Abstract
Motivating parents to take certain safety precautions when traveling with their children remains challenging for advocates. Caregivers of booster-aged children are particularly difficult to reach because they do not consider their children to be of “safety-seat” age and have inherently low perceptions of vulnerability to crash injury. Unfortunately, most booster seat programs fail to adequately motivate their intended population because they are primarily informational in nature and rely on caregivers to seek out and attend to the information. In this article, interventions using threat appeal tactics and progressive dissemination methods are recommended to effectively target participation and perceptions of vulnerability among this population. Recent research on risk communication indicates that threat appeals are supported when they contain high threat and high efficacy components. Threat appeal tactics are particularly desirable when perception of vulnerability is low, as is the case with parents of booster-aged children. In addition to theoretical arguments for more aggressive intervention approaches, a case example is presented wherein such techniques were used to promote booster seat use. The intervention resulted in significant increases in knowledge, risk-reduction attitudes, sense of efficacy, and observed booster seat use. Through use of progressive dissemination methods, the intervention has reached an audience of 431,600 people and counting.
Motor vehicle crashes are the leading cause of death for US children (Centers for Disease Control and Prevention, 2007a, 2007b). Properly used child restraints (including booster seats) and back-seat positioning dramatically reduce injury risk. Booster seats reduce crash injury risk by 45% versus just a safety belt for 4- to 8-year-olds (Arbogast, Jermakian, Kallan, & Durbin, 2009). Yet only 43% of booster-sized (i.e., approximately 40-80 lbs, under 4 ft 9 in. tall, and about 4-8 years old) US children ride in booster seats (National Highway Traffic Safety Administration, 2009). Children seated in front seats of vehicles are at 40% greater risk of injury compared to those seated in the back (Durbin, Chen, Smith, Elliott, & Winston, 2005). Yet 30% of US children ride in the front seats of vehicles, and this percentage increases with increasing age (Durbin, Chen, Elliott, & Winston, 2004; Ferguson, Wells, & Williams, 2000).
Low perceived risk among caregivers further compounds the problem (Will & Geller, 2004). Motor vehicle travel is familiar, occurs in a well-understood system, permits one to feel in control while behind the wheel, has the added perk of convenience, and disperses injuries and deaths over time and space. Research has shown that all of these characteristics of motor vehicle travel lead to reduced perception of risk (Sandman, 1991; Slovic, 1991; Will & Geller, 2004). Consequently, caregivers struggle with an immunity fallacy (Will, 2005), or a reduced perception of personal or familial risk for injury in a crash. This is unfortunate given that recognition of personal vulnerability to a hazard is a necessary prerequisite to behavior change (Bandura, 1986; Sandman, 1991; Slovic, 1991; Weinstein, 1988). According to the precaution adoption process model (PAPM; Weinstein, 1988), without feelings of vulnerability, the audience of caregivers remains unengaged—even if fully informed of the problem.
The PAPM (Weinstein, 1988) is a stage model that provides a framework for understanding how individuals progress toward, adopt, and maintain behavior change (see Figure 1). The PAPM includes both an “unaware” stage where individuals are not informed of the problem, and an “unengaged” stage where individuals can be fully informed of the problem but not motivated to do anything about it (Weinstein, 1988). This is often because of low recognition of personal vulnerability. The combination of many factors leaves many caregivers of booster age children in the unengaged stage of the PAPM.
The Stages of the Precaution Adoption Process Model
When trying to motivate an unengaged audience, it is important to examine whether or not the message is appropriate. There are two basic types of child passenger safety interventions (Will, 2005). The first is passive, where caregivers must initiate or seek the intervention. These are primarily educational and include parent training, websites, brochures, and child safety seat checkup clinics. The second type is aggressive, where caregivers are intervened upon. An example includes legislation coupled with enforcement. The immunity fallacy is especially problematic for passive interventions. Unfortunately, the bulk of current child passenger safety interventions are passive and thus, interventions should be redesigned to be more aggressive.
