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Identifying Information That Promotes Belt-Positioning Booster Use Volume 2: Appendices 1. Report No. 2. Government Accession No. 3. Recipient's Catalog No. DOT HS 811 019 4. Title and Subtitle 5. Report Date Identifying Information That Promotes Belt-Positioning Booster Use Volume II: Appendices July 2008 7. Authors 8. Performing Organization Report No. 6. Performing Organization Code Flaura K. Winston, M.D., Ph.D.; Danielle C. Erkoboni 9. Performing Organization Name and Address 10. Work Unit No. (TRAIS) The Center for Injury Research and Prevention The Children’s Hospital of Philadelphia 34th and Civic Center Blvd. Philadelphia, PA 19104 11. Contract or Grant No. DTNH22-01-C-05845 12. Sponsoring Agency Name and Address 13. Type of Report and Period Covered Office of Behavioral Safety Research National Highway Traffic Safety Administration 1200 New Jersey Avenue SE Washington, DC 20590 Quantitative and qualitative research conducted July 2003 to October 2006 14. Sponsoring Agency Code 15. Supplementary Notes 16. Abstract Many parents with low educational attainment prematurely graduate their children to seat belt restraint rather than use belt-positioning booster seats. This study aimed to identify interventions that promoted booster seat use among this population. Focus groups were used to elicit factors contributing to booster seat nonuse, which informed subsequent intervention development. A first phase (10 focus groups, n=117) identified parents’ perceived barriers, benefits, and threats relating to booster seats. These findings were used to identify existing and create new interventions. A second phase (20 focus groups, n=171) elicited parent’s reactions to these interventions and provided parents with belt-positioning booster seats and education on their use. Follow-up interviews were conducted six weeks later. Lack of education and fear of injury were the primary barriers to booster seat use. Parents were motivated by interventions that provided clear, concrete messaging relating to use. Parents favored the intervention that presented a real story detailing a child’s severe injury that could have been prevented with appropriate restraint. At follow-up, parents credited this intervention with motivating booster seat use most often Although parent’s cited their child’s lack of comfort and noncompliance as barriers to use, they were not as motivated by interventions that addressed these barriers. Effective intervention programs can be created by identifying and addressing factors that contribute to a population’s intention to use belt-positioning booster seats. In addition, successful programs must use messages that motivate the target population by addressing their perceived threats to booster seat nonuse. 17. Key Words 18. Distribution Statement motor vehicle safety, child safety seat, booster seat, qualitative research, focus groups This report is free of charge from the NHTSA Web site at www.nhtsa.dot.gov 19. Security Classif. (of this report) Unclassified 20. Security Classif. (of this page) Unclassified i 21. No. of Pages 22. Price Table of Contents 1. Phase 1 Appendices........................................................................ 1 1.1 Phase 1 Recruiting Flyers ..........................................................................................1 1.2 Phase 1 Screening Form.............................................................................................2 1.3 Phase 1 Focus Group Moderator’s Guide..................................................................6 1.4 Phase 1 Consent Form .............................................................................................11 1.5 Phase 1 Participant Information Form .....................................................................13 1.6 Phase 1 Coding Rubric.............................................................................................17 1.7 Phase 1 Focus Group Discussion Summary ............................................................19 2. Phase 3 Appendices .............................................................................................35 2.1 Phase 3 Recruiting Flyers ........................................................................................35 2.2 Phase 3 Screening Form...........................................................................................39 2.3 Phase 3 Focus Group Moderator’s Guide................................................................43 2.4 Phase 3 Consent Form (English and Spanish) .........................................................50 2.5 Phase 3 Participant Information Form (English and Spanish).................................52 2.6 Phase 3 Coding Rubric.............................................................................................64 2.7 Phase 3 List Ranking ...............................................................................................66 2.8 Phase 3 List Ranking Top Five................................................................................67 2.9 Phase 3 List Ranking Discussion Summary ............................................................77 2.10 Phase 3 Focus Group Intervention Discussion Summary......................................90 2.11 Phase 3 Booster Seat Giveaway Consent Form...................................................102 2.12 Phase 3 Booster Seat Giveaway Script ................................................................108 2.13 Phase 3 Booster Seat Giveaway Form .................................................................110 2.14 Phase 3 Post-Discussion Forms (English and Spanish).......................................114 2.15 Follow-Up Telephone Interview Script ...............................................................120 3. Injury Free Coalition For Kids (IFCK) ....................................................131 3.1 IFCK Background Information..............................................................................131 iii APPENDIX 1.1: PHASE 1 RECRUITING FLYERS 1 APPENDIX 1.2: PHASE 1 SCREENING FORM Screener Name: _________________________ City: Date: _________________________ ____________________ Criteria for Groups (need 10 people per group): • Race: African American, Hispanic or White (depending on city) • Parents or stepparents of children 3-6 • Must regularly drive or ride with children in vehicles (excluding public transportation) • High school or less education. • Aged 21 and above • Use car seats or booster seats, at least occasionally OR • Use safety belts Why are you holding this focus group? ¾ To find out parents’ opinions about booster seats and young children while riding in vehicles. What is a focus group? ¾ An informal discussion with about 10 people. There are no right or wrong answers. We are looking for opinions. Participation is confidential. Thank you for calling. My name is ___________ and I work for the Pacific Institute for Research and Evaluation. We’re recruiting parents for a group discussion at ______________ community center on ___________day/date. We will pay $60 and provide food for parents who take part in a 2-hour group discussion. I’d like to ask you a few questions to see if you will be able to participate. Screening Questions: 1. How did you hear about our study? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. Do you have any children between the ages of 3 and 8 years of age? Yes No [THANK AND END] 2 3. Are you the: birth parent adoptive parent step parent other [THANK AND END] 4. What is your racial or ethnic background? (Continue or end conversation based on groups needed) African American/black Caucasian/White Hispanic/Latino Asian/Pacific Islander Mixed Race Other 5. (If Hispanic) What language are you most comfortable with? English Spanish Note to screener: Based on your interaction with participant: Could he or she participate in an English language focus group, or is a Spanish Language group needed? English Spanish 6. Are you 21 or older? Yes No [THANK AND END] 7. NOT COUNTING public transportation like buses and subways, How often do you drive or ride with your children in a vehicle,? Is it … Every day Several times/week Several times/month Several times/year [THANK AND END] Never [THANK AND END] 8. What is the highest level of education you have completed so far? Grade school/ Elementary School Junior School/ Middle School High School/ GED College [THANK AND END] Graduate School [THANK AND END] Other _______________________ [THANK AND END] 3 While we know that child safety seats, booster seats and seatbelts are a good idea, we also know that there may be times when they are not used. For your children aged 3 to 6 9. Do you ever put them in car seats or booster seats when they are in a vehicle? Yes [Assign to group] No [GO TO QUESTION 10] 10. Do you ever put them in safety belts when they are in a vehicle? Yes [Assign to group] No [THANK AND END] PROVIDE DETAILS TO THOSE WHO QUALIFY: A. Because of the nature of the groups and because we do not have child-care, no children will be allowed (so please don’t bring your kids). B. I can give you the directions now, and we will follow up by mailing the directions to you, also. [give directions] C. May I have your full name, address, and daytime and evening telephone number, where we can reach you? We will keep this totally private and will only use this information to contact you about the group discussion. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ D. We have a few suggestions when you come to the group: a. Please arrive 15 minutes ahead of time. b. If you cannot make it, please cancel at least 24 hours before the group so that someone else can take part in the study. c. Bring your reading glasses, if you need them. d. Also, before you come to the meeting, please take a moment to write down the type of child seat you have. We are glad you’ll be joining us. Please put this on your schedule. We will see you on [DATE]. We will also send you a confirmation letter and directions. Please call me at _____________ if you have any questions or need to cancel. 4 TO END CONVERSATION FOR SOMEONE WHO DOES NOT QUALIFY: We appreciate your interest in this project. At this time, we don’t have any openings for you in the focus groups we are trying to fill. If you’d like to leave your name and number, we will call if we get an opening. Name ________________________________ Phone Number __________________________ Thanks for calling. 5 APPENDIX 1.3: PHASE 1 FOCUS GROUP MODERATOR’S GUIDE FOCUS GROUPS MODERATOR’S GUIDE Note: This is a guide, not a script. Moderators may vary topics and probes to accommodate particular sites and groups. Introduction • • • • • • • • • • Moderator welcomes participants and introduces self and co-facilitator. Introduce any observers. Explain what CHOP/PIRE is and who is paying for their participation. Explain the study and the purpose of the group discussion (e.g. to learn more about what you, as parents of 3-6 year old children, think about how children ride in motor vehicles) Preview what will happen during the group, when they will be paid, etc. We are interested in your opinions. There are no right or wrong answers. Information we collect will be summarized only for this project. What you say will be kept totally private. We will not use any names or quote anyone by name. Read and explain the consent form to the participants and answer questions they may have. We value the information you will share with us today and want to make sure we capture all of it. So we will be taping the session and taking notes. If at any time you want to say something without the recorder on, tell us and we’ll turn it off. Is everyone okay with that? This will be an informal discussion. We will talk for 1½ hours. There will be no formal breaks, but please feel free to get up at any time to stretch, go to the bathroom (provide location), or get something to eat or drink (indicate table with refreshments). We appreciate your input very much. Any questions? Ground Rules of Group Discussion • We would like only one person to talk at a time. But we hope that each of you will speak up, and tell us your thoughts and feelings, even if they are different from what others have said. We are interested in both negative and positive comments. • We know that some of you may have more than one child between the ages of 3-6 years old. When we ask you about your child, we mean your YOUNGEST child who is between the ages of 3-6 years. • Since there are several types of motor vehicles, when we ask about your child in a VEHICLE, we mean personal automobiles like cars, pick-up trucks, vans, and sports utility vehicles (SUVs). NOT public transportation vehicles like trains, buses, or taxi­ cabs. 6 (Turn on Recorder) ICEBREAKER This first question helps highlight the common characteristics of the participants and that they all have some basis for sharing information. • “Let’s go around the room, one at a time…”: Ask participants to introduce themselves with first name only and tell the group the number and ages of their children (note: we normally have first name “tents” on the table to facilitate the discussion) Discussion Topics and Probes I. CHILD’S REACTION TO RESTRAINT • How active is your child when riding in a vehicle? Describe his or her activities (i.e., getting out of CSS/BS/SB or changing seats). • Who usually has control over how children behave while in the vehicle? • What are some of the rules that your children must follow when they ride in a vehicle? How does your child react to these rules? • How does your child react to being in a restraint (CSS, BPB or seatbelt)? How do you respond when/if your child fights again using a restraint? (Probe: type of negotiation, games, bribes, etc.) • How does your child react when s/he sees other children his/her age riding in a child safety seat or booster seat? How do you respond to this? • If your child had a choice to use a CSS or BS, SB or nothing at all, which one do you think he or she would choose? For what reasons? II. CPS MESSAGES AND KNOWLEDGE • Tell me what you’ve heard or know about booster seats? From whom (person, media, etc)? What did this information mean to you? • Do you think there is a difference to a child’s safety in whether the child uses a booster seat or a seat belt (without the child seat)? • What people (no names, just who it is – like “sister,” or “friend”) or names of groups do you believe would/would not want you to use a booster seat for your child? • Is there a booster seat law in your State? What’s the law about CRS use in your State? Where did you hear about the law? How well do you think the law is enforced? III. PERCEIVED THREATS AND BARRIERS • How often do you think about or worry about the possibility of being in a vehicle crash (parent & child involved)? What triggers these thought or worries? • In a crash, what are some things that would make your child more likely to be seriously hurt? 7 • What things do you do to prevent a crash? To prevent your child from being injured? • What would make it HARD for you to use a booster seat for your child? VI. PERCEIVED BENEFITS • What would make it EASY for you to use a booster seat for you child? • If a hospital in your community OR other health or safety-related agencies (e.g. Girl Scouts, hospitals, churches) wanted to get people to use booster seats with their children, how would you recommend they do it? (probe: what would make you want to use one; not want to use one) • How do you expect your child to ride in a vehicle when he or she is 7 or 8? • For Seat belt users Only: What, if anything, would make you consider moving your child to a booster seat? IV. PRIOR RESTRAINT USE (For Seat Belt Users Only) • When did your child start using seat belts regularly (alone) when riding in a motor vehicle? Why did your child start using seat belts regularly at that time? • What, if anything, was the child