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Sitting in the rear seat of a vehicle rather than in the front seat reduces children's risk of injury or death by 35% in the event of a crash. As road trauma is a leading cause of child morbidity and mortality in highly motorised nations, even in countries where restraint use is high, encouraging parents to place children in the rear seats of vehicles offers a low-cost avenue to improving children's overall health. However, little is known about the factors that affect parents' decisions about seating positions.
To explore parental perceptions of barriers to placing their children in the rear seat of passenger vehicles whenever possible.
Focus group discussions were held with urban parent-drivers to elicit their concerns about children's car safety and barriers to rear-seat use.
Most parents had a rule that children should sit in the rear seat. Parents said that they relaxed these rules for a variety of reasons including social pressure, perceptions of the trip as short and because children regard sitting in the front seat as a treat. Parenting style, child cooperativeness, social pressure and inability to justify the risk of injury were identified as barriers to rear-seat travel.
Effective interventions to increase the proportion of children travelling in the rear seat should address parents' experiences of pressure to relax seating rules and risk perception, as well as provide strategies that support sound parental safety decisions.
Despite considerable advances in road safety, road trauma is still the leading cause of death and disability for children in highly motorised countries such as the US, Canada, New Zealand and Australia.1,2,3
Although in Australia mandating the use of restraints for children seems to have been effective, with surveys showing that around 90% of child passengers wear a restraint of some kind, increasing the level of compliance may prove costly and difficult to achieve.4 This levelling off of safety gains as public health measures to increase restraint use to reach their maximum effectiveness is likely to be an issue for other highly motorised countries too. To make substantial gains in safety, other, more cost-effective avenues may need to be explored.
One simple, low-cost method to improve children's safety in cars is to restrain them in the rear seat rather than in the front, whenever this is possible. For children, US studies have established that sitting in the rear seat of a vehicle (without airbags) is about 35% safer than sitting in the front, in the event of a crash.5,6,7 Analyses of data from large US crash-databases such as the Fatality Analysis Reporting System have shown that restrained children sitting in the front seat account for a much higher percentage of child fatalities than those sitting in the rear seat.6 Similarly, one recent Australian in-depth study that examined injuries to children aged 2–8 years presenting to two hospital emergency departments after a crash found that children sitting in the front seat of the vehicle were 2½ times more likely to have serious injury than those occupying the rear seats.8 Moreover, seating position and restraint use have an interactive effect on safety: wearing a restraint and sitting in the rear seat provides the best protection of all.9
The percentage of vehicles with children travelling in the front seat seems to vary across countries.10 Studies in the US have estimated that 25–40% of vehicles carrying children carry them in the front seat, and estimates for Australia suggest that the proportion there may be higher.11 Moreover, this practice is not prohibited in Australia, except for infants <12 months old. Even for countries where exposure rates are lower than for the US, encouraging children to travel in the rear seat involves no cost or technology and thus represents an easy solution with considerable health and safety benefits for a vulnerable road-user group.