Designing a Better Intervention
Step 1: Change the Message
To better motivate caregivers, our research employs high-threat messages. Research in many health areas strongly supports the use of threat appeals that are properly designed and targeted appropriately (Witte, 1998; Witte & Allen, 2000). There are two key elements of properly designed threat appeals: threat and efficacy. Specifically, messages must have a high threat component and promote high efficacy for protecting oneself from the hazard (i.e., they should provide an action plan; Witte, 1998; Witte & Allen, 2000). In other words, a threat appeal should not only scare the audience, it should also provide the audience with the confidence and tools needed to successfully counteract the hazard.
There are three important issues to consider when using threat appeals (Witte, Meyer, & Martell, 2001). First, one must expand the definition of threat appeals. Namely, gore is not necessary for threat appeals to be effective. This is one reason modern “fear appeals” are aptly renamed threat appeals or health risk messages. Threat appeals should be highly threatening, but need not be gruesome. Second, threat appeals without efficacy components fail to motivate change. Self-efficacy is a person’s confidence in their ability to perform a task (e.g., I can do it), and response efficacy is a person’s beliefs about the worth or benefit of performing the task (e.g., it will work; Bandura, 1986, 2004). When fear of a hazard exceeds efficacy for combating the hazard, threat appeals will fail (Witte, 1998). Third, one must consider the audience and its existing fear as well as self-confidence when deciding whether a threat appeal is appropriate. For example, the authors would not use a threatening child passenger safety message when targeting expectant parents because new parents have low efficacy regarding their parenting skills and high fear that they will make a mistake. By contrast, a threat appeal can be used with experienced parents because they are largely overconfident that they can protect their children in the car.
Step 2: Change the Approach
In addition to changing the message design, safety advocates should consider changing their intervention approach when trying to reach an unengaged audience of caregivers. It is important to consider that if the intended audience is in the “unengaged” stage of the PAPM, it is unlikely they will read a brochure (even one handed to them), watch a video on their own, or attend a safety event for the issue. Indeed, passive interventions that require the audience to seek out or attend to the message will not reach the intended audience with an immunity fallacy (who are often the very people we are trying to reach). While safety advocates wait for legislation with adequate publicity and enforcement to catch up to best-practice recommendations, safety professionals should use more progressive and varied dissemination tactics to bolster message effectiveness and scope of reach.
Making an inherently passive approach progressive requires transforming it from one that must be sought out by the intended audience to one that intervenes upon the intended audience. Interventionists should consider carefully the best distribution points for the audience. Parents of booster-age children who are not using booster seats do not attend safety-seat checkup events. Nor do they read booster seat brochures or websites. On the other hand, parents of booster-age children do frequent shot clinics as they prepare for their child’s kindergarten enrollment (at which time immunizations are often mandated). Thus, a shot clinic is one example of an ideal setting for a booster seat intervention. But being progressive means more than simply placing an intervention in a venue that is frequented by an intended audience. If the audience is in the “unengaged” stage of the PAPM, they will disregard the intervention if permitted. Thus, showing a DVD or other information to parents is a better use of resources than handing it to parents directly (as in the latter case, most will never look at the material).
Considering the best distribution points are not often safety venues, partnering with professionals in other settings who are already working with the intended audience will be necessary. Establishing partnerships is difficult at times because of competing priorities and logistical constraints; however, if the intervention method is flexible, is mutually beneficial, and requires no effort (or the effort is properly staffed), partnerships can be successful. It is important to make the dissemination plan as malleable as possible (within reason) and avail intervention components in multiple formats (such as Internet, DVD, CD, and/or print formats). Also, keep in mind that the partnership is a process, not an endpoint. Successful dissemination partnerships will require a great deal of correspondence and adjustments for each site’s needs.
A Case Example Using Threat Appeal and Progressive Dissemination Techniques
In recent years, our research team has used both threat appeal and progressive dissemination techniques to make our booster seat messaging more effective. The results of these efforts are summarized here.
