Overloaded and Unrestrained: A Qualitative Study with Local Experts Exploring Factors Affecting Child Car Restraint Use in Cape Town, South Africa
Abstract
:1. Introduction
- What factors influence children’s road safety in Cape Town, South Africa?
- What are the current attitudes and behaviours relating to child restraints in Cape Town and what are the factors that influence this?
- What type of intervention would have the most potential to increase the use of child restraints in Cape Town?
2. Materials and Methods
2.1. Recruitment and Data Collection
2.2. Data Analysis
3. Results
3.1. Individual Factors Influencing Restraint Use
3.1.1. Perceptions of Risk among Parents and Carers
“They see that the chance [of a crash] is very remote … The fundamental thing is that people believe for example that they can hold a baby on their lap. People do not understand that at 20km/hr if you come to a sudden halt that the child is going to go through the windscreen or at the very least be very severely injured. People just do not—there is no understanding of the risks.”Participant_1 (Government)
“It’s a total myth. You can get nasty bruising of course, but if you get nasty bruising that is a sign that if you hadn’t been restrained you would have probably hit something with a lot more force and had a much more serious injury…. So people don’t really think things through. And South Africans in particular have an extraordinary ability to make excuses for their behaviour in traffic.”Participant_12 (Road safety engineer)
3.1.2. Perceptions that Convenience Overrode Safety
“Then there is an attitude of convenience. It is far more convenient to have a child bouncing around on your knees on the front passenger seat than having to turn around and deal with someone who is restrained behind you. So I think a lot of it is inconvenience versus convenience and laziness versus diligence.”Participant_11 (Paediatric surgeon)
3.1.3. Perceptions of Risk among Older Children
“Children need to understand why they use seat belts and car seats. Then they will be more willing [to use] them”Participant_4 (NGO for road safety and children)
3.1.4. Perceptions of Financial Barriers
“What I have heard is that our people are poor and poor people can’t afford expensive car seats and car seats are expensive. So are the people poor? Yes, they are poor. Are they rich enough to afford a motor car to drive in? Yes, they are. Can they put a tank of petrol in that car? Now you know it is R700 for a tank of petrol, which actually is the price of a cheap car seat. … don’t accept poverty as an excuse. If you are going to take the responsibility of driving a car with a child in it I really think that you need to supply that. So poor people, but rich enough to afford a car, if you are rich enough to afford a car, you can afford a car seat.”Participant_11 (Paediatric surgeon)
“There is the poverty aspect of whether they can afford a car seat or not but I think that is being made unnecessarily complicated because there are ways to get cheap car seats or free car seats. Car seat banks and things like that.”Participant_3 (Emergency medical officer)
3.2. Relationship
3.3. Community
3.3.1. Public Campaigns
3.3.2. Modes of Transportation Impact Capacity to Use Restraints and Risk Perceptions
“I’d say there are three different ways [children are transported]: There is in a private car—so my son has gone to Cape Town today with a school trip and we had to specify to the teachers which parents are allowed to take him because the majority of parents in his class do not restrain their kids and they will have a sedan with seating for five and they will have six or seven kids in there just on the school run regularly. So private cars there is a minority of children who are transported properly restrained both anecdotally and from a study I did a couple of years ago where we stood on the side of the road and we had observers—about 60% of adults had seat belts but only 20% of kids … my anecdotal experience in private cars it is either unrestrained or the majority are just with a seat belt not with proper fitted car seat. The second is bakkies—so especially in rural areas—bakkies full of kids either with a cover on the back or without—15 on the back of a bakkie is not unusual. And third is the minibus taxi either in Cape Town minibuses with mixed passenger loads or the dedicated school buses and the same out in rural areas. And they are usually overloaded and unrestrained.”Partcipant_3 (Emergency medical officer)
“There is no consistent focus to police it as such. And the realities—you have got to ask is are you going to rather allow those children to walk 10–12 km to school every day or are they going to transport them on the bakkie. You know if you look at the number of pedestrian kids killed then actually it is almost safer … transporting them on a bakkie than allowing them to walk.”Participant_ 7 (Traffic officer)
3.3.3. Perceptions of Socially Embedded Practices
“People have a profile of taking risk thinking that it will not happen to them and thinking that their children are strong enough. Not understanding the vulnerability specifically of children with underdeveloped or less developed spines and skulls as adults. And it is that good old stubbornness of people in countries that have a history of frontier people and that is just that they won’t be told what to do.”Participant_ 4 (NGO for road safety and children)
