AJPH OPEN-THEMED RESEARCH

Parent-Based Intervention to Improve Child

Restraint Use Among Kindergarteners in China
Huiqian Lei, MD, Ran Gao, MD, Jingzhen Yang, PhD, and Liping Li, PhD

Objectives. To evaluate the effectiveness of parent-based child restraint system (CRS) plus hands-on CRS installation training, and
education and hands-on CRS installation training. control. All of the parents from the same
Methods. We conducted a randomized trial with cluster sampling from May 2016 to kindergarten received the same study
January 2017 in 6 selected kindergarten classes in Shantou and Chaozhou, China. Parents condition.
Eligible parents were those who (1) had
were randomly assigned to receive 1 of the 3 study conditions: CRS education only, CRS
a child aged 2 to 5 years, (2) were living in
education plus hands-on CRS installation training, or control (child electricity safety).
Shantou or Chaozhou for more than 6
Results. Three months after the intervention, significantly higher CRS use was re-
months, (3) owned a car and had no CRS,
ported in the CRS education plus hands-on CRS installation training group than was and (4) had a valid driver’s license. Parents
reported in the control group (41.2% vs 18.5%; P = .011). However, no significant dif- who had already bought a CRS or were
ference in CRS use was found between the CRS education only and the control groups unable to read or write were excluded. A total
(26.7% vs 18.5%; P = .33). The ratings on child passenger safety awareness increased of 328 parents in the 6 kindergarten classes
significantly in both intervention groups but remained unchanged in the control group were invited to participate in the study. Of
after the intervention. these, 177 parents who met the inclusion
Conclusions. The CRS education plus hands-on CRS installation training increased the criteria were enrolled in the study). Of these,
use of child restraints, but the CRS education only condition did not. Both intervention 52 were in the CRS education only group,
methods helped to improve child passenger safety awareness. (Am J Public Health. 60 were in the CRS education plus hands-on
CRS installation training group, and 65 were
2018;108:1524–1526. doi:10.2105/AJPH.2018.304650)
in the control group. Three months after the
intervention, 27 parents were lost to follow-
up. Of the 150 remaining parents who

C hild restraint systems (CRSs) have been

effective in reducing deaths and injuries
in children in motor vehicle crashes.1,2 Nu-
merous intervention efforts, including child
passenger restraint laws, have been made in
China to increase CRS use.3,4 Although
China does not have a national law, 1
province (Shandong) and 3 cities (Shanghai,
Hangzhou, and Shenzhen) have enacted child
passenger restraint laws since 2015. Currently,
the rates of CRS use in areas with the laws
range from 16% to 27%, but the rates are
lower than 1% in Shantou where such a law is
lacking.5 The main reason for low CRS
use was lack of parental awareness of CRSs.
Recent evidence shows that education
combined with free child safety seats led
to an increase in CRS use among parents
of newborns.6
We evaluated the effectiveness of
parent-based CRS education with and
without a hands-on CRS installation training
program implemented in kindergarten classes.
We hypothesized that CRS education would
improve CRS use and that augmenting
CRS education with hands-on CRS in-
stallation training would further improve
the outcomes.
completed the follow-up, 45 were in the
CRS education group, 51 were in the CRS
education plus hands-on CRS installation
training group, and 54 were in the control
group.
METHODS Interventions
We conducted a randomized trial with The CRS education only group received
cluster sampling from May 2016 to January the following: (1) a pamphlet on child pas-
2017. Six kindergarten classes were conve- senger safety and CRS legislation, (2) two
niently selected from the 2 medium- to 5-minute videos (1 displayed road traffic
small-sized cities located in eastern China: crash outcomes with and without the CRS,
Shantou and Chaozhou. We then randomly and another showed how to use a CRS
assigned the selected kindergartens (3 from correctly), and (3) a 30-minute lecture on
each city) into 1 of 3 study groups, with child passenger safety.
randomization occurring at the kindergarten The CRS education plus hands-on
level: CRS education only, CRS education CRS installation training group received the
ABOUT THE AUTHORS
Huiqian Lei, Ran Gao, and Liping Li are with the Injury Prevention Research Center, Shantou University Medical
College, Shantou, China. Jingzhen Yang is with the Center for Injury Research and Policy, The Research Institute at
Nationwide Children’s Hospital, Columbus, OH.
Correspondence should be sent to Liping Li, PhD, Injury Preventive Research Center, Shantou University Medical College,
Shantou, China 515000 (e-mail: lpli@stu.edu.cn). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This article was accepted July 1, 2018.
doi: 10.2105/AJPH.2018.304650