Message Creation and Evaluation
With funding from the Centers for Disease Control and Prevention, our team created a 6-minute video-intervention entitled Boost ‘em in the Back Seat that uses a threat appeal approach to inform parents of the importance of placing their children in booster seats and in the rear seats of vehicles. The video includes crash test footage, portraying the power of crash forces and evoking high emotion by means of vivid imaging (without gore). It simultaneously targets increased fear related to the hazard and increased efficacy related to the recommended protective behaviors. Efficacy is enhanced in the video through modeling and discussing the ease of booster seat installation, techniques for getting a child to accept and use a booster seat, the low cost of booster seats, and by combating other key barriers cited by caregivers as reasons for nonuse.
The video-intervention program was evaluated at two after-school care centers via an interrupted time series design with two similar control sites for comparison. The study is detailed in a publication in Accident Analysis and Prevention (Will, Sabo, & Porter, 2009); therefore, only a brief summary of the findings is provided here. Caregivers (N = 226) completed pre–post surveys assessing knowledge, fear, and efficacy related to childhood motor vehicle hazards. In addition, researchers observed booster seat and rear-seat use in school parking lots before, during, and after video program implementation (for 20 weeks).
The study’s results were in the hypothesized directions and indicate that the video program was successful. Compared with baseline and control assessments, the treatment groups’ child passenger safety knowledge, risk-reduction attitudes, and behavioral intentions increased significantly from pretest to posttest. The video significantly increased parents’ sense of threat related to the hazard and sense of self-efficacy and response efficacy related to the recommended behaviors. Trend analyses of behavioral data confirmed that, as hypothesized, there were significant increases in observed booster seat use following exposure to the intervention video compared to both baseline and to control sites. Although no changes were noted regarding rear-seat use (possibly because of ceiling effects), the intervention resulted in a 16% increase in booster seat use over baseline level. Although these results are certainly promising, additional research with the video is needed, including research with a longer follow-up and an education-only comparison group.
Message Dissemination
Once the video was developed and initial research supported its efficacy, our research team began exploring methods of dissemination. We received two grants for various aspects of dissemination research with the video: (a) a 3-year federal Highway Safety Grant from the US Department of Transportation and Virginia Department of Motor Vehicles and (b) a 2-year private grant from Obici Healthcare Foundation. Our goals for dissemination were to be progressive when informing the public; thus, rather than giving the video to parents (who may or may not watch it later), we focused on showing it to parents. In considering the placement for the intervention, we partnered with other agencies to arrange for sensible distribution points. Our dissemination venues included health service agencies, coalitions and safety agencies, and the Internet.
Intensive partnerships with health service providers
Effective booster seat programs require distribution channels that are likely to reach a large majority of parents of 4- to 8-year-olds in a community. Therefore, our initial mode for disseminating the Boost ‘em in the Back Seat video was to use well-child clinics, car seat/booster seat clinics, shot clinics, WIC clinics, and other avenues of contact with parents at physician offices and health departments. We partnered with the staff at 20 offices and trained them to show the video to parents and caregivers (rather than giving parents a copy).
Each partnering site established their own means of incorporating the video into the routine (e.g., showing the video on the TV in the waiting area, on portable DVD players in exam rooms, or during training/education sessions). Successful implementation of the program depended on it becoming a part of the everyday office routine, as relegating the intervention to “down-times” inevitably led to low use. Partner sites administered a brief parent survey when feasible and completed periodic staff feedback sheets to communicate their frequency of use. Email correspondence was maintained weekly, and phone or face-to-face contact occurred approximately bimonthly on an as-needed basis.
The program tended to be difficult for the busy schedules of many physician offices, because of time pressures and lack of insurance reimbursement for the physician’s/nurse’s time. Those physicians who were able to incorporate the video successfully showed the video during wait times and designated two or three staff members as program coordinators who were responsible for showing the video and administering surveys. The parent surveys, especially, were difficult to incorporate in many physician settings because of time constraints. Thus, the surveys were made optional for many sites. Health department partnerships were quite fruitful, because these partnering sites opted to show the video and administer the survey during safety trainings and WIC clinics that were part of the process of receiving services (e.g., parents qualifying for a free child restraint were required to attend a child passenger safety training).