“My parents had me on their laps, and their parents had them on their laps, so why shouldn’t I have my kid on my lap in the front seat.”Participant_13 (Forensic pathologist)
3.4. Society
Legislation and Enforcement
“No one has ever told them, there is no public education about it, there is a law but it’s not really well enforced and if it is enforced they don’t really know understand [sic] why they have to do it.”Participant_3 (Emergency medical officer)
“There should be consequences to the drivers who drive the vehicles because there is clearly—we need to bring public transport into the party—currently they are excluded. Taxis—it is not legal for them to put car seats in. We need to change that. And the practicality of that I fully understand, but we need to bring the laws in line with what is acceptable levels of safety for children and then we need the enforcement. There needs to be consequences for the driver”Participant_4 (NGO for road safety and children)
3.5. Feasibility of a Child Restraint Program
“… enforcement plays a very important role, but they are currently over-stretched. So there needs to be a multisectoral response to the issue from government, corporates such as health insurance firms, drivers of minibus taxis and scholar transporters as well as parents and children.”Participant_2 (Child injury researcher)
“I think the biggest one is the lack of knowledge. People just do not understand what seat belts do and what child restraints do. I teach our second years transport course and one of things [sic] I explain to them is the three impacts in a crash. And they have never heard of this before. And every year I have students coming to me to say I didn’t know that and so now I will never get into a vehicle without a seat belt again. So if we can bring that education earlier on in their lives and if we can extend that education to parents, I think that would make a difference. I think that parents even such highly qualified parents driving around Stellenbosch whose children are unrestrained if they could just understand what happens in the event of a crash, I think that that would be a big win.”Participant_12 (Road safety engineer)
“There is enough money in private and government schools to have one child in a seat in a minibus. I think that if you can afford a car—every car has seat belts—you can seat the bigger child in the seat belts and if you can afford a car you can afford a car seat. There are also charitable donations of car seats and booster seats—for people who have a 20-year-old beaten up car—there are ways to get them.”Participant_3 (Emergency medical officer)
“I think the middle bits harder where there are bakkie loads of kids who if they don’t get into the bakkie in a rural area they don’t get to school. And I don’t have a solution to that. I think that it is a gradual societal change and educating people.”Participant_3 (Emergency medical officer)
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
- Peden, M.; Scurfield, R.; Sleet, D.; Mohan, D.; Hyder, A.A.; Jarawan, E.; Mathers, C. (Eds.) World Report on Road Traffic Injury Prevention; World Health Organization: Geneva, Switzerland, 2004. [Google Scholar]
- Peden, M. World report on child injury prevention appeals to “Keep Kids Safe”. Inj. Prev. 2008, 14, 413–414. [Google Scholar] [CrossRef] [PubMed]
- Krug, E. Decade of action for road safety 2011–2020. Injury 2012, 1, 6–7. [Google Scholar] [CrossRef] [PubMed]
- United Nations. Sustainable Development Goals: Knowledge Platform. Available online: https://sustainabledevelopment.un.org (accessed on 29 March 2020).
- United Nations. Global Road Safety Performance Targets. 2017. Available online: https://www.who.int/violence_injury_prevention/road_traffic/12GlobalRoadSafetyTargets.pdf (accessed on 29 March 2020).
- World Health Organisation. Global Status Report on Road Safety 2018: Summary; World Health Organization: Geneva, Switzerland, 2018; (WHO/NMH/NVI/18.20); Available online: https://www.who.int/violence_injury_prevention/road_safety_status/2018/English-Summary-GSRRS2018.pdf (accessed on 29 March 2020).
- Adeloye, D.; Bowman, K.; Chan, K.Y.; Patel, S.; Campbell, H.; Rudan, I. Global and regional child deaths due to injuries: An assessment of the evidence. J. Glob. Health 2018, 8, 1–11. [Google Scholar] [CrossRef] [PubMed]
- Matzopoulos, R.; Prinsloo, M.; Wyk, V.P.-V.; Gwebushe, N.; Mathews, S.; Martin, L.J.; Laubscher, R.; Abrahams, N.; Msemburi, W.; Lombard, C. Injury-related mortality in South Africa: A retrospective descriptive study of postmortem investigations. Bull. World Health Organ. 2015, 93, 303–313. [Google Scholar] [CrossRef]
- Albertyn, Z.; Mathews, S.; Coetzee, D.; Bastiaan Van As, A. Morbidity and mortality from road traffic crashes in children in metro west, City of Cape Town—2014. Int. J. Inj. Control Saf. Promot. 2019, 26, 115–123. [Google Scholar] [CrossRef] [PubMed]
- Statistics South Africa. National Household Travel Survey 2013: Statistical Release P0320. 2014. Available online: http://www.statssa.gov.za/publications/P0320/P03202013.pdf (accessed on 29 March 2020).
- Rice, T.M.; Anderson, C.L. The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005. Am. J. Public Health 2009, 99, 252–257. [Google Scholar] [CrossRef] [PubMed]
- South African Department of Transport. Decade of Action and Arrive Alive: National Road Safety Strategy 2011–2020. South Africa. Available online: https://www.arrivealive.co.za/documents/Road%20Safety%20Strategy%20for%20South%20Africa%202011.pdf (accessed on 29 March 2020).
