HEALTH EDUCATION RESEARCH
Vol.30 no.5 2015
Pages 683–692
Advance Access published 4 September 2015
A smartphone app to communicate child passenger
safety: an application of theory to practice
A. C. Gielen1*, E. M. McDonald1, E. Omaki1, W. Shields1, J. Case1 and
M. Aitken2
1
Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD 21205, USA and 2Arkansas Children’s Hospital Research Institute, University of Arkansas Medical School,
Little Rock, AR 72202, USA
*Correspondence to: A. C. Gielen. E-mail: [email protected]
Received on February 16, 2015; accepted on August 6, 2015
Abstract
Introduction
Child passenger safety remains an important
public health problem because motor vehicle
crashes are the leading cause of death for children, and the majority of children ride improperly restrained. Using a mobile app to
communicate with parents about injury prevention offers promise but little information
is available on how to create such a tool. The
purpose of this article is to illustrate a theorybased approach to developing a tailored,
smartphone app for communicating child passenger safety information to parents. The theoretical basis for the tailoring is the elaboration
likelihood model, and we utilized the precaution adoption process model (PAPM) to reflect
the stage-based nature of behavior change. We
created assessment items (written at 6th
grade reading level) to determine the child’s
proper type of car seat, the parent’s PAPM
stage and beliefs on selected constructs designed to facilitate stage movement according
to the theory. A message library and template
were created to provide a uniform structure for
the tailored feedback. We demonstrate how
messages derived in this way can be delivered
through new m-health technology and conclude
with recommendations for the utility of the
methods used here for other m-health, patient
education interventions.
As the leading cause of death for children in the
United States, motor vehicle crashes pose the
single greatest health risk to children [1]. Child restraint devices (CRDs) are the best protection for
infant and child motor vehicle occupants.
However, to provide maximum protection, the
CRD must be the correct seat for the child’s age,
weight and size, and it must be used properly and
consistently.
According to a 2008 study, children under age
two are 75% less likely to be killed or suffer
severe injuries in a crash if they are riding in a
rear-facing restraint rather than a forward facing
one; in fact, for children 1–2 years of age, riding
rear facing is five times safer [2]. Convertible seats
available today allow children to remain riding rear
facing until they weigh 30–45 pounds. Forwardfacing safety seats, appropriate for children who
are over the age of two years and at least 40
pounds, can accommodate children up to 65
pounds and are known to reduce fatal injury by
54% [3]. Belt-positioning booster seats, for children
who have outgrown their forward-facing seat have
been extremely effective in reducing crash-related
injuries, decreasing risk by as much as 59% [4–6].
Use and misuse of CRDs
Usage rates for CRDs vary by the age of the child. In
2008, 21% of US children under 1 or <20 pounds
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doi:10.1093/her/cyv035
A. C. Gielen et al.
were not restrained in a rear-facing safety seat [3]. In
a 2008 NHTSA study, 40% of children weighing
20–40 pounds were not restrained properly [3].
Most studies show that appropriate use of booster
seats in the US hovers between 20–40% [7–11].
Not only do many children continue to ride unrestrained or restrained in the wrong device for their
age and size but many of the correct devices are
being used improperly, greatly compromising their
protective benefits [12–16]. One US study across six
states found an 84% misuse rate among rear-facing
seats [17]. Misuse is also common among those
using forward-facing seats—81%—usually due
to loosely or improperly secured harnesses or seat
belts [17].
Because of the prevalence and pervasiveness of
car seat installation errors and other types of misuse,
many families now use the services of a child passenger safety technician (CPST). CPSTs are individuals who have completed a 4 day course,
successfully passed a written exam, completed a
supervised car seat check, and have maintained
their certification by earning continuing education
credits on CPS issues periodically [18]. CPSTs, who
can be found in all 50 states and US territories, provide installation and seat check services, typically at
community events or through hospital- and fire department-based programs.