Partnerships with coalitions and safety advocates
In Year 2 of the dissemination period, we began partnering with various coalitions and safety advocates who used the video in their educational efforts, but did not participate in the evaluation (survey) portion of the program. The inclusion of coalition and safety advocates greatly increased the program’s scope of reach. These partners used their vast connections to disseminate the video to other groups and safety professionals, creating a ripple effect for the program.
Web-based dissemination
In Year 3 of the dissemination effort, we created a website that contained the free, downloadable Boost ‘em in the Back Seat video in English and Spanish languages, as well as useful child occupant information and resources for parents and professionals. The website URL was forwarded to approximately 1,700 safety advocates/agencies in the United States, notifying them of the website and the empirically supported video available for free download to use in their education efforts. This was a key step in spreading the message. While downloading the video, people were given the option to complete a very brief survey about their intended use of the video. To further enhance networking capability, we also posted the video on YouTube and created a Facebook page for the program.
Survey and Process Evaluation Results
Results of pre–post parent surveys in health service sites
At some partnering health service sites, caregivers viewing the video had the option to complete a pre–post survey. The 24-item survey assessed pre- and postintervention attitudes and knowledge regarding booster seats. Survey respondents (N = 688) were mostly females (85.0%) who were younger than 30 years (63.6%) and had an annual income of less than $16,000 (52.9%). Race was fairly evenly distributed between Blacks (48.6%) and Whites (39.9%). Education level varied, with about one third each reporting having a high school diploma (32.5%) or some college (29.7%).
Five subscales were assessed, and all revealed significant positive increases from pre- to postintervention. The results of these parent surveys replicate and support the findings of the initial evaluation study. Specifically, parents’ perception of threat severity significantly increased from preintervention (M = 4.14, SD = 1.12) to postintervention (M = 4.55, SD = 0.93), t(687) = −9.85, p < .001, indicating an increase in parents’ perceived severity of the consequences of not using a booster seat. Parents’ perception of susceptibility significantly increased from preintervention (M = 11.74, SD = 3.10) to postintervention (M = 12.07, SD = 3.16), t(665) = −3.51, p < .001, indicating parents’ increased belief that their child is susceptible to injury if not in a booster seat. Response efficacy significantly increased from preintervention (M = 4.34, SD = 0.87) to postintervention (M = 4.67, SD = 0.68), t(685) = −9.91, p < .001, indicating an increase in parents’ belief that using a booster seat for their child would lessen the likelihood of crash injury. Self-efficacy significantly increased from preintervention (M = 4.38, SD = 0.87) to postintervention (M = 4.65, SD = 0.67), t(687) = −8.18, p < .001, indicating an increase in parents’ belief that they can use a booster seat successfully. Finally, knowledge significantly increased from preintervention (M = 32.52, SD = 5.42) to postintervention (M = 35.12, SD = 6.09), t(642) = −10.06, p < .001, indicating an increase in parents’ overall knowledge about booster seats, including why they are important and how to properly use them. Regarding perceptions of the video, 92% of parents agreed that they learned a lot from the video. In all, 96% of parents agreed that every parent of a booster-age child should see the video.
Frequency feedback from staff in health service sites
To monitor health service sites’ use of the video, we collected periodic staff feedback sheets from partnering sites from June 2008 to September 2010. During that time frame, we received 96 feedback sheets from 12 partnering sites. Based on this feedback, racial demographics of caregivers who viewed the video are as follows: 52% Black, 41% White, 5% Hispanic, 1% Asian, and 1% other. Caregivers who were shown the video were mostly female (91%), and represented a variety of age groups: 47% aged 18 to 25 years, 37% aged 26 to 34 years, 15% aged 35 to 45 years, and 1% older than 45 years. These demographic data are representative of the clientele of our partnering sites. Sites’ reported use of the video varied greatly, from several times a day (14.7%) to once or twice a week (16.8%), and approximately one-third of sites reported that they used the video once or twice a month (28.4%). The number of caregivers who were recruited to view the video each month varied greatly, as well, ranging from 1 to 309. Following a careful process of working with the sites to determine how to work the video into their routines, the vast majority of partnering sites reported that the video did not greatly distract from their normal routine (84.8%), which is promising.