using before going to regular use of a seat belt? How long was the child using that type of restraint? • What did your child like/dislike the most about using the CRS? How did you respond when/if your child fought against using the CRS? (Probe: type of negotiation, games, bribes etc.) • When your child moved from the CRS to the seat belt, did you feel there was any difference in how well protected your child was? If YES, how would you describe the difference? Would you have preferred an alternative to the seat belt at the time? V. CURRENT RESTRAINT USE Thinking about your youngest child between the ages of 3 and 6… • What kind of restraint do you use for your child? • Are there any recent changes in the type of restraint used? If yes, why? • How long do you think your child will use the type of restraint he/she currently uses? What will he/she use next? • Under what circumstances would your child NOT use a restraint? • For seat belt users only: How does the seat belt fit your child? What, if anything, do you or your child do with the seat belt to make the child more comfortable? • For Booster Seat Users Only: Do you have any advice for parents about using boosters? CARD SORT EXERCISE We’re going to take a few minutes to do something different now. We are going to pass out a piece of paper. At the top of this paper, we want to know what type of restraint you use for your youngest child between the ages of 3 and 6. First, please check whether it is a child seat, a 8 booster seat, a seatbelt or you don’t know. Next, if you are using a child restraint, please circle the picture that looks most like the one your child uses. Don’t put your name on the paper because we’re going to be collecting it later. Now, we are going to pass out an envelope to each of you. In the envelope, there are cards with words on them that you might use to describe the good and bad things about using a child restraint for your child. I am going to read through the words on the cards and you will pick out the ones that you agree with and put them to the side. Read list of words: • • • • • • • • • • • • • • • • • • • • • • • • Comfortable Uncomfortable Safe Unsafe Easy to use Hard to use Light weight Heavy Easy to move to another car Hard to move to another car Inexpensive Expensive Good features, such as cup-holders No features Takes up too much space Child dislikes Enables child to see out of window Child likes Child thinks it's a “big kid” seat Child thinks it's a “baby” seat Keeps child under control Child can easily get out Easy to put in car Hard to put in car 9 [After reading through list]: Put only the cards that you chose back into the envelope and leave the other ones on the table. Please hand in the envelope. Discussion: • What are the good/bad things about using a restraint for your child all the time/some of the time? (i.e. child-related issues/reasons/advice to parents, purchasing/obtaining a seat, placing it in car, etc)? • What does your child like/dislike the most about using a restraint? • For car/booster seat users only: In what cases would your child ride in a seat belt rather than in a child safety seat or booster seat? What motivates you to put your child back into a child safety seat or booster seat the next time you are in the car? Summary and Closing • • • • Moderator Summary/Key Points Are there any final comments? Thank participants Distribute cash envelopes; have participants sign the receipts 10 APPENDIX 1.4: PHASE 1 CONSENT FORM Research Consent Form Building on Findings of the Partner’s Study – Identifying Interventions that Promote Child Restraint Use Purpose: You are being invited to participate in a research study to find out information about what parents think and believe about using child safety seats (such as infant seats and booster seats) for their children, when traveling in motor vehicles (personal automobiles: cars, pick-up trucks, vans, and sports utility vans [SUVs]). You will also be asked about what ideas you might have to help parents improve their use of child safety seats for their children. Selection of Subjects: You have been asked to be a part of this study because motor vehicle crashes are a leading cause of death and acquired disability among children in the United States. The use of child safety seats reduces the risk of injury and death, but many children, especially those 4-8 years old, often ride in motor vehicles, while in child safety seats that are used incorrectly, inappropriately, or without using them at all. As parents of children ages 4-8 years old, the information that you can provide is very important and may be used to guide the development of programs to examine and promote the use of child safety seats. Focus groups recruited to participate in this study will include at least two groups from the Children’s Hospital of Philadelphia, totaling at least 16-20 participants. Procedures: This study has two parts and will last about two hours. In the first part, you will complete a registration form and a brief questionnaire. You will be asked to answer a series of questions about how you feel about using a child safety seat for your child, when traveling in a motor vehicle. You will also be asked information about your background and factors or things that influence your use of a child safety seat for your child. This part of the session will take about ½ hour to complete. The second part of the study is an open focus group discussion that will last about 1½ hours. You will be asked about your thoughts and beliefs on topics such as the risk of children traveling in motor vehicles without being in a child safety seat, and the benefits of using a child safety seat for your child when traveling in a motor vehicle. Although specific questions will be directed to the entire group, you are encouraged to answer individually and respond freely. Notes will be taken on the responses provided and the session will be audio taped. Members of the research team from the Children’s Hospital of Philadelphia will observe focus group sessions. This will take place by using a room with a one-way mirror. If this type of room is not available, the sessions will be video taped so that team members can observe through a television monitor located in another room. Note taking, audiotaping, and observations for this part of the study, is necessary, so that your information is not lost or misunderstood for future use. Any videotaping or audiotaping that takes place will be destroyed at the close of the study. Potential Risks: The possible risk of being a part of this study is that you may be upset due to some of the personal questions asked, and/or the nature of motor vehicle occupant injury-related 11 facts provided. If you are too uncomfortable by the facts provided, you are to notify the staff immediately. Also, if you are uncomfortable answering any question on the written questionnaire, you may skip it and write “too personal” in the margin. Benefits: You will benefit directly from being a part of this study. Benefits that you will receive include: 1) your answers to the questions, which are very important, may be used to guide the development of programs to examine and promote child safety seat use; and 2) you will be given important information about the use of child safety seats for your children Alternatives: The alternative to participating in this study is not to participate. Confidentiality: All information collected in this study, including videotapes (if session is taped) and audiotapes, will be kept strictly confidential, as permitted by law. If any publication results from this research, you will not be identified by name. Your name will not be placed on the questionnaire. Instead a code number will be used. You will not be identified by your last name on the audiotapes or videotapes to ensure confidentiality. All information will be kept in a secure location. Audiotapes will be destroyed at the close of the study. Any videotaping that