

    Hapgood R, Kendrick D, Marsh P. How well do socio-demographic characteristics explain variation in childhood safety practices? J Public Health Med 2000; 22: 307-11.

    • Crossref
    • PubMed
    • Export Citation
  • 30

    Reading R, Jones A, Haynes R, Daras K, Emond A. Individual factors explain neighbourhood variations in accidents to children under 5 years of age. Soc Sci Med 2008; 67: 915-27.

    • Crossref
    • PubMed
    • Export Citation
  • 31

    Strine TW, Beck LF, Bolen J, Okoro C, Dhingra S, Balluz L. Geographic and sociodemographic variation in self-reported seat belt use in the United States. Accid Anal Prev 2010; 42: 1066-71.

    • Crossref
    • PubMed
    • Export Citation
  • 32

    Chaudhary NK, Solomon MG, Cosgrove LA. The relationship between perceived risk of being ticketed and self-reported seat belt use. J Safety Res 2004; 35: 383-90.

    • Crossref
    • PubMed
    • Export Citation
  • 33

    Mihevc Ponikvar B, Rudolf A. Perinatalni informacijski sistem Republike Slovenije: primerjava podatkov med regijami za leto 2010. Ljubljana: Inštitut za varovanje zdravja Republike Slovenije, 2012.

  • 34

    Kanjuo Mrčela A, Ignjatović M. Women, work and health. Zdr Varst 2013; 52: 137-47.

  • 35

    Aday LA, Cornelius LJ. Designing and conducting health surveys: a comprehensive guide. 3rd ed. San Francisco: Jossey-Bass, 2006.

  • 36

    Durbin DR, Kallan MJ, Winston FK. Trends in booster seat use among young children in crashes. Pediatrics 2001; 108: e109.

    • Crossref
    • PubMed
    • Export Citation
  • 37

    Quinlan KP, Holden J, Kresnow M. Providing car seat checks with well-child visits at an urban health center: a pilot study. Inj Prev 2007; 13: 352-4.

    • Crossref
    • Export Citation
  • 38

    Nansel TR, Weaver NL, Jacobsen HA, Glasheen C, Kreuter MW. Preventing unintentional pediatric injuries: a tailored intervention for parents and providers. Health Educ Res 2008; 23: 656-69.

    • PubMed
    • Export Citation
  • 39

    Tessier K. Effectiveness of hands-on education for correct child restraint use by parents. Accid Anal Prev 2010; 42: 1041-7.

    • Crossref
    • PubMed
    • Export Citation
  • 40

    Gittelman MA, Pomerantz WJ, Laurence S. An emergency department intervention to increase booster seat use for lower socioeconomic families. Acad Emerg Med 2006; 13: 396-400.

    • Crossref
    • PubMed
    • Export Citation
  • 41

    Brixey S, Guse CE, Ngui E. Free child passenger restraints for patients in an urban pediatric medical home: effects on caregiver behaviour. WMJ 2009; 108: 352-8.

Footnotes

******

Statistically significant at p≤0.001

****

Statistically significant at p≤0.01;

****

Statistically significant at p≤0.01;

******

Statistically significant at p≤0.001

****

Statistically significant at p≤0.01;

****

Statistically significant at p≤0.01;

**

Statistically significant at p<0.05;

****

Statistically significant at p≤0.01;

****

Statistically significant at p≤0.01;

****

Statistically significant at p≤0.01;

**

Statistically significant at p<0.05;

**

Statistically significant at p<0.05;

******

Statistically significant at p≤0.001

******

Statistically significant at p≤0.001

**

Statistically significant at p<0.05;

****

Statistically significant at p≤0.01;

**

Statistically significant at p<0.05;

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1

    MacKay M, Vincenten J. Child Safety Report Card 2012: Europe Summary for 31 Countries. Birmingham: European Child Safety Alliance, Eurosafe, 2012.

  • 2

    Ma X, Layde P, Zhu S. Association between child restraint systems use and injury in motor vehicle crashes. Acad Emerg Med 2012; 19; 916-23.

    • Crossref
    • PubMed
    • Export Citation
  • 3

    Rice TM, Anderson CL. The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collision: 1996-2005. Am J Public Health 2009; 99: 252-7.