Increasing the correct use of CRDs
Despite decades of research on promoting car safety
seats, the gaps in proper and consistent use described
earlier demonstrate the critical need for innovative
ways to reach parents with potentially life-saving
information. A systematic review [19] found that
the effectiveness of education-only programs has
yet to be demonstrated and called for research to
identify the ‘amount and quality of content necessary to change knowledge, attitudes and behaviors’.
Although the American Academy of Pediatrics recommends that car seat education be included in anticipatory guidance [20], such counseling is done
infrequently [21, 22]. Moreover, clinicians may
not be equipped (either in terms of time or skills)
to address the new complexities of proper use across
684
the range of available products. It has been well established that child passenger safety laws (now in all
50 states) and education coupled with access to
loaner or low-cost seats is effective in increasing
overall use rates [19]. However, how best to communicate with parents in ways that will provide the
information necessary to increase proper and consistent use remains to be determined.
Use of communication tailoring
Health communication research has demonstrated
the superiority of tailored over generic messages
for health behavior change programs and the importance of behavioral theory in achieving success [23].
Tailored communication is intended to reach a specific individual with information that is based on
characteristics unique to that person, related to the
outcome of interest and derived from individual assessment [24]. The theoretical basis for tailoring
comes from the elaboration likelihood model,
(ELM) [25], which states that people are more
likely to actively process information if they perceive it to be personally relevant [26–29]. Tailored
messages are more likely than generic messages to
be read and remembered, perceived as interesting
and personally relevant, saved, discussed with
others and acted upon [30–34]. Tailored interventions have been used with promising results in a
number of pediatric injury prevention studies,
including work conducted by members of the current study team in community and pediatric emergency department settings [35–41].
The precaution adoption process model (PAPM)
is well suited for making messages personally relevant because it reflects the stage-based nature of
behavior change [42, 43], which allows messages
to be tailored on a person’s readiness to change as
well as on the constructs that are thought to move
someone from one stage to the next. The PAPM
distinguishes among people who are at different
stages of awareness and readiness to act—unaware,
unengaged, undecided, decided not to, planning,
acting and maintenance—and identifies theorybased constructs to facilitate stage movement. The
PAPM has been successfully used to understand a
App for child passenger safety: theory to practice
range of behaviors [44–46], including our earlier
work on child passenger safety [37, 47].
Use of mobile technology
Paralleling the recognition of tailoring as an effective health communication approach has been an explosion of interest in e-health [19, 20, 48, 49] and mhealth [50]. According to the World Health
Organization (WHO), there are now more than 5
billion wireless subscribers, and commercial wireless signals cover more than 85% of the world’s
population, making the use of mobile and wireless
technologies a credible and potentially very valuable tool for promoting health. In the United
States, an estimated 58% of all adults and 83% of
those ages 18–29 have smartphones [51]. In a pediatric emergency department setting that serves an
urban and predominantly lower income population,
which was one of the settings for the study reported
here, we found that 95% reported owning a cell
phone, and among these, 88% were smartphones
(W. C. Shields et al. unpublished data).
Our search for computer applications in injury
prevention, found four studies that successfully
used kiosk-based, tailored health communication
for child injury prevention [37, 38, 47, 52]. Four
additional studies successfully used internet-based
programs for an array of injury topics and audiences
[53–56], only one of which [53] used communication tailoring. These studies provide little detail on
the process of developing the intervention content,
and no studies using smartphone applications were
found. There is a clear need for more research on
using m-health technologies for teaching parents
about child injury prevention.
Aims
The purpose of this article is to illustrate a theorybased approach to developing a tailored, smartphone
app for communicating child passenger safety information. The article describes how we utilized the
PAPM to (i) reflect the stage-based nature of behavior change related to the use of CRDs and (ii) tailor
messages based on PAPM stage to inform and persuade parents to use the proper CRD consistently.
We demonstrate how messages derived in this way
can be delivered through new m-health technology
and discuss recommendations for the utility of the
methods used here for other m-health, patient education interventions. Next steps in evaluating the
PAPM-derived m-health intervention through a randomized, controlled trial are also described.
