Analysis of factors influencing the use of child restraint system by parents of children aged 0–6 years: an information, motivation, behavioral skills model-based cross-sectional study

In recent years, private automobiles have displaced public transportation as children's principal source of transportation [1]. The ever-increasing complexity of the traffic situation on the roadways posed a grave threat to the safety of children [2]. Approximately 10,000 children die annually from traffic-related injuries on Chinese roadways [3], with children aged 0 to 6 years old accounting for 60% of these deaths and riding accounting for 44% of all fatalities [4]. Over the past 10 years, child fatalities without use of the CRS have accounted for a higher proportion of child traffic injury deaths, averaging 43.9% [5]. In addition, studies have shown that infants and children who did not use CRS in vehicles are three times more likely to be injured and up to eight times more likely to die [6]. Due to parental neglect or inappropriate usage of Child Restraint Systems (CRS), the number of children injured while riding in automobiles continued to increase [7].

CRS has the potential to significantly lower infant mortality rates by more than 60% [8]. Most countries in the EU have legislation mandating the use of safety restraints for children traveling in cars, and CRS use rates in these countries have generally reached 90% after the legislation [9], and countries have seen significant decreases in child passenger injuries, such as the United States and Germany, where the number of child road traffic deaths has decreased by about 50%, only 76 children died in cars in Germany in 2011 [10]. However, less than 20% of CRS utilization occurred in China, which was significantly lower than the 90% utilization rate in other countries [11, 12]. In an effort to boost the utilization rate of CRS in China, the newly revised "Law on the Protection of Minors" includes CRS for the first time in national legislation in June 2022 [13]. In addition, the "Guidelines for Development of Chinese Children (2021–2030)" issued by the State Council mandated that CRS will be promoted and implemented in September 2022 [14]. However, CRS legislation has just been put into effect, and no appropriate sanctions have been put in place to enforce its usage. The legislation has to be further improved and publicized. Under the background of the introduction of legislation, the strategies of improving the use of CRS should be explored. Nevertheless, there were few studies on the factors affecting the use of CRS in China [15].

Information, Motivation, and Behavioral Skills model (IMB), one of the widely used theories for comprehending and assessing health behaviors, contained three components: information, motivation, and behavior skills [16]. Personal and social motivation includes attitude and social support, respectively. Behavioral skills consist of personal objective skills for performing the behavior and a perceived sense of self-efficacy [17]. This model posits that information and motivation influence behaviors directly or indirectly while behavioral skills directly influence behaviors [18]. The usefulness of IMB model has been proven continuously in various fields of medical care [19‐21]. Figure 1 shows the IMB model framework used in this study.

Existing research on factors influencing parental behavior in CRS use has focused on demographic base information and parental theoretical perceptions, and there is a lack of research parents' motivation and objective skills of using CRS [22]. Research has shown that incorrectly installed CRS increases the risk of child injury and death in accidents. Since the installation of CRS is mostly done by parents and the installation is difficult, it is a very challenging job for parents. Due to the lack of installation skills, CRS installation errors often occur, which poses a huge threat to children's safety. So it is equally important to understand the objective skills of parents for CRS use [23]. In order to offer a scientific basis for further promoting the use of CRS in China, this study aimed to examine, using the IMB model, the factors that influence parents' usage of CRS for children aged 0 to 6 years.

In the present study, the CRS utilization rate was 56.1%, and the high frequency use rate was 29.0%, both of which are higher than the CRS utilization rate in the country as a whole and in other regions in China [26‐28]. This may be a result of the state's increased promotion of the benefits of CRS use in recent years [29]. However, the rate is still quite inferior to that in other countries [30]. The primary cause is the early implementation of required measures in other countries to penalize parents who did not use of CRS [31]. This finding acted as a reminder to China's relevant ministries to increase the law's universality and enforceability. Local governments and organizations also need to execute targeted penalties expeditiously to increase the CRS utilization rate.