Although there seems to be considerable potential to improve children's safety by encouraging parents to buckle them in the rear seat, we have little information on the factors that affect parents' decisions about where to seat their children. This information is vital to designing effective interventions. US-based studies suggest that knowledge on safety is not the primary factor.12 Similarly, parental decisions do not seem to be based on whether there is a vacant rear seat: Australian and US observational surveys show that around 80% of vehicles with children in the front seat have at least one seat available in the rear.11,13
This study used an interpretive phenomenological qualitative approach with focus groups as the method for gathering material. Qualitative approaches have not been used extensively in injury research, although they are becoming more common in health research areas such as nursing, occupational health and safety, and health promotion.14,15,16 Qualitative methods may be particularly appropriate to prevention efforts because they can provide valuable insight into the antecedents of injury, which are necessary to designing effective interventions.17 Focus groups were chosen for two reasons. Firstly, they allow greater access to participants' beliefs, attitudes and experiences than survey or observational methods.18,19 These psychological factors are likely to be critical in understanding the barriers to placing children in the rear seats of vehicles when travelling. Although in-depth interviews also allow access to detailed information about experiences, these are more resource intensive. Secondly, focus groups are often useful in the early stages of exploration of a phenomenon because they allow important unanticipated dimensions to emerge through the social context and through interaction of participants.19
Parents of children aged 12 years who regularly drive their children in passenger vehicles (with a rear seat) were recruited by personal approach in the open-air car-parks of two urban shopping centers primarily retailing food and grocery items in Brisbane, Queensland, Australia. These centers were selected on the basis of the socioeconomic status (SES) indicators of the surrounding suburbs (one in an upper SES area; one drawing on lower SES suburbs).20 Initially it was hoped that groups could be separated on the basis of SES, but this did not prove practical and the resulting groups consisted of parents from a mixture of SESs. Discussion groups were planned for both daytime and evening to allow both employed and unemployed parents to participate. Group size was deliberately limited to a maximum of eight parents to make it easier for the facilitator to establish rapport with the group and to encourage conversational relationships between participants. Groups of this size have been shown to be effective in generating useful information.21
Except for one group where notes were taken, discussions were transcribed by a professional stenographer to allow the accurate recall of exact terms used by parents.22 Participants were offered a $A30 gift voucher in acknowledgement of their time. Ethics approval was granted by QUT's University Human Research Ethics Committee.
The discussions were prefaced by a general introduction to the facilitator, the study, its purpose and the procedure, during which written consent to record the discussion was sought. In the introduction, the facilitator emphasised the underdeveloped state of the field, saying that this made parents' understanding and experience important to the research. They were encouraged to talk to each other as part of generating this information and invited to introduce themselves briefly. Beginning in this way was designed to minimize parents' perceptions of the facilitator as an expert and to establish a relaxed environment where parents would feel comfortable with one another and with the facilitator. Largely, this seemed to be effective, although it was clear that some parents had agreed to attend the session because they were keen to ask some questions themselves, and may thus have initially regarded the facilitator as a source of expert knowledge. When these parents posed their questions (eg, about the existing legislation in relation to child restraints), in most instances other members of the group supplied the answers rather than the facilitator.
To encourage contribution and to allow emergence of unanticipated material, the discussion schedule was only semistructured. It began with the opening question “What do you think are the most important issues when it comes to your children's safety in the car?”, which was designed to encourage conversation among participants and to elicit the safety concerns uppermost in their minds. The schedule then allowed for probe questions to be used to elaborate the themes and interests emerging in each group.
It was anticipated that one focus issue, children occupying the front seat and parents' views on this, would arise naturally in the course of discussing children, safety and car experiences, and this did occur in three of the five groups. In the other two groups, after allowing discussion around themes of interest to the group to proceed for some time, the facilitator asked about front seating. Questions were also posed in relation to the barriers to getting children to sit in the rear seat and parents' suggestions or strategies to overcome these.
Transcripts and discussion notes were analysed using QSR NVivo 2.0 to allow storage and display of the material.23 Transcripts were subjected to thematic analysis, following the process described by van Manen,24 where key words and phrases that seem particularly revealing about the issues are identified and then grouped into themes. Analysis of transcripts began after the first discussion and is on-going. The descriptions offered in relation to the research interests became repetitive by the end of the fifth discussion, with no new information in relation to these appearing, and hence it was deemed that saturation of these themes had been reached.
A total of 24 parents (21 mothers and 3 fathers) participated in 5 separate groups, which were all facilitated by the author. Groups consisted of 4–7 parents, with discussions lasting about 1 h. Consistent with the population from which they were drawn (urban Queensland), most of the parents were Caucasian. Most parents were aged between 30 and 39 years (16/24), had at least some post secondary education (20/24) and were full-time parents (10/24), with two or three children (15/24). Annual family income ranged from under $A30000 to >$A100000, with around half (13/24) of the parents indicating family income >$A60000 per annum (consistent with national figures for median income for couple-families with children).20 There were two stepfamilies and at least two sole-parent families.