takes place will be destroyed after the research team observes group sessions. The research team and other staff at The Children's Hospital of Philadelphia, the Pacific Institute for Research and Evaluation (company conducting focus groups), the Institutional Review Board at The Children's Hospital of Philadelphia, the sponsor (National Highway Traffic Safety Administration) and any government agencies involved in the oversight of this research may have access to information that identifies you as a subject in this research. PIRE will store audiotapes and videotapes. The PI and Co-PI will be responsible for maintaining all of the collected participants’ personal information and all data collected from the Participant Information Collection Instrument in a locked file cabinet that will be located in TraumaLink, at CHOP. Financial Considerations: There are no financial costs for you to be a part of this study. You will be paid $60.00 for being in this study. Questions: All of your questions should be answered to your satisfaction before you consent to participate in this study, but if you have any further questions about the study you may call Dr. Flaura K. Winston at (215) 590-3118 or Dr. Edith M. Simpson at (215) 898-2280. If you have any questions about the rights of research subjects, you may call Lynn Bevan in the Office of Research Regulatory Affairs at 215-590-2830. Voluntary Consent: You are free to withdraw or refuse your consent, or to discontinue your participation in this study at any time without jeopardizing the care that you and your child may receive now or in the future from the Children’s Hospital of Philadelphia. I voluntarily give my consent to participate in this research study. I understand I will be given a copy of this consent form. Subject’s Name: _________________________________ (please print) Subject’s Signature: ______________________________ Date: _________________ Person Obtaining Consent: ________________________ Date: _________________ 12 APPENDIX 1.5: PHASE 1 PARTICIPANT INFORMATION FORM PHASE ONE PARTICIPANT INFORMATION FORM We would like to learn a little more about you. We will not use your name with this information. If you don’t want to answer a question, you can skip to the next one. All answers will be kept private and confidential. Please DO NOT PLACE YOUR NAME on any part of this form. Let us know if you have any questions. Section 1. Information About You 1. How old are you? ________ years. 2. Are you? Living with partner Single, never married Separated 3. Are you? Married Divorced Other:__________________ African American/Black Hispanic/Latino Asian/Pacific Islander White Mixed Race Other:__________________ 4. Do you work outside the home? No (If No, go to # 5) full time? IF YES: Do you work Yes part-time? What is your job title? ______________________________________ 5. What are the ages of your children that live with you? ____ 6. Do you drive a vehicle? Yes ____ ____ No IF YES: Is there a vehicle that you usually drive? Yes No 7. What make (like Honda or Toyota) and year of vehicle do you drive most of the time? Make: ___________________ Year: __________ 8. What type of vehicle do you drive the most? Car Pick-up Truck SUV Other ____________________ 13 Van ____ ____ Section 2. Children in Vehicles When we ask about your child, we mean your YOUNGEST child between 3 & 6 years old. 9. Of all my children, between 3 and 6 years old, my YOUNGEST child is ______ years old. 10. Not counting buses and subways, in the past 3 months, how often did you and your child usually ride together in a vehicle? Almost every day A few times a week Never A few times a month Don’t know 11. Of these times, how often were you the driver? Always Sometimes Never Rarely Don’t know 12. Who usually decides where your child sits in the vehicle? You spouse/partner no one child other: __________ 13. Who usually decides whether your child sits in a car seat, a booster seat, uses a seatbelt, or uses nothing? You spouse/partner no one child other: __________ 14. The next page shows photos of booster seats. Have you ever used a booster seat for your child? Yes No Never heard of a booster seat until now. 15. In the past 3 months, how often has your child used any of the following? For example, if you child usually uses a booster seat when he or she is in your car, but occasionally rides in another car with a seat belt, then you would answer "Sometimes" to Booster seat and "rarely" to seat belt only. A. Car Seat Always Sometimes Never Rarely Don’t know 14 B. Booster Seat Always Sometimes Never Rarely Don’t know C. Seat Belt Only Always Sometimes Never Rarely Don’t know 16. In the past week, how many days did you drive or ride in the car with your child? Number of Days _______ 17. In the past week, how often did your child use any of the following? A. Car Seat Number of Days ________ B. Booster Seat Number of Days ________ C. Seat Belt Only Number of Days ________ 18. In the next 3 months, how often do you expect that your child will use any of the following? A. Car Seat Always Sometimes Never Rarely Don’t know B. Booster Seat Always Sometimes Never Rarely Don’t know C. Seat Belt Only Always Sometimes Never Rarely Don’t know 15 WHAT IS A BOOSTER SEAT? A booster seat raises your child up so the seat belt fits right. These are common types of booster seats: 16 APPENDIX 1.6: PHASE 1 CODING RUBRIC I. Concepts and characteristics that describe participants in general terms A. Child passenger safety information 1. 2. 3. 4. 5. Child passenger safety messages received by respondents Sources of CPS messages Respondents’ knowledge of CPS Source of CPS knowledge Why and when changes from one type of restraint to another a. How to use a booster seat b. Child passenger safety laws and fines c. Situational influences i. Child’s activity in car ii. Other drivers’ behavior iii. When unrestrained B. Personality characteristics C. Perceived driving skills C. Past behavior E. Previous experiences II. Fundamental concepts on which summary concepts build A. Perceived threats B. Perceived benefits 1. 2. 3. 4. 5. Why child likes booster seat Why child likes child safety seat Why parents like booster seat Why parents like child safety seat Positive outcomes C. Perceived barriers 1. 2. 3. 4. 5. 6. Why child doesn’t like booster seat Why child doesn’t like child safety seat Why parents don’t like booster seat Why parents don’t like child safety seat What child prefers as restraint Obstacles to CRS use 17 D. Current behavior E. People who matter F. Control beliefs 1. Who has control over behavior? 2. Control over preventing crash or injury G. Perceived self-efficacy 1. Rules in the vehicle 2. Discipline strategies to maintain safe behavior 3. Child’s reaction to rules III. Intermediate summary concepts that pull together fundamental concepts A. Behavioral beliefs B. Outcome evaluation 1. Enforcement of laws C. Normative beliefs 1. People who don’t interfere with safety behaviors 2. People who support safety behaviors 3. People who interfere with safety behaviors D. Motivation to comply E. Subjective norm F. Perceived behavioral control 18 APPENDIX 1.7: PHASE 1 FOCUS GROUP DISCUSSION SUMMARY Child passenger safety (CPS) knowledge General CPS knowledge held by respondents Largely, the CPS messages held by participants were unclear and lacked focus on important details. Many parents cited misinformation or conflicting information, especially relating the age at which children should be moved from one type of restraint to another. Examples: A: Because there are some, like one that my son has, it says that from twenty pounds, twenty or twentyfive pounds, up to ten years. A: I imagine the booster seat is up to seven years. A: I had heard that up to eight or nine years they had to use the regular seat, the safety seat, and the booster one is for the ten or eleven-year-olds, I think that's what I heard. A: I know it's up to six years. A: From there on it's the seat belt... A: Yes, me too. Up