According to research, families with strong financial standing are more likely to use CRS, which is in line with the findings of previous studies [32]. In order to address the low purchase rate caused by the price, foreign nations provided complimentary safety baskets for infants to assure their safety on the journey home [33]. In China, it is difficult to freely offer CRS to every household with children and a car due to economic concerns [34]. However, by offering discount coupons or low-cost rentals, the pertinent departments can encourage parents to buy and use CRS [35]. Furthermore, parents who have attended training on unintentional child injuries had a high rate of CRS utilization. Because those parents had more opportunities to learn about CRS knowledge [36], which also signifies that they would have greater capacity to prevent riding-related accidents in injuries to children if they possessed a greater amount and reliability of knowledge [37]. The results of the univariate analysis of this study indicated that family status was associated with CRS use. With the liberalization of the "two-child" policy, the number of children in the family increases, and family members may give up using CRS due to the narrow space in the car [38]. Therefore, in addition to educating parents, educating other family members such as grandparents and relatives is also very important. In addition, car and safety seat manufacturers should consider the interior space layout of multi-child families, and how to further optimize the design of safety seats with wide applicability and portability, so that they can play a protective role in the limited car interior space.

The study also indicated that CRS use relevant knowledge, including children's riding mode cognition and CRS type cognition, was an important factor affecting parents' use of CRS, which is in line with the findings of earlier studies [39‐41]. The likelihood and severity of a child's injury following a vehicle collision will increase if there is not an appropriate and effective restraint in the vehicle [42]. For instance, there will be significant safety risks for kids if parents sit in the back with kids in their arms and put the seat belts on them too early. Parents need to master solid knowledge to choose the right mode of transportation and the type of constraint for their children, rather than only rely on subjective judgment. Therefore, relevant departments must regularly educate parents of young children and widely disseminate pertinent information in order to decrease the incidence of riding-related injuries in kids.

Similar to the work by Li et al. [43], our study found that the use motivation of CRS, including the awareness of the serious injury caused by motor vehicle collisions to children and the parents' cognition of the use CRS benefits, are major influencing factors to promote the use of CRS. Currently, due to rapid development of the internet, information about children's injuries brought on by the improper administration of CRS can be rapidly disseminated online. Parents have a more intuitive understanding of the awareness and severity of children's riding injuries, so that they could take measures to prevent injury [44]. Additionally, the authority suggestion promotes the use of CRS, which is compatible with the research findings by Jin [45]. In Malaysia, a study on the factors influencing parents' decision to use CRS found that 42.7% of parents used CRS as a result of advice from medical professionals and nurses as well as recommendations from friends and family [46]. The possible reasons include: CRS involves a relatively professional field, it needs guidance from experts from different fields. Their guidance may be the basis and motivation to eliminate the obstacles to parents’ CRS using [47]. In addition, CRS research was just recently conducted in China, where CRS is less well known and understood by parents than those in other nations [48]. Therefore, parents in China would be strongly urged to utilize CRS for their children when they receive advise from specialists such as medical personnel and get recommendations from friends and family members nearby [45]. In the future, together with strengthening the education of parents' theoretical knowledge, improving parents' motivation must be particularly stressed.

The current study also shown that CRS was utilized more frequently if parents had greater installation skills. Parents of children in Shantou and Chaozhou kindergartens investigated by Yan et al. [49] received training in restraint systems and behavioral skills had the highest utilization rate and correct use rate of CRS, indicating that the combination of theoretical knowledge and practical operation could produce a better result than that only including knowledge component. This is consistent with the IMB's proposition [18]. Due to the professionalism and sophistication of CRS installation, the safety of children while riding would be gravely compromised if parents were unable to obtain dependable CRS installation skills [50]. Therefore, in addition to introducing information about CRS use, training on pertinent behavior skills of CRS installation, including the installation location and interface type, will be significant to encourage parents' use willingness and behavior of CRS in programs of popular science publicity and health education for parents in the future.

In summary, the study results revealed that parents' cognitive, motivation and behavioral skills of CRS have a significant impact on increasing parents' use of CRS, which provides a direction and theoretical basis for designing more targeted programs to increase the use of CRS in the future. Apart from continuing to strengthen and disseminate relevant laws and regulations, government departments also need to provide financial assistance to parents to reduce the burden of using CRS. In addition, further study needs to focus on knowledge and skill training provided by hospitals, communities, and child care centers. In the meantime, healthcare professionals and experts in various fields should give full play to their guiding role, inspire parents to use CRS, and raise their awareness of safety precautions.