Although data on children's restraint use and seating location was not specifically gathered in this study, figures from an earlier observational study conducted in the same suburbs from which parents for this study were drawn are available ((tablestables 1 and 22).). The methods and preliminary results for this earlier study have been described elsewhere.11 The final results from the earlier study comprised a total of 1643 passenger vehicles carrying 2507 children. Half of these vehicles (816/1643) had a child occupying the front passenger seat. As table 11 shows, most of the children sitting in the front seat seemed to be aged 7 years (91%) and were restrained in adult seat belts (95%). Rear-seated children (table 22)) tended to be younger and wore a greater variety of restraints. The seating location and restraints worn by children of the parents in the discussion groups are assumed to be distributed similarly.
In response to the opening question, in four of the five groups, the first issue raised was about making sure that all children were restrained properly. However, in relation to this there was considerable concern expressed by parents about child restraints, their degree of fit and whether they were as safe as they were purported to be. Parents stated doubts about their safety, referring to the extent to which restraints could be moved around in the vehicle once they were supposedly secured. These concerns were mostly about the restraints for children who had outgrown the rear-facing restraints and seemed to arise for participants when children transitioned from one type of restraint into the next: “although it's [approved forward-facing child restraint] attached properly … you can grab the side of it and you can wriggle it around and they [registered restraint-fitter she consulted] say it's fine but to me … I just wonder how safe they'd be in a seat of that sort … I'd like it to be firmer in the car”.
Belt-positioning booster seats in particular were judged as untrustworthy: “I don't think they are safe—they are more dangerous than a car seat [forward-facing child restraint]” and from another mother: “I wasn't thinking of safety issues [when I bought it] because a booster seat is just a bit of foam that's got nothing”. Possibly for this reason, many parents said that they had moved their children into seat belts at age 5–6 years.
Generally parents were aware of the extra risks inherent in sitting in the front seat and most parents indicated that they had a rule forbidding their younger children from sitting there. For some families, rule enforcement effectively dealt with front-seating issues.
However, other parents reported experiencing pressure as their children grew, or they began transporting the older children of friends or relatives, to relax or abandon their seating rules. These parents were uncomfortable about allowing children to sit in the front seat, but were finding social norms and pressure from their children harder to resist as children got older. A common response to this was to search for official backing for their stance, since most parents believed that children were not legally allowed to sit in the front seat until a certain age. Among the sources parents reported consulting were the police, the motoring associations, the ambulance service and the department of transport. Parents were surprised and frustrated when they discovered that Australian legislation does not cover seating position except for infants <12 months old, who must be restrained in the rear seat in an approved restraint.
There were at least two distinct ways that parents reported dealing with this absence of legislation. In the first, parents simply assumed responsibility and reasserted their current rules or changed them to suit: “I used to make it until they turned eight … [and when they turned eight] then I changed the rule and I said “well you can only get in the front if there are no seats in the back” … and I have just said to [my son] “the children's place is in the back””.
The remaining parents were more ambivalent and less decisive about what to do. These parents were looking for guidance in making the decision: “I really wanted it [the brochure she obtained] to say “you can't put children in the front seat if they are under 5 or 8 [years] or whatever””.
Parents in every group believed that clearer legislation that encompassed front seating would be useful in guiding parents, encouraging safer behaviors and countering the arguments from their children: “if they can introduce some kind of legislation that says if you have a spare seat in the back until they are this age and this weight [then] that's where they go” and “the [other] mums this morning I was speaking to said they would be so happy if somebody said “here is the law: you have to be 12, you have to be 45 kilos; you have to do this” because then its simple and they can say to their kids “this is the law””.