to six years. (Langley Park, Hispanic Females) A: Listen, I didn't know, but since I'm here learning, after 5 children, thank God! It's because I never drove before. She says that it depends on the weight, because I have my 6-year-old daughter and my 3-year­ old son, and the daughter outweighs the son by 5 pounds, and I buckle her in normally with a regular seatbelt, just like mine, and she's 6 and weighs 44 pounds and the boy weighs 39 pounds and he rides in a car seat. (Little Rock, Hispanic Females) Parents took height and weight into greater consideration than age when making decisions about what type of restraint to use. Examples: A: But it also depends on the weight, the size, because if you have a child who is really thin and is 7 or 8 years old, if he is so light then yes, he has to ride curled up in a booster seat. (Little Rock, Hispanic Females) A: That's what they told me when they gave me the seat, that’s why they gave me the seats based on what they weighed; the police gave me the seats. (Little Rock, Hispanic Females) Q: A: A: A: A: How will you know when to move your child into a booster seat? Or, I'm sorry, a seatbelt? A seatbelt? The weight. Height. What is the height and weight? Oh, goodness, I don't know. (Cincinnati, African American Females) Other parents chose to base their restraint decisions on factors outside of their child’s height, weight, and age. Examples: Q: Okay, for those of you who have more than one child between the ages of three and six, what's the difference in how they are restrained in the car? Is there any difference that one of them could be in a booster seat and one could be in a car seat? A: One's in a booster seat. 19 Q: What's the difference? Is it an age thing? Is it the weight thing? Is it just the way they want to do it? A: They've got like different spots where they like to sit. A: Attitude. (Cincinnati, African American Females) Many White parents expressed that when their children complained about a child restraint, they became worn down and eventually changed from a CRS to something more comfortable. Tired of constant opposition, these parents admitted to giving in to their children against their better judgment. Examples: A: There's not enough room, that's why they're supposed to say 65 pounds, but I finally just took my daughter out of a booster seat, and she's six, she's getting ready to be seven. And I'm like, "I'm done playing this game." I mean she's really tall. (Cincinnati, White Females) A: Um-hmm. She'd climb all over the car. She just wanted to sit in the seatbelt, so we tried it, and she's real good about it. A: Probably a sense of being, you know, a little bit grown-up. They don't have to use the baby seat anymore. They're not babies. They can just sit like the big people. (Cincinnati, White Females) The majority of participants did hold several key safety messages to be true. Almost all participants agreed that children should not be seated in the front of the motor vehicle and that infants should be restrained in backward facing car seats. Examples: A: See, I don't let any children ride in the front with me. Q: Without being restrained. A: They don't ride in the front, period. Because of the airbag, and you know, with the underweight thing, you know. (Cincinnati, African American Females) Q: A: A: A: A: A: In a crash, are there things that would make your child more likely to get seriously hurt? Air bags. I think so. If you have them in the front. Uh-huh. Their arms stuck out the window. (Cincinnati, African American Females) A: A: A: A: Right. I think that's even unsafe. I mean, you know, that makes it more unsafe. Um-hmm. That's right. Right, they say you should put it in backwards. It depends on the position of the seat you have, that is to say, if it's a baby seat, it's a bad position to have it in, facing toward the front, isn't it? (Cincinnati, African American Females) Knowledge on CPS laws and fines Participants were often unclear about child passenger safety laws and fines. Many were unsure whether state laws were in place governing car seat and booster seat use, and several maintained that penalties existed for improper restraint regardless of an existing law. In cases where participants all agreed that law was in place, they often could not agree what the law specified. Examples: Q: And what is the law? A: You have to be 60 pounds, 50 pounds-50 or 60 pounds. 20 A: They start out, I think in the city limits, the tickets is $210. But from $210 to like anywhere from 400 and something dollars. A: And then if you don't pay, you'reA: That's if you don't have your child restrained. A: Yeah, or you not having a seatbelt. A: And then if you don't pay, you have a certain amount of days to pay. And then it doubles after that. A: You've got seven days, and then if you don't pay in the seven days, it doubles. If you don't pay it in the next seven, you've got a warning. (Cincinnati, African American Females) Q: Okay. And do you know what that law is? A: It's under so many pounds. A: Forty pounds and four years old or something. A: You've got to have them facing the rear. A: Under 40 pounds? Is it four years old or 40 pounds? A: Under 40 pounds they got to be facing the rear. A: Yeah. And they used to turn them around after a weight. A: One and over 40 pounds, in the car facing front. Q: Does anybody know what the fine is? I'm just curious. A: A thousand dollars. A: A couple hundred, isn't it? A: A thousand dollars if your child is not in a car seat. However many kids are not in a car seat that is supposed to be in a car seat, it's a thousand dollars a child. A: It's supposed to be the parent of the child, but whoever the driver is. Or if there are two adults in the front, they ask whose child, and they give the ticket to that person. But if it's one personA: They usually don't give the ticket, they be so much. That's why they keep giving you warnings (Cincinnati, African American Females) Knowledge on the safety benefits of child restraints The majority of parent participants insisted that there would be no situation where their children would ride unrestrained, as a result of two factors: concern for their child’s safety and fear of fines and tickets. Examples: A: And then to just see a car wreck, you know? I mean that just like puts more thought on your brain to make you want to look on your child and worry. (Cincinnati, African American Females) A: And my son wants to get up there kind of with me. And I won't sit my daughter in the middle of nobody's car. She got to be able to get on the end, and if we don't have a car seat, well, we don't usually go. My friend doesn’t like that. She comes to get us to go to the mall; she does not like that. She's, "Well, I don't got no," "Well, we ain't going." Because their car seat is in their daddy's car and we're not going. And I don't have no money to pay for no ticket. (Cincinnati, African American Females) A: Yeah, and I don't need another ticket. That hurt my pocket real bad! (Little Rock, African American Females) A: Lock them in a car seat, make sure they are always, before you get in the car, check their seatbelt, make sure they're properly buckled down in their seatbelt … I know, I'm real cautious, because I just got a ticket once, $250. Child, I mean, out of their seatbelt. (Little Rock, African American Females) Participants shared their experiences of having an unrestrained child receive injuries during a crash. These incidents and other likes them, encouraged parents to restrain their children properly, by emphasizing the importance of appropriate restraint in motor vehicles. 