Methods
This work is part of a multisite intervention trial to
increase the proper and consistent use of car safety
seats, including booster seats, among children in
Baltimore, MD and Little Rock, AR. The intervention is being designed for parents or guardians of
children from birth through age eight who will be
recruited from waiting rooms within the pediatric
emergency departments in two hospitals. The intervention is a mobile application for use on iPhone
and Android smartphones. The intervention builds
on a previous Safety in Seconds kiosk-based program [37, 47]. Parents will download the app and
use it to answer a series of assessment items about
their knowledge, beliefs and car seat behavior for
any age-eligible children in the family. The app will
provide feedback in real-time and parents will be
able to return to it any time to review the information
and can reassess a child after responding to recommended changes. The app will also provide a link to
a parent portal, where additional child passenger
safety information will be available through links
to online resources. Throughout the process of developing the app, parents were involved through a
focus group, survey and two rounds of pilot testing;
results from these data collection activities and an
evaluation of the app will be separately reported
elsewhere. Here, we focus on the application of
theory to creating the app.
Defining the behavior
Correct and consistent car seat use is the behavioral
goal of our app. This complex behavior is in reality
made up of numerous component behaviors, including characteristics specific to the vehicle, the child
and the type of restraint. Based on our assessment of
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A. C. Gielen et al.
the literature, experience in running child passenger
safety programs and with input from CPSTs on staff,
we selected four component behaviors that are critical to child passenger safety behavior and that can
be accurately assessed by self-report, a key feature
of computer-tailored applications. The four component behaviors to be addressed in the app were (i)
correct type of child restraint for child’s age and
weight; (ii) correct location of child restraint in vehicle; (iii) use of child restraint for all rides and (iv)
use of CPST to install or check the seat.
Applying the PAPM
The PAPM provides the theoretical basis for understanding the adoption of the car safety seat behaviors
of interest [42]. An important utility of applying
PAPM is that it recommends specific persuasive message concepts at each stage [42, 43]. For instance, in
the earliest stages, a person needs messages that increase awareness and personalization of the hazard
and the precaution. After becoming aware of a threat
and how to reduce it, individuals need to feel capable
of performing the behavior, and that it is consistent
with social norms and what significant others want
them to do. Once someone has begun performing the
behavior, they need to experience a reward or positive
reinforcement to maintain the behavior.
The PAPM as used in this study is illustrated in
the following example. An individual parent could
be at different stages of readiness for each of the four
behavioral components. For instance, a parent who
always places her 5-year-old buckled up in a seat
belt in the back seat may be unaware of the superior
protection provided by a belt-positioning booster
seat, or she may have decided not to use a booster
seat because she thinks her child won’t like it, and
she may have never thought about getting advice
from a car seat expert. This parent is in a more
advanced stage for using a device all the time and
putting her child in the back seat but she is in an
early stage with regard to booster seat use (correct
seat type) and going to a CPST. This illustrates the
complexity of defining the behavioral outcomes and
the need for different (i.e. tailored) messages to address each component of the behavior. In this
686
example, the parent should be acknowledged for
correctly placing the child in the back and being
consistent about buckling up but she needs to be
fully informed and persuaded that a booster seat is
a better choice and that a car seat expert can be a
useful resource for her and her family.
Creating tailored messages
We created assessment items (written at 6th grade
reading level) to determine: (i) what type of CRD
would be correct for the child’s age and weight, (ii)
the parent’s PAPM stage for each component behavior and (iii) participant’s beliefs on selected constructs designed to facilitate stage movement
according to the PAPM: perceived risk of a crash,
self-efficacy for avoiding a crash, barriers to each of
the component behaviors and social influence for
keeping the child safe (see Table I). A message library was created to provide educational messages
(written at 6th grade reading levels) in response to
each of these tailoring variables. Individuals’ answers to the assessment questions are stored in a
database and processed by a computer program
that uses predetermined decision rules to link each
answer to a specific message. Messages are combined for each behavioral outcome and delivered
via screens on the app that the parent can scroll
through as well as print out.