Parents reported that they voluntarily relaxed their rules for reasons that they saw as legitimate. These included separating children who were fighting, and to fit in with other drivers with different rules. Parents also said that occasionally they would allow a child to travel in the front seat as a special treat or because the trip was perceived as a short one. Another reason seemed to be a desire to support children in their maturation and perceiving the move to the front seat as part of this: “there's a sense that your kid is growing up and you kind of want to—it feels good when they're taking their little steps like that and I guess subconsciously you weaken”.
Similar to findings reported by others in relation to booster-seat use,12,25,26 parenting style was identified as a barrier to encouraging consistent rear-seat positions for children: “[some] parents just let their children make the rules … there are times when you do that but there's times when their safety is at risk [then] you just make the rules”. This was particularly manifest for some parents in difficulty countering the arguments mounted by their children solely on the basis of safety. As one parent, whose children were allowed to sit in front seat, put it: “My daughter says “well you do it [sit in the front] so why can't I?” [if I say] “its not safe” [she'll say] “well you do it”. What do you say then?” Even parents who did not relent highlighted that the apparently small risk of a crash, and of injury resulting from it, made rear seating difficult to justify to children: “it's a ‘just in case', you know … you haven't had an accident so far; you're just driving down to the school … its hard for them [12- and 14-year-old daughters] to understand [why I say no]”.
Other factors that parents identified as barriers were the personality (and therefore level of cooperation) of the child, inconsistency in the rules set by different adults in the same family, social pressures exerted by children's peers and other parents, and decay in parents' knowledge about safety issues as children matured.
Although allowing children to sit in the front seat was not uppermost in their minds when it came to car safety, the parents in these groups had given the issue a lot of thought and many were concerned about how to deal with it. In Australia, top tethers are mandatory for all rear-facing infant restraints and for forward-facing child restraints that suit children up to 18 kg (40 lbs). Essentially, this means that children up to the age when parents stop using these types of restraints are restrained in the rear seat because the anchor points/bolts for these tethers are virtually exclusively located in the rear and vehicle-design rules govern the anchor specifications. A high proportion of young children use these restraints in Australia, which means that parents do not really have to think about where to seat children until they reach about 3½ years of age. As indicated, parents commonly set a family rule about what age or stage children should be before they are permitted to sit in the front seat.
However, these were less effective as children grew older and parents began to experience social and family pressures to relax or abandon their sound rules about seating position. These pressures seemed to affect all parents. Although some parents in this study were able to maintain their rules despite these pressures, and even on discovery that rear seating for children is not mandated, others were not so assertive. For this second group, invoking safety concerns did not seem to be a sufficient counterargument by itself. Parents in this group expressed the view that they would find it much easier to counter arguments from children and others if they could refer to some external authority, such as well-defined legislation. Interventions should attempt to equip parents with ways to counter arguments relating to their safety choices and support them in their parenting role.
Parental perceptions of risk, especially in relation to allowing children to sit in the front seat because the length of the trip is short or because children perceive it as a treat, seem worthy of specific attention. This is particularly important in light of recent findings that it is short, routine trips, such as school travel, that are the most likely to result in injury to children.27
Mistrust of child-specific restraints is a concern and interventions should deal with this by informing and reassuring parents of the safety benefits conferred by these devices, particularly in comparison to adult seat belts, as well as affirming their concern to ensure good fit.
The period of preschool and early school age (4–8 years old) may be the optimal time for intervention to encourage parents to keep children in the rear seat as this stage marks the transition to booster seats for many children. It is also the time most likely to coincide with increased pressure to relax seating rules and thus a time when parents may be most in need of affirmation and support.
This research was funded through a grant from the Centre for Accident Research and Road Safety, Queensland, Australia. I thank the parents involved in the study, the anonymous reviewers who provided useful suggestions for improvements and my colleagues, Dr Mark King and Adjunct Professor Allan Williams, for thoughtful comments on the drafts.
SES - socioeconomic status
Competing interests: None.