Intended-use feedback from the website survey
Using the Internet was, by far, the best means of disseminating the video to the greatest number of people. When individuals download the Boost ‘em in the Back Seat video from the website, they have an option to complete a survey regarding intended use of and audience for the video. Among those who completed the optional survey (N = 165), we have garnered some exciting information. The majority of individuals who downloaded the video and completed a survey were safety advocates from across the United States (primarily) with the intent of showing the video to caregivers as well as industry professionals during trainings, classes, presentations, and exhibitions. After viewing the video online, 96.3% of respondents indicated that they will show the video to others. The intended frequency of showing the video to others varied greatly, ranging from one time to daily. The number of intended people to whom they will show the video varied greatly as well, ranging from 10 to 80,000 annually. Based on the website surveys alone, it is estimated that approximately 183,000 individuals will be shown the video in the next year.
Outreach summary
These varied dissemination methods have allowed us to make an otherwise passive intervention more progressive. Through the natural process of diffusion of innovations (e.g., Internet forwarding and word of mouth), we have distributed approximately 3,561 copies of the Boost ‘em in the Back Seat video to 1,284 agencies. Through their reported dissemination efforts and ours, our conservative estimate is that the video has been viewed by approximately 431,600 individuals in 3 years.
Discussion and Conclusions
Safety advocates are presented with both challenges and opportunities for promoting booster seat use. On the one hand, recommending a booster seat is a relatively straightforward recommendation (when compared with say, losing weight or quitting smoking), which results in dramatic improvements in safety (i.e., 45% better protection than a safety belt; (Arbogast, Jermakian, Kallan, & Durbin, 2009). On the other hand, caregivers of booster-age children are a difficult group of caregivers to reach given low perceptions of risk, poor recognition of booster seat effectiveness, flawed understanding of crash forces, and a number of other competing factors such as child protest and legal loopholes.
Stage models such as the PAPM remind us that it is important to examine whether or not a health message is appropriate for the audience. Education-only messages common in child passenger safety are only appropriate for caregivers in the “unaware” stage of the PAPM. If much of the US booster seat audience is in the unengaged stage, then our task as public health professionals is to design a more aggressive intervention to motivate action. This will mean not only enhancing the health risk message to motivate action but also changing the intervention approach from passive to more aggressive. Threat appeal and progressive dissemination techniques may target participation and perceptions of vulnerability among this population more effectively than traditional education-only messages where the audience must seek out the intervention. Our research using these techniques to promote booster seat use produced significant improvements in knowledge, risk-reduction attitudes, efficacy, perceived threat, and an observed 16% increase in booster seat use over baseline level. Armed with research supporting the intervention’s efficacy, we then used progressive dissemination techniques to reach a wide audience of more than 431,600 people and counting.
Footnotes
Acknowledgements
Portions of this research were supported by Grant Number 1 R49 CE000240-01 from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Grant Numbers OP-2008-58238-3174, RS-2009-59177-3480, and K3-2010-50119-3739 from the US Department of Transportation and Virginia Department of Motor Vehicles, and Grant Number 36 from the Obici Healthcare Foundation. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, the National Center for Injury Prevention and Control, US Department of Transportation, Virginia Department of Motor Vehicles, or Obici Healthcare Foundation. The Boost ‘em in the Back Seat intervention video is available for free download at 
. (Video Copyright 2005, 2010, Kelli England Will, Ph.D.). The authors wish to thank the many health professionals, research assistants, and student volunteers who helped with the data collection and video dissemination.
Authors’ Note:
Krystall E. Dunaway, PhD, is now a Program Evaluation Specialist at Virginia Beach City Public Schools, Virginia Beach, Virginia, USA. Diane A. Kokorelis, MS Ed, is now a graduate student in the Department of Education for Biology at Old Dominion University in Norfolk, Virginia, USA. Cynthia Shier Sabo, MS, is now a Scientific Administrator in the Department of Biostatistics at Virginia Commonwealth University in Richmond, Virginia, USA. Edward J. Lorek Jr., MS, is now a Human Systems Specialist at Research and Engineering Development, Inc., in Lexington Park, Maryland, USA.