    • Crossref
    • Export Citation
  • 4

    Bilban M. Uporaba varnostnega pasu in prometna varnost. Delo Varnost 2014; 3: 48-54.

  • 5

    Laflamme L, Hasselberg M, Burrows S. 20 years of research on socioeconomic inequality and children’s unintentional injuries - understanding the cause-specific evidence at hand. Int J Pediatr 2010; pii 819687.

    • PubMed
    • Export Citation
  • 6

    Towner E, Dowswell T, Emington G, Burkes M, Towner J. Injuries in children aged 0-14 years and inequalities. London: Health Development Agency, 2005.

  • 7

    Schluter PJ, Paterson J. Vehicle child restraint usage for Pacific children aged 6 weeks to 4 years: findings from the Pacific Islands Families study. Accid Anal Prev 2010; 42: 2075-81.

    • Crossref
    • PubMed
    • Export Citation
  • 8

    Yanchar NL, Kirkland SA, LeBlanc JC, Langille DB. Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia – a population–based study. Accid Anal Prev 2012; 45: 326-33.

    • Crossref
    • PubMed
    • Export Citation
  • 9

    Chen X, Yang J, Peek-Asa C, McGehee DV, Li L. Parents’ knowledge, attitude and use of child restraints, Shantou, China. Am J Prev Med 2014; 46: 85-8.

    • Crossref
    • PubMed
    • Export Citation
  • 10

    Snowdon AW, Hussein AA, Ahmed SE. Children at risk: predictors of car safety seat misuse in Ontario. Accid Anal Prev 2008; 40: 1418-23.

    • Crossref
    • PubMed
    • Export Citation
  • 11

    Macy ML, Cunningham RM, Resnicow K, Freed GL. Disparities in ageappropriate child passenger restraint use among children aged 1 to 12 years. Pediatrics 2014; 133: 262-71.

    • Crossref
    • Export Citation
  • 12

    Keay L, Hunter K, Brown J, Bilston LE, Simpson JM, Stevenson M. et al. Child restaint use in low socio-economic areas of urban Sydney during transition to new legislation. Accid Anal Prev 2013; 50: 984-91.

    • Crossref
    • Export Citation
  • 13

    Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Too small for seatbelt: predictors of booster seat use by child passengers. Pediatrics 2003; 111: 323-7.

    • Crossref
    • Export Citation
  • 14

    O’Neil J, Daniels DM, Talty JL, Bull MJ. Seat belt misuse among children transported in belt-positioning booster seats. Accid Anal Prev 2009; 41: 425-9.

    • Crossref
    • PubMed
    • Export Citation
  • 15

    Kakefuda I, Yamanaka T, Stallones L, Motomora Y, Nishida Y. Child restraint seat use behavior and attitude among Japanese mothers. Accid Anal Prev 2008; 40: 1234-43.

    • Crossref
    • PubMed
    • Export Citation
  • 16

    Lemeshow S, Robinson D. Surveys to measure programme coverage and impact: A review of the methodology used by the Expanded Programme on Immunization. World Health Stat Q 1985; 38: 65-75.

    • PubMed
    • Export Citation
  • 17

    Rogers RW. Cognitive and physiological processes in fear appeals and attitude change: a revised theory of protection motivation. In: Cacioppo JT, Petty RE, editors. Social psychophysiology. New York: Guilford, 1983: 153-76.

  • 18

    Koppel S, Muir C, Budd L, Devlin A, Oxley J, Charlton JL, Newstead S. Parents’ attitudes, knowledge and behaviours relating to safe child occupant travel. Accid Anal Prev 2013; 51: 18-26.

    • Crossref
    • PubMed
    • Export Citation
  • 19

    Girasek DC. Public beliefs about the preventability of unintentional injury deaths. Accid Anal Prev 2001; 33: 455-65.

    • Crossref
    • PubMed
    • Export Citation
  • 20

    Will KE. Child passenger safety and the immunity fallacy: why what we are doing is not working. Accid Anal Prev 2005; 37: 947-55.

    • Crossref
    • PubMed
    • Export Citation
  • 21

    Kamin T, Kolar A, Steiner PM. The role of cultural capital in producing good health: a propensity score study. Zdr Varst 2013; 52: 108-18.

  • 22

    Leganger A, Kraft P. Control constructs: do they mediate the relation between educational attainment and health behaviour? J Health Psychol 2003; 8: 361-72.