21 Examples: A: Or that using the car seat can prevent. Because, for example, the truth is I'm always really forgetful about the car seat and, try to remember, eh, we went to Houston and my cousin arrived really frightened because there had just been an accident and the little kid wasn't in a car seat, he went flying and all and the mother ... well, the kid died instantly and they arrested the woman for not having her child buckled into a car seat, and this is what I always think about, so if they would tell you what you can avoid by putting your child in the car seat, I think that it makes you much more careful. (Little Rock, Hispanic Females) A: Well, we were rear-ended, when they were a six-year-old and a year and a half, by a dump truck. So every time I get in the car I'm paranoid. I'm in the rearview mirror the whole time. (Cincinnati, White Females) A: Buckle in the kids, but most of the time or sometimes we don't do it because they don't want to sit, they cry, they struggle, or they want to look out the window and in order to not fight, okay, get in the back or do it yourself, okay my girl climbs in herself, but it's happened to me that all of a sudden I'm on the freeway and I hit the brakes and she went "smack!". "Oh, Mommy, you told me to put on my seat belt!" I tell her, "you see?" We're both frightened, both of us, but yes, it's happened to me. (Little Rock, Hispanic Females) Participant’s current child restraint behavior Most participants stated that under no circumstances would their child go unrestrained; they did, however, differ on what they considered appropriate restraint. Many considered some form of restraint, even if not optimal, significantly better than none at all. Examples: A: Of course there's a difference, it's much safer to use the car seat than to ride with only a seat belt. Or if they don't wear anything, much less. (Langley Park, Hispanic Females) A: Yes, because when, sometimes there are accidents, the first thing they ask is whether the child was buckled up in a safety seat, isn't it? So it's pretty important. It's for the child's safety. (Langley Park, Hispanic Females) A: Or, you take the car seat out and let them sit in the seatbelt, and try to tighten the seatbelt in as tight as you can. You know, I mean... Q: Well, you just alluded to my next question I was going to ask, how does the seatbelt fit the child? I mean do you have to do a lot of adjusting to get it to fit, or do theyA: No, it depends on the child's size. A: It depends on the child's size and the car. A: But sometimes, you know, seatbelts, they got seatbelts to where they only adjust to the child, and then they've got some seatbelts where you've got to pull them and adjust them yourself. (Cincinnati, African American Females) Factors that affect participants’ restraint behaviors Perceived threats Participants were fearful that their children would be injured in a crash as a result of being restrained sub-optimally. Parents were also concerned that their children would distract them, if they were not restrained properly. In addition, parents continued to emphasize their fear of encounters with police officers. Parents found the high penalties associated with restraining one’s child inappropriately to be an important consideration when deciding how to restrain their children. 22 Examples: A: With my daughter I say, "Do you want them to give me a ticket? Do you want me to get a ticket?" and she says, "No, Mami." (Little Rock, Hispanic Females) A: But it's just that its pure chance, I think that it's luck if, if, that is, you're going along and if the police happen to be checking, but if they don't see you, because if he sees he tickets you. It's happened to me. (Little Rock, Hispanic Females) A: Because let's think about it, if he goes in the car seat, and there's an accident, the seat isn't going to move that easily, and also, if he's just seated, or maybe with the seat belt, it could be that in an instant, in the crash it could be that the seat belt isn't that safe or that it could be, it could be a little loose, that he comes out, or if he's not wearing a seat belt, well, God shield me, it will be worse. (Langley Park, Hispanic Females) A: I think they would be, you know, if we were in an accident, them not being, they won't be, if they weren't in their, the booster seat, I think about, you know - I know they can get hurt even, you know, in the booster seat, or whatever, but if they weren't in one, you know, it would be worse. (Little Rock, African American Females) A: I think I worry about the, if we are in an accident, and they were in just a seatbelt, what type of damage that would be done on the neck and shoulder, versus them being in the booster seat and the seatbelt is strapped across their chest more, and not on the neck. (Little Rock, African American Females) Perceived benefits Parents emphasized their child’s comfort or contentedness as a benefit resulting from booster seat use. Parents emphasized that their children had a better view of through the window while in a booster seat. Children also were happy to have a designated seat; parents noted that their children enjoyed the responsibility of their own seat, and the comfort they were provided by not having to be squeezed in an overcrowded car. Children also expressed that they felt like “big” boys or girls in a booster seat. Examples: A: Sitting up high. A: Yeah, sitting up high. A: Yep, they have to keep doing just like, "That's my town." Look back and have the little hand swings, you know. (Little Rock, African American Females) A: Mine likes the fact that the seat’s his. His brothers have their seats, and he has his seat. A: That's how my son is, because my daughter's not in a car seat or a booster seat anymore, and my fouryear-old is. And then when she has to get in there and I have my niece and my nephew, and they all are saying, "Right here." And he's like, "Not my seat." [Laughter.] "I've got my seat, y'all are squished over there, but I've got my seat." (Cincinnati, White Females) A: Because the booster seat is more like an adult seat belt. You know, it can grow with them, and the seatbelt, as they get 5-year-old, a 6-year-old, it can cross over it just like the front can do. So it's more, I think at about 5 or 6, they want to sit in the front, because they know that the moms or dads seatbelt can go over across. But the booster seat has a seatbelt go across it too. A: Make them think they're older. A: Right. And they think like they older, instead of being babies. A: Well it gives them that peace of mind like, "I'm grown up now," yeah. (Cincinnati, African American Females) A: Yeah, they are all high, makes your child feel more privileged and seem like they're more of a big child because they don't have to be in a baby seat, but they're still in a car seat. Tell them how it makes the child feel, and how the child could see out the window more and have more room, they don't feel all stuffed in this little car seat. (Little Rock, African American Females) 23 Again, parents emphasized that the primary benefits of child restraints were their ability to keep children safe. Other benefits included: that boosters were easy to use, lightweight, inexpensive, and prevented arguing between their children. Examples: Q: Do you think your child is safer in a booster seat or a seatbelt? A: Booster seat. A: Um-hmm. (Cincinnati, African American Females) A: The main reason to use the safety seats is for security, to save their life if there is an accident, or that's the main reason and to keep the children from standing up or leaning out the window, if they're not using a car seat or the booster, because they always tend to stand up, they're restless. (Little Rock, Hispanic Females) A: They like more gadgets. The more gadgets or toys on the car seat or booster seat, the better. You know what I mean, keep them more quiet, at least for a little while till you get where you're going. So the more little toys they've got, the more better. A: Or pockets and cup holders. A: Yeah. A: Cup holders and pockets. Because they can stick toys in there. A: They forget things in there, and when you on that long drive, they pull they out like, "I found this toy!" (Cincinnati, African American Females) Participants found that booster seats reduced conflict regarding seat choice among siblings and