Research Article| Volume 21, ISSUE 5, P892-899, July 2021

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An Adapted Child Safety Seat Hassles Score Is Associated With Suboptimal Child Passenger Safety Behaviors Among Parents

  • Sadiqa Kendi
    Address correspondence to Sadiqa Kendi, MD, CPST, Boston Medical Center, Boston University School of Medicine, 801 Albany Street, Boston, MA 02119
    Children's National Medical Center (S Kendi and JM Chamberlain), Washington, DC

    George Washington University School of Medicine and Health Sciences (S Kendi and JM Chamberlain), Washington, DC
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  • Jessica L. Winkels
    University of Michigan Medical School (JL Winkels), Ann Arbor, Mich

    Department of Emergency Medicine, Washington University St. Louis (JL Winkels), St. Louis, Mo
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  • James M. Chamberlain
    Children's National Medical Center (S Kendi and JM Chamberlain), Washington, DC

    George Washington University School of Medicine and Health Sciences (S Kendi and JM Chamberlain), Washington, DC
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  • Michelle L. Macy
    Department of Emergency Medicine, Michigan Medicine (ML Macy), Ann Arbor, Mich

    Division of General Pediatrics, The Susan B. Meister Child Health Evaluation and Research (CHEAR) Unit, Michigan Medicine (ML Macy), Ann Arbor, Mich

    University of Michigan Injury Prevention Center (ML Macy), Ann Arbor, Mich

    Ann & Robert H. Lurie Children's Hospital of Chicago (ML Macy), Chicago, Ill

    Northwestern University Feinberg School of Medicine (ML Macy), Chicago, Ill. Dr Kendi is now with Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Mass
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Published:February 09, 2021DOI:



      We modified the Child Safety Seat (CSS) Hassles Scale to characterize CSS hassles in a diverse population and test for associations between hassles and caregiver-reported child passenger safety behaviors.


      Secondary analysis of a 2-site survey of caregivers seeking emergency care for their ≤10-year-old child in 2015. Caregivers answered questions regarding CSS hassles, child passenger safety behaviors, and demographics. Size-appropriate restraint use was defined by the American Academy of Pediatrics (AAP) 2011 Guidelines for Child Passenger Safety. We tested for associations between the number of hassles and adherence to AAP guidelines (including the consistent use of a size-appropriate CSS, travel in a back seat, and never traveling unrestrained).


      There were 238 caregivers included in analyses. Overall, caregivers endorsed a median of 5 hassles (interquartile range 2, 8). Half (50.8%) of caregivers endorsed child passenger safety behaviors that were nonadherent to AAP guidelines. Compared with caregivers reporting no hassles, there was an increased odds of not adhering to AAP child passenger safety guidelines for each additional hassle reported (adjusted odds ratio [aOR] 1.11; 95% confidence interval [CI] 1.03, 1.19). In addition, a higher number of hassles was associated with the inconsistent use of a size-appropriate CSS (aOR 1.15; 95% CI 1.06, 1.25) and as sometimes traveling unrestrained (aOR 1.13; 95% CI 1.03, 1.23).


      Caregivers who reported more CSS hassles were more likely to report behaviors that were not adherent to AAP guidelines. Addressing CSS hassles may provide solutions for nonadherence of AAP child passenger safety guidelines.


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