Qualitative Consumer Input for Enhancing Child Restraint Product Information to Prevent Misuse: Preliminary Results

Child restraint system misuse is a global public health issue leading to increased risk of injury and death in motor vehicle crashes. Although some interventions are effective at reducing misuse, they are prohibitively costly to adopt at a population-level. We aim to develop a novel, consumer-driven intervention to counter misuse embedded in product information supplied with child restraints. If effective, this cost efficient measure can be broadly implemented via product standards. The first stage of this project involved using a semi-structured discussion guide to conduct six in-depth focus groups (N = 44; 95% female) to elicit problems and preferences with current product information. There are some distinctions between the different populations of child restraint users sampled here (i.e., reliance on graphics versus text instruction), but preliminary results suggest that at a minimum, restructuring information, improving graphics, removing text, and providing links to other sources of information will increase the attractiveness and ease of understanding instructions and labels supplied with child restraint systems. Background Child restraint systems (CRS): Nonuse, misuse, and age-inappropriate use The use of child restraint systems (CRS) for children travelling in motor vehicles is common in most developed countries and it is becoming the norm for legislation to cover the protection of children in cars worldwide (WHO, 2013). In Australia, the law requires that children under seven years of age be restrained in an approved booster seat or child restraint system that is appropriate for the child’s height and weight. Recent estimates of use have predicted that more than 99% of children 0-7 years are restrained (Brown et al., 2010). The same estimates predict that about half of all children are incorrectly restrained (Brown et al., 2010). While mandating the use of a child restraint might promote use, it does not ensure the seat is being used correctly; that is, installed and used as intended by the manufacturer. Correct use is predominantly measured by the presence or not of errors in installation (CRS in vehicle) or securing (child in CRS) (e.g., Rudin-Brown et al., 2004). Very loose or twisted harnesses, seatbelts routed incorrectly, and non-use of a top tether are examples of serious errors that would reduce the restraints’ crash protection potential (Brown et al., 2011). As more countries mandate restraint use and population estimates of use increase, the focus of child passenger safety is now shifting to preventing misuse from promoting appropriate use. A number of studies have identified demographic factors associated with an increased likelihood of errors in use. Brown et al. (2013) found that children from a family who speak a language other than English at home are more than twice as likely to be incorrectly restrained. Children from low-income families have also been found to be substantially more likely to have errors in child restraint or booster seat use (Bilston, Du, & Brown, 2011). While Bilston et al. (2011) did not find a significant relationship between education level and restraint use, other research indicates that lower health literacy (ability to understand and use health information) is associated with low injury prevention behaviours Full Paper – Peer Reviewed Hall et al. Proceedings of the 2016 Australasian Road Safety Conference 6 – 8 September, Canberra, Australia (Heerman et al., 2014). Lack of information and experience with restraints are also predictors of misuse (Arbogast, 2014; Bilston et al., 2011; Rudin-Brown et al., 2004). Some predictors of incorrect use (i.e., lack of information and experience, low health literacy, etc.) suggest that the misuse of restraints is due to a user’s skill deficit. Information on how to use a restraint is communicated on the labels and instruction manuals accompanying the restraint. It is inevitably the first point of communication for new restraint users. In Australia, all child restraints must be approved under the Australian Standard AS/NZS 1754. It is this product standard that stipulates the content and layout of information given to consumers about installation and use of child restraint devices. And while product information provides instructions on correct use and warnings against misuse, continuing high rates of errors in use suggest there is a gap between the correct use messages being sent and how users are responding (using) the restraint. Basic communication principles suggest that there are characteristics of the message (i.e., correct use), channel (i.e., instruction manuals/labels), recipients (i.e., child restraint users), and environment (i.e., first time) that will affect how information is processed. Although most research on communication for health is focused on patient decision-making in clinical care situations, there are some public health and literacy principles concerning risk communication and medical product information (Fischhoff, Brewer, & Downs, 2011). The gold standard in health communication also involves taking a consumer centric approach to the development of information materials. While child restraint users have typically been seen as passive recipients of safety information, there is a move in health research toward designing consumer-centred information. Researchers in Australia, Canada, and North America have recently developed some educational interventions targeting restraint misuse that involve consumer-centred design processes. In Australia, the product standard for child restraints (AS/NZS 1754; 2010) was amended to include shoulder-height marker labels affixed to restraints that visualised for parents when a child had outgrown their restraint (child’s shoulders are above dotted line). Although the law still makes recommendations of appropriate restraint use based on age, the shoulder height markers being used were designed using size of child (height) as a proxy for appropriate use – an indication leading to more appropriate use (Brown, Fell, & Bilston, 2010). In 2002, Rudin-Brown et al. (2004) designed new ‘optimal’ labels for child restraint systems that were aligned with human factors principles that performed better than the traditional label for rearward-facing mode installation and use. More recently, Klinich et al. (2010) and Kramer et al. (2015) found similar results with instruction manuals and labels they designed. However, despite the fact these studies used best practice in designing the information, and the participants in these studies were highly motivated to perform correctly, and had access to correct information in an appropriate format, the absolute improvement in errors was relatively small. This indicates that a communication gap between the information being conveyed in the instructions and labels and the information received and enacted continues to exist. We believe that the critical step to ensuring users can understand and act on instructions and labels is by involving them in the process of design, and continuing re-design until the behaviour is being performed correctly. A modified consumer-testing and consensus design method is being used to design new instructions, labels, and videos that aim to increase the correct use of restraints. The consumer-centred design process is the critical step to success, not the re-designing of materials themselves. With the final prototypes of enhanced instructions and labels, we will then be able to look retrospectively into the critical elements of design and feedback that made the most significant changes and translate these processes into recommendations for manufacturers. Full Paper – Peer Reviewed Hall et al. Proceedings of the 2016 Australasian Road Safety Conference 6 – 8 September, Canberra, Australia The first stage of this consumer-centred design process is qualitative focus groups to identify barriers to using and understanding current child restraint product information in a diverse population of users. We aim to elicit specific feedback on how to improve current child restraint informative materials. The preliminary results presented below are being used to design the first prototype of new child restraint product information to be tested in a consumer-testing cycle and later laboratory trial.