greatly expedited the process of assembling their children in the car. An additional important benefit for parents was the peace of mind they received from knowing their child was in a booster. Examples: A: He just sort of identified that as it can be your seat, or different, could be your seat. Or when Nicholas is with us, he's like, "Nicholas is there." He just, I think he might be a little bit jealous, but mostly he just identifies that as somebody else's seat. And I think that, you know, the good might be, "That's my seat, and that's Mommy's seat." A: Everybody has their assigned seats. A: Yeah. Just like at the dinner table, everybody sits at the same spot, and they have their seat. A: So it makes him, there's no confusion on where I want to sit when I get in the car today. A: Right. (Cincinnati, White Females) A: One of the other big benefits is, if your kid isn't in the booster seat, if they're not tall enough, which 4'9" is how tall they should be before they go into a seatbelt. They can get seatbelt syndrome, because the belt, the lap belt is up higher on their abdomen instead of being down over their hips. And so like your hips are hard, and the seatbelt should go there, but the booster seat helps position it there. Because if the seatbelt were on their belly, it's all organs and soft stuff in there, and if you get in a wreck, then it can burst organs and cause all sorts of internal damage. And that's one of the major benefits to a booster seat. (Little Rock, African American Females) Perceived barriers Parents expressed that their children did not like to be restrained, and as a result, the children often complained that boosters were hot, itchy, too tight, and generally uncomfortable. Many participants cited giving in to their child’s complaints, and allowing them to ride in a seatbelt, or unrestrained. 24 Examples: A: Well, but sometimes when it squeezes them it bothers them ... that's why they don't want to, but you have to do it for safety. (Langley Park, Hispanic Females) A: You know what bothers them sometimes? For example, if you've your car to clean it and it's hot, they get in and their seat is hot, "No! It's hot!" they say, "It's burning me." (Little Rock, Hispanic Females) Q: Is it that they, do you think it's because, one, that that is just restraining them, or is it actually uncomfortable do you think? A: Both. A: "It's choking me! It's choking me!" My daughter used to do that. A: I think every one, and then you're choking. A: It was with the ones that went like that. "I'm choking." (Cincinnati, African American Females) A: It could be around the child's side, and it really, it still can be uncomfortable. Because if you have a tall kid that has to fit in a car seat, it's uncomfortable. A: Right. A: No matter how you strap it in, they don't hardly know where to move. (Cincinnati, African American Females) The groups also included participants who were skeptical about the benefits of any form of restraint and were especially wary of booster seats. Parents in Little Rock clung to the fear that in a crash their child, if restrained in a booster seat, would be trapped in the car. Examples: Q: Do you think your child is safer in a booster seat or a seatbelt? A: Seatbelt. A: Seatbelt. A: I don't know. (Cincinnati, African American Females) A: Um-hmm. I'm going to get into a car accident, the car is going to catch on fire, and I ain't going to be able to get the seatbelt off me. A: Right. Yeah. A: I'm afraid if I've got a seatbelt. A: Or pressure on it like in a river or something, and you ain't got no knife. (Cincinnati, African American Females) Q: Does anybody else have anything they want to add on that? That you think that, right now you think that the kids are safer in a seatbelt, is that what I'm getting, the idea? At least for most of you, but some of you think that the booster seat is moreA: I'm not sure. A: It depends. Really, I don't know. A: Because you can be safe in a car seat, or you can be safe in a seatbelt, and you can be unsafe in either one. (Cincinnati, African American Females) A: Oh, by weight. No but what you were saying about the booster seats, some booster seats don't work. Some booster seats ain't, they don't have any safety. A: Security. A: Security like, they have to this one booster seat where it goes across their waist and you put the seatbelt across the booster seat and you strap it in. If you would have a car accident, the booster seat would fall out, because it has no security, it has no-it's not tightened in. I was in a car accident and my godson was in one of them car seats, and the car seat slipped out. A: You mean the kind that has like a bar that comesA: Yeah, he just sits in it, you snap it closed. A: And you stick the seatbelt through it like this, and you tighten the seatbelt like to the seat. So every time you get out, you have to retighten it, but it's not-it's not secure. Q: You don't' think it's secure enough. A: No. (Cincinnati, African American Females) 25 Some participants were well versed in the benefits of restraint in a motor vehicle and simply had reservations booster seats. These participants felt the car seat held their children more securely, because the car seat did not solely rely on the vehicle’s seatbelt. Examples: A: The car seat is safer because it's more strapped. You've got the harness or the overhead. So, but, then again, it's also getting him ready for when he has to come out of a car seat, in a way booster, because when he'd sit in the back seat, when he's old enough to sit in the back seat without either/or, it's still going to be wrapped around his stomach. So I feel like it's just getting him ready for when he's able to get out of a car seat and just wear a seatbelt only. (Little Rock, African American Females) A: I think it depends on the booster seat, because besides new modern technology of booster seats, some of them weren't-back in the day, I don't think they were safer than seatbelts. Q: Um-hmm. But you think the technology is improved now, that they are-it's notA: They're safer, but in my opinion now, I think a seatbelt might be safer because, especially if it's a good one that crosses right here and here. (Cincinnati, African American Females) A: I think myself I don't need it. I mean, I can't-if it's not safe for them, I mean I'd rather keep them in a car seat until they just can't car seat no more, for safety reasons. And I never really thought about it until now, if the booster seat really is safe. Because I know they're safe when I'm driving. And I know how I drive, you know, having been in a couple of accidents too, but not as my fault. But I don't feel the booster seats would be very safe, and that I would let my kids outgrow a car seat. (Little Rock, African American Females) A: I wouldn't promote a booster seat because I wouldn't know how safe it is. But I, like I say, I'm doing good with promoting a car seat. I think car seats really work. I mean car seats, they usually strap and plus you've got that little holsters that you can stick a strap down in the car, if you have a van, that keep those car seats really safe. (Little Rock, African American Females) Lack of education was the most significant obstacle to booster seat use. Some parent participants did not feel that they knew enough about boosters to make a well-informed decision on whether to sue them or not. A minority of respondents needed clarification on the definition of a booster seat and was not aware that booster seats for automobiles existed. Examples: A: Because I seriously didn't know what a booster seat, I really thought Wendy's or at home A: Yeah. But that's what they call them at a restaurant. A: Um-hmm. Q: Booster seats, yeah. A: Um-hmm. I'm not going to fit one of them in my car. A: Because I used them high chairs. A: That's what they called, high chairs. That's what we called them. (Cincinnati, African American Females) A: I know car seat a little, but I didn't think about booster seats. A: I didn't know, I thought all of them could sit in a car seat. A: I don't either. A: Car seat, yeah. A: So I didn't know anything about a booster seat, I thought it was just the next level from a car seat, but still a car seat. (Little Rock, African American Females) Children’s behavior was also an obstacle for parents concerning to CRS use. This behavior was suggested in three forms: distracting their parent driver; removing their restraints; fighting in the vehicle. Very few of parents cited having pleasant experiences while riding with their children. 