- Janmohammed, A.; Attwood, P.; Mtambeka, P.; Prinsloo, M.; Peden, M. The need for stronger child restraint laws. S. Afr. Med. J. 2019, 109, 545. [Google Scholar] [CrossRef]
- Clay, C.; van As, S.A.Β.; Hunter, K.; Peden, M. Latest results show urgent need to address child restraint use. S. Afr. Med. J. 2019, 109, 66. [Google Scholar] [CrossRef]
- Puvanachandra, P.; Janmohammed, A.; Mtambeka, P.; Prinsloo, M.; Van As, S.; Peden, M.M. Affordability and availability of child restraints in an under-served population in South Africa. Int. J. Environ. Res. Public Health 2020, 17. [Google Scholar] [CrossRef] [Green Version]
- Isaac, K.N.; Van Niekerk, A.; Van As, A.B. Child road traffic crash injuries at the Red Cross War Memorial Children’s Hospital in Cape Town, South Africa in 1992, 2002 and 2012. Int. J. Inj. Control Saf. Promot. 2015, 22, 352–358. [Google Scholar] [CrossRef]
- Keay, L.; Hunter, K.; Brown, J.; Simpson, J.M.; Bilston, L.E.; Elliott, M.; Stevenson, M.; Ivers, R.Q. Evaluation of an education, restraint distribution, and fitting program to promote correct use of age-appropriate child restraints for children aged 3 to 5 years: A cluster randomized trial. Am. J. Public Health 2012, 102, e96–e102. [Google Scholar] [CrossRef] [PubMed]
- Hunter, K.; Keay, L.; Clapham, K.; Lyford, M.; Brown, J.; Bilston, L.; Simpson, J.M.; Stevenson, M.; Ivers, R.Q. Buckle-Up Safely (Shoalhaven): A process and impact evaluation of a pragmatic, multifaceted preschool based pilot program to increase correct use of age appropriate child restraints. Traffic Inj. Prev. 2014, 15, 483–490. [Google Scholar] [CrossRef] [Green Version]
- Tessier, K. Effectiveness of hands-on education for correct child restraint use by parents. Accid. Anal. Prev. 2010, 42, 1041–1047. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Michie, S.; Van Stralen, M.M.; West, R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement. Sci. 2011, 6, 1–11. [Google Scholar] [CrossRef] [Green Version]
- Tong, A.; Sainsbury, P.; Craig, J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 2007, 19, 349–357. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- World Health Organization Violence Prevention Alliance. The Ecological Framework. Available online: https://www.who.int/violenceprevention/approach/ecology/en (accessed on 29 March 2020).
- Bronfenbrenner, U. The Ecology of Human Development; Harvard University Press: Cambridge, MA, USA, 1979. [Google Scholar]
- Lee, B.C.; Bendixsen, C.; Liebman, A.K.; Gallagher, S.S. Using the socio-ecological model to frame agricultural safety and health interventions. J. Agromed. 2017, 22, 298–303. [Google Scholar] [CrossRef] [PubMed]
- Classen, S.; Lopez, E.D.; Winter, S.; Awadzi, K.D.; Ferree, N.; Garvan, C.W. Population-based health promotion perspective for older driver safety: Conceptual framework to intervention plan. Clin. Interv. Aging 2007, 2, 677–693. [Google Scholar]
- Moran, M.; Baron-Epel, O.; Assi, N. Causes of road accidents as perceived by Arabs in Israel: A qualitative study. Transp. Res. Part F Traffic Psychol. Behav. 2010, 13, 377–387. [Google Scholar] [CrossRef]
- Ebel, B.E.; Coronado, G.D.; Thompson, B.; Martinez, T.; Fitzgerald, K.; Vaca, F.; Rivara, F.P. Child passenger safety behaviors in Latino communities. J. Health Care Poor Underserved 2006, 17, 358–373. [Google Scholar] [CrossRef]
- Rivara, F.P.; Bennett, E.; Crispin, B.; Kruger, K.; Ebel, B.; Sarewitz, A. Booster seats for child passengers: Lessons for increasing their use. Inj. Prev. 2001, 7, 210–213. [Google Scholar] [CrossRef]
- Hunter, K.; Keay, L.; Clapham, K.; Brown, J.; Bilston, L.E.; Lyford, M.; Ivers, R.Q. “He’s the number one thing in my world”: Exploration of the use of child restraints in a regional community in New South Wales. Aust. J. Health Promot. 2014, 14, 1206. [Google Scholar] [CrossRef] [Green Version]
- Bhaumik, S.; Hunter, K.; Matzopoulos, R.; Prinsloo, M.; Ivers, R.Q.; Peden, M.M. Facilitators and barriers to child restraint use in motor vehicles: A qualitative evidence synthesis. Inj. Prev. 2020. [Google Scholar] [CrossRef] [PubMed]
- Brown, J.; Burton, D.; Nikolin, S.; Crooks, P.J.; Hatfield, J.; Bilston, L.E. A qualitative approach using the integrative model of behaviour change to identify intervention strategies to increase optimal child restraint practices among culturally and linguistically diverse families in New South Wales. Inj. Prev. 2012, 19, 6–12. [Google Scholar] [CrossRef] [PubMed]
- Bilston, L.E.; Finch, C.; Hatfield, J.; Brown, J. Age-specific parental knowledge of restraint transitions influences appropriateness of child occupant restraint use. Inj. Prev. 2008, 14, 159–163. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hall, A.; Ho, C.; Keay, L.; McCaffery, K.; Hunter, K.; Charlton, J.L.; Hayen, A.; Bilston, L.; Brown, J. Barriers to correct child restraint use: A qualitative study of child restraint users and their needs. Saf. Sci. 2018, 109, 186–194. [Google Scholar] [CrossRef] [Green Version]