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 AJPH OPEN-THEMED RESEARCH

CRS education described in the previous TABLE 1—Outcomes and Demographics of Parents and Children Among 3 Groups in
paragraph. In addition, parents received the a Parent-Based Intervention to Improve Child Restraint System (CRS) Use: Shantou and
following: (1) hands-on training on in- Chaozhou, China, May 2016–January 2017
stallation of a CRS conducted in a small group
(3–4 parents per group) by 2 child passenger CRS Education
safety technicians trained in the study pro- Only Control
(n = 45), No. CRS Education Plus Hands-on CRS Installation (n = 54),
tocol and (2) a 3-month free trial of a CRS Items (%) Training (n = 51), No. (%) No. (%) P
used in the parent’s own car.
Intervention outcomes
The control group received a lecture about
child electricity safety but no information on CRS use .035a,b
child passenger safety or CRS use. Yes 12 (26.7) 21 (41.2) 10 (18.5)
No 33 (73.3) 30 (58.8) 44 (81.5)
Child passenger safety
Measures
awarenessc
We conducted a baseline survey before
Preintervention (54.1) (54.3) (54.3)
the intervention asking about child passenger
Postintervention (80.7) (86.3) (69.8)
safety awareness, CRS use, and demo-
Differenced (26.7) (32.0) (15.4)
graphics. We sent a WeChat link to the
follow-up survey 3 months after the inter- Demographics
vention to measure study outcomes on child Parent gender .93
passenger safety awareness and CRS use. Male 11 (24.4) 13 (25.5) 15 (27.8)
Female 34 (75.6) 38 (74.5) 39 (72.2)
Parent age, y .10
Data Analysis
£ 35 27 (60.0) 39 (76.5) 42 (77.8)
We used the c test to assess differences in
2
> 35 18 (40.0) 12 (23.5) 12 (22.2)
child passenger safety awareness and CRS use
before and after the intervention across the Parent education level .40
3 groups, with an a level of .05. We analyzed the £ high school 22 (48.9) 20 (39.2) 28 (51.9)
data with SPSS version 21.0 (IBM, Somers, NY). ‡ college 23 (51.1) 31 (60.8) 26 (48.1)
Family monthly income, .08
yuan
£ 5000 10 (22.2) 16 (31.4) 7 (13.0)
RESULTS > 5000 35 (77.8) 35 (68.6) 47 (87.0)
The average age of parents was 33.7 years No. of children in family .28
(range = 25–44), and the average age of 1 22 (48.9) 22 (43.1) 18 (33.3)
children was 4.2 years (range = 2–5). Of the ‡2 23 (51.1) 29 (56.9) 36 (66.7)
participating parents, 26.0% were men. More
Child gender .28
than half of the parents had attended some
Male 20 (44.4) 31 (60.8) 29 (53.7)
college or higher and had more than 5 years of
Female 25 (55.6) 20 (39.2) 25 (46.3)
driving experience. No significant differences
Child age, y .39
in demographics were observed across the
£4 28 (62.2) 38 (74.5) 35 (64.8)
3 study groups (Table 1).
>4 17 (37.8) 13 (25.5) 19 (35.2)
Three months after the intervention, a
a
significant difference in CRS use occurred CRS education only group was not statistically significant (P = .33) compared with the control group.
b
across the 3 intervention groups (Table 1). CRS education plus hands-on CRS installation training group was statistically significant (P = .011)
Specifically, a significantly higher proportion compared with the control group.
c
This was based on percentage of the correct responses to the 4 child passenger safety items.
of CRS use was observed among parents in d
Differences in rating before and after intervention.
the CRS education plus hands-on CRS in-
stallation training group than in the control
group (41.2% vs 18.5%; P = .011). However, no
significant difference in CRS use was observed DISCUSSION knowledge and attitudes but did not increase
between the CRS education only and control This research documented that the CRS CRS use. CRS use is low in China and only
groups (26.7% vs 18.5%; P = .33). Child pas- education plus hands-on CRS installation 1% in Shantou; even in cities with legislation,
senger safety awareness in both intervention training increased the use of child restraints such as Shanghai and Shenzhen, CRS use is
groups was increased after the intervention as 3 months after the intervention; the CRS 16% to 27%.5 By contrast, in Australia and the
compared with the control group. education only condition improved United States, the CRS use was 90% and 86%,

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AJPH OPEN-THEMED RESEARCH
respectively.7 When children are secured in
a correctly installed, age-appropriate CRS,
they are far less likely to be seriously injured
in crashes.8 Given that China currently has
more than 285 million vehicles and no national
CRS use requirement, it is vital to implement
effective interventions to increase CRS aware-
ness and use to improve child passenger safety.
Our results demonstrated that education
alone did not help increase CRS use are
consistent with our previous findings that
parents of newborns who received the edu-
cation combined with free child safety seats
were significantly more likely to use CRSs
after an intervention compared with parents
who received education only.6 These results
suggest that education plus hands-on in-
terventions might be essential in improving
CRS use and should be implemented widely
in China to prevent child passenger injuries.
Existing studies suggested that demo-
graphics are associated with CRS use. Spe-
cifically, child safety car seats are used less
frequently in families with low income9,10
and low parental educational attainment.5,11
In this intervention study, distribution of
demographic characteristics were balanced in
the 3 groups, so confounding factors were
well adjusted, and the research results were
more reliable.
This study had some limitations. The
self-report method used to assess the in-
tervention effect may have led to reporting
bias. Child passenger safety awareness and
CRS use were measured only in the short
term (i.e., 3 months). Thus, future studies
must assess the long-term effect of the in-
tervention. Despite the limitations, this study
showed that CRS education plus hands-on
CRS installation training increased CRS use
but that education alone did not. A combi-
nation of both methods helped improve CRS
use and child passenger safety.
CONTRIBUTORS
L. Li conceptualized and designed the study. H. Lei col-
lected the data. H. Lei and R. Gao were co-first authors
and analyzed the data and wrote the article. R. Gao and
J. Yang revised the article.
ACKNOWLEDGMENTS
All authors express appreciation for the support of the
sample-selected participants and all the investigators.
HUMAN PARTICIPANT PROTECTION
The study, conducted from May 2016 to January
2017, was in accordance with the Declaration of Helsinki
1526 Research Peer Reviewed Lei et al.
and approved by the Ethics Committee of Shantou
University Medical College (Code: SUMC-2015-38).
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