26 Examples: A: Five minutes after you put them in the car, he's asleep. A: Oh, mine's, yeah. A: They usually have little toys that they can play with in the car until-unless they throw it, and then they all get taken away. (Cincinnati, White Females) A: Well, mine, they do pretty good. I always keep like books and stuff in the car. Q: So they're not very active, moving around and things. A: I have a van, so it's like roomy in there, so they, yeah they're pretty good for that part. (Cincinnati, Black Females) Parents felt that their children learned how to remove their CRS easily, which evolved into a barrier for parents attempting to restrain their children appropriately and to keep them safe. Examples: A: Oh, my kids learned very early how to get those suckers off. My daughter did the same-both of my kids, they learned before they were three years old how to get out of theirs, because they-the ones that snap right here. A: All they've got to do is take it off and you've got to push the button and jerk down. And they've seen Mommy do it so many times, they're not dumb, they watch. (Cincinnati, White Females) A: They usually like to jump around, get out of the car seat. It's hard for me to do that because I always have to pull over, put them back in the car seat-because I have two of them that-well, three of them that's in a car seat. A: Oh, my goodness. A: And it's hard. With my five-year-old, I don't even put her in a car seat or a booster, I put her in a seatbelt. It's just too hard. They're always jumping around in the front and the back. It is so hard! (Cincinnati, White Females) Changes from one type of restraint to another were explained to be impermanent or based on situational influences. Parents reported using seatbelts for children normally in car or booster seats only when space confines and availability allowed. Examples: A: If we're getting a ride, or if there's too many children in the car. A: Yeah. A: Usually it's when like if you're getting a ride from somebody, you know, if they say, "I'll give you a ride," you know I, you don't have a car seat on you all the time, you might be walking down the street, and it could be somebody you know getting ready to ride past your house or whatever, and you ride with them, you don't always have a car seat with you. (Cincinnati, African American Females) A: Well, once I had to pick up a lot of people and there wasn't enough room for the car seat, and I took it out. And he's got twin, two of my nieces, because there wasn't enough room, and everybody had to go. A: Before I got my mom the car seat, if she forgot to get it out of my car, or she didn't have it, then she'd have to ride with the safety belt on. Q: Is there any other circumstances that your child would be in a seatbelt only? A: If they was in a car with someone other than myself. (Little Rock, African American Females) A: For example, when ... I don't know if this only happens with my children, when some family member comes and wants to take them out, for example, Grandma, and ... A: There's no room. A: Of course! Or she doesn't have the booster seat, my husband has it, for example, and it's not there, then she takes her just like that with her... Q: With the seatbelt. A: Yes, with the seatbelt. (Little Rock, Hispanic Females) 27 Influences from people who matter Sources of CRS information Participants mentioned several different media from which they obtained information about child passenger safety. Most parents looked to prominent community-based figures such as law enforcement and medical professionals for information on how best to restrain their children. Examples: A: The doctor's office has a lot of stuff. A: My doctor, my kids, they have an African-American pediatrician, and she keeps me informed on everything. Just like the booster seats, y'all, if some of y'all parents don't know how to handle car seats or nothing, y'all take your kids to Children's Hospital, they give you seats. So that's how I got my baby's seat, because I didn't have no money. And I just, she said, "Hon, well, do you have a car seat?" You've got to watch the little video. Okay, I watched the video, answered the questions too. If it's free, instead of $50, $60, honey. But, they've got a lot going on. People don't know­ (Cincinnati, African American Females) A: Often, too, in the kids' schools they send you the brochure. A: Yes, in school, because in Soledad School they sent me the brochure. (Little Rock, Hispanic Females) A: In this state program there the police teach you and they buckle them in pretty tight, because they taught me how to install a car seat and if it's loose on my child I don't seat him, I get up above it, insert the belt behind and make it pretty tight, and that's when I see that my seat isn't moving, because that class tells you how to fasten in a seat. (Little Rock, Hispanic Females) A: If they're not buckled in correctly, and we've had the thing back this way, you can take your car over to Children's Hospital and they will check your safety seat and make sure that it's, you know, in appropriate. And I like the fact that, with the hospitals now before you leave, you have to have your car seat, and they come out and inspect it and make sure that it is in correctly. So, I just worry about her, because she is so grown, and I have to tell my mom, like when she's driving with her, "Just make sure she's sits down and [uses her transport?]." Because I bought my mom a safety seat, and I have my own safety seat now because she will not sit down. They were like twenty dollars and I was like, "Okay, I'm just going to have to break down and just do this and get it," because she is a handful. (Little Rock, African American Females) Parents also wished to receive information about restraint from programs like Head Start and Moms of Healthy Babies. Other trusted sources include family members with young children. Examples: A: And I participated with Booster America, it was a thing UAMS had, they sponsored the, you know, car seat checks. And I knew about the booster seats thing and making sure they're properly installed because if they're not properly installed, it doesn't make any sense putting them in there. You know, they're not really properly safe. It's a lot to install the car seat and the booster seat, you know, you have to really make sure they're installed properly. (Little Rock, African American Females) A: I heard it from my Moms for Healthy Babies coordinator. A: It's a mobile van that goes around and helps mothers. A: Young teen mothers. A: Single parents. (Cincinnati, African American Females) A: And since your kids are in, if they're in Head Start, Head Start helps you know, you with some information on booster seats. (Little Rock, African American Females) 28 Participants noted that they were most attentive toward messages from television and radio commercials, movie theater previews, health programs in clinics or stores, and billboards. Examples: A: On the news, the TV, the store, the doctor's office, the newspapers, the radio, everywhere. (Cincinnati, African American Females) A: Yeah, television commercials, you know, they were having the car seat checks at like Wal-Mart, UAMS, any type of fairs that they had, you know, they always had a car seat check point or something like that. If they was having the Greek Festival, they had a car seat checkpo

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