- Michie, S.; Lou, A.; Robert, W. The Behaviour Change Wheel: A Guide to Designing Interventions; Silverback Publishing: London, UK, 2014. [Google Scholar]
- Brown, J.; Keay, L.; Hunter, K.; Bilston, L.E.; Simpson, J.M.; Ivers, R. Increase in best practice child car restraint use for children aged 2–5 years in low socioeconomic areas after introduction of mandatory child restraint laws. Aust. N. Z. J. Public Health 2013, 37, 272–277. [Google Scholar] [CrossRef] [Green Version]
COM-B 1 Domains | Descriptors | Enablers | Barriers |
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Capability | An individual’s knowledge and skills to use child restraints | ||
Physical | Capacity to use child restraints. |
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Psychological | Capacity to engage in necessary thought processes around child restraint use. |
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Opportunity | The external factors that enable or act as barriers to the use of child restraints | ||
Physical | Environmental factors that prompt or promote the use of child restraints (outside the individual). |
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Social | Factors (including cultural) that shape the way individuals conceptualise the use of child restraints and the degree to which these impact on the behaviour. |
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Motivation | Internal processes that direct behaviour relating to the use of child restraints | ||
Automatic | Unconscious brain processes (i.e., habit and emotion) that energise and direct behaviour relating to child restraints. Can be increased through habit forming or imitative learning. |
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Reflective | Conscious brain processes (i.e., goals, decision making) that energise and direct behaviour relating to child restraints. Can be achieved through increased knowledge and understanding of the behaviour. |
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COM-B Domain | Targeted Behaviour | Intervention Types |
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Capability (Psychological) | Individual factors Understanding the risks of not using seatbelts/restraints Knowledge on how to use seatbelts and/or restraints. Knowledge of when to transition from one restraint to the next |
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Opportunity (Physical) | Individual factors Access to a child car restraint Relationship/community factors Access to safe transport options Reduced overloading |
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Opportunity (Social) | Individual factors Attitudes around staying seated while travelling Relationship/community factors Increasing acceptance that seatbelt and restraint use are social norms Societal factors Enforcement of legislationAccess to safe transport options (with car seats) |
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Motivation (Automatic) | Individual factors Automatic reaching for seatbelt Automatic restraining a child in a car seat |
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Motivation (Reflective) | Individual factors The use of seatbelts The use of restraints Believing there will be consequences Societal factors Perception of enforcement of restraint rules |
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Share and Cite
Hunter, K.; Bestman, A.; Dodd, M.; Prinsloo, M.; Mtambeka, P.; van As, S.; Peden, M.M. Overloaded and Unrestrained: A Qualitative Study with Local Experts Exploring Factors Affecting Child Car Restraint Use in Cape Town, South Africa. Int. J. Environ. Res. Public Health 2020, 17, 4974. https://doi.org/10.3390/ijerph17144974
Hunter K, Bestman A, Dodd M, Prinsloo M, Mtambeka P, van As S, Peden MM. Overloaded and Unrestrained: A Qualitative Study with Local Experts Exploring Factors Affecting Child Car Restraint Use in Cape Town, South Africa. International Journal of Environmental Research and Public Health. 2020; 17(14):4974. https://doi.org/10.3390/ijerph17144974
Chicago/Turabian StyleHunter, Kate, Amy Bestman, Madeleine Dodd, Megan Prinsloo, Pumla Mtambeka, Sebastian van As, and Margaret Mary Peden. 2020. "Overloaded and Unrestrained: A Qualitative Study with Local Experts Exploring Factors Affecting Child Car Restraint Use in Cape Town, South Africa" International Journal of Environmental Research and Public Health 17, no. 14: 4974. https://doi.org/10.3390/ijerph17144974