    • Crossref
    • PubMed
    • Export Citation
  • 23

    Ueland O, Kraft P. Safety measures taken by Norwegian mothers. Inj Prev 1996; 2: 197-201.

    • Crossref
    • PubMed
    • Export Citation
  • 24

    Weitoft GR, Haglund B, Hjern A, Rosen M. Mortality, severe morbidity, and injury among long-term lone mothers in Sweden. Int J Epidemiol 2002; 31: 573-80.

    • Crossref
    • PubMed
    • Export Citation
  • 25

    Leskošek V. Social determinants of health: the indicators for measuring the impact of poverty on health. Zdr Varst 2012; 51: 21-32.

  • 26

    Leininger LJ, Ryan RM, Kalil A. Low-income mothers’ social support and children’s injuries. Soc Sci Med 2009; 68: 2113-21.

    • Crossref
    • PubMed
    • Export Citation
  • 27

    Rok-Simon M. Stališča staršev novorojenčkov glede uporabe avtomobilskega sedeža. Zdr Varst 2004; 43: 19-28.

  • 28

    Brixey S, Guse CE, Meurer J. Booster seat use in inner-city day care center population. Traffic Inj Prev 2008; 9: 238-42.

    • Crossref
    • PubMed
    • Export Citation
  • 29

    Hapgood R, Kendrick D, Marsh P. How well do socio-demographic characteristics explain variation in childhood safety practices? J Public Health Med 2000; 22: 307-11.

    • Crossref
    • PubMed
    • Export Citation
  • 30

    Reading R, Jones A, Haynes R, Daras K, Emond A. Individual factors explain neighbourhood variations in accidents to children under 5 years of age. Soc Sci Med 2008; 67: 915-27.

    • Crossref
    • PubMed
    • Export Citation
  • 31

    Strine TW, Beck LF, Bolen J, Okoro C, Dhingra S, Balluz L. Geographic and sociodemographic variation in self-reported seat belt use in the United States. Accid Anal Prev 2010; 42: 1066-71.

    • Crossref
    • PubMed
    • Export Citation
  • 32

    Chaudhary NK, Solomon MG, Cosgrove LA. The relationship between perceived risk of being ticketed and self-reported seat belt use. J Safety Res 2004; 35: 383-90.

    • Crossref
    • PubMed
    • Export Citation
  • 33

    Mihevc Ponikvar B, Rudolf A. Perinatalni informacijski sistem Republike Slovenije: primerjava podatkov med regijami za leto 2010. Ljubljana: Inštitut za varovanje zdravja Republike Slovenije, 2012.

  • 34

    Kanjuo Mrčela A, Ignjatović M. Women, work and health. Zdr Varst 2013; 52: 137-47.

  • 35

    Aday LA, Cornelius LJ. Designing and conducting health surveys: a comprehensive guide. 3rd ed. San Francisco: Jossey-Bass, 2006.

  • 36

    Durbin DR, Kallan MJ, Winston FK. Trends in booster seat use among young children in crashes. Pediatrics 2001; 108: e109.

    • Crossref
    • PubMed
    • Export Citation
  • 37

    Quinlan KP, Holden J, Kresnow M. Providing car seat checks with well-child visits at an urban health center: a pilot study. Inj Prev 2007; 13: 352-4.

    • Crossref
    • Export Citation
  • 38

    Nansel TR, Weaver NL, Jacobsen HA, Glasheen C, Kreuter MW. Preventing unintentional pediatric injuries: a tailored intervention for parents and providers. Health Educ Res 2008; 23: 656-69.

    • PubMed
    • Export Citation
  • 39

    Tessier K. Effectiveness of hands-on education for correct child restraint use by parents. Accid Anal Prev 2010; 42: 1041-7.

    • Crossref
    • PubMed
    • Export Citation
  • 40

    Gittelman MA, Pomerantz WJ, Laurence S. An emergency department intervention to increase booster seat use for lower socioeconomic families. Acad Emerg Med 2006; 13: 396-400.

    • Crossref
    • PubMed
    • Export Citation
  • 41

    Brixey S, Guse CE, Ngui E. Free child passenger restraints for patients in an urban pediatric medical home: effects on caregiver behaviour. WMJ 2009; 108: 352-8.

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