Results
Tailored feedback
To provide a uniform structure for the feedback, we
created a template that includes the elements of the
message that will be delivered to individuals at each
of the stages, along with the theoretical concepts to
be addressed. Table II provides an example for the
first component of car seat behavior, which is
whether the child is in the correct seat for his or
her age and weight.
The first message element is an introduction that
feeds back the information the parent input, which is
a way of framing the entire message, emphasizing
that the accuracy of the feedback is dependent upon
the information the parent provided, personalizing it
App for child passenger safety: theory to practice
Table I. Assessment variables and items
Variables
Personalizing variables
Behavioral components
Use of correct device
Use of device in back seat
Use of device all the time
Car seat inspection
Perceived risk of a crash
Items
Child’s name, age, weight
Self-efficacy for avoiding a
crash
Perceived barriers
Social influence
How does [child’s name] ride in the [vehicle type] most often?
How often does [child’s name] ride in the back seat of the car?
How often does [child’s name] ride in a [seat type] when [he/she] travels in a car?
Was [child’s name]’s [seat type] installed or looked at by a car seat expert?
How worried are you about keeping your [child/children] safe when riding in the car?
How worried are you about getting in an accident when your [child is/children are]
riding in the car?
How sure are you that you can keep your [child/children] safe when riding in the car?
How sure are you that you can avoid being in an accident when your [child is/children
are] riding in the car?
What is the main reason why
you haven’t started using a [correct seat type] for [child’s name]?
[child’s name] does not ride in the back seat all the time?
[child’s name] does not travel in a [child’s seat type] all the time?
you have not had [child’s name] seat installed or looked at by a car seat expert yet?
Besides your own, whose opinion matters to you most when thinking about keeping
your [child/children] safe in a car?
and giving the parent an opportunity to correct any
misinformation.
The second and third elements are intertwined.
The second element is the stage-specific link,
which is intended to directly respond to the parent’s stage of readiness (e.g. ‘there are many reasons to change your mind. . . .’ for those in Stage
4). This is designed to link to the messages that are
tailored on risk perception, self-efficacy, barriers
and social influence, which is the third element of
the message. Here, there is some overlap across
the stages; for instance, people in Stages 3–5
should all respond to a message tailored on their
self-efficacy. But, for those who are in Stage 3,
appealing to social influences may enhance the
self-efficacy appeal. Those in Stages 4 and 5
will have already identified reasons why they are
not doing the behavior, and their message will
need to include a direct response to these perceived barriers. We expect that this messaging
not only makes the information more personally
relevant but also enhances the potential impact on
behavior of the factual information about CRDs.
The fourth element is the factual information that
provides the rationale for the specific behavioral
component, which we believe is a necessary
aspect of our persuasive appeal. Individuals need
to understand why they are being asked to perform
a specific behavior. In this example, we are encouraging parents to use the correct car seat, so the underlying rationale has to do with how a car seat, booster
seat or seat belt provides protection depending on
the size of the child occupant. A brief message explaining the facts will be provided to parents and
will be framed to reflect their child’s age and
whether they are using the correct or incorrect seat.
Finally, all communication messages need to
have a specific call to action so that the receivers
understand what is being asked of them. This call to
action is prefaced by a heading titled ‘What You
Can Do’ to make it clear that parents are able to
take action to prevent injury. As shown in Table
II, we will provide a stage-specific call to action,
and all parents will receive referral information on
where they can purchase a car seat or receive a
loaner seat. Additionally, harnessing the power of
mobile technology, the smartphone app can send
ongoing reinforcement via automated reminders
about the information learned in the tailored
feedback.
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688
Stages 1,2
High perceived risk for an
accident: car crashes are
leading cause of death
Low perceived risk for an
accident: accidents can
happen any time; chances
of injury greater in [current incorrect seat type];
[correct seat] is best
protection
Tailored
comments
Call to action
Underlying
rationale
The safest way to ride for
children of [child’s
name]’s age and size is in
a [correct seat type].
Stage-specific
link
There are many reasons to
change your mind and use
a [correct seat] for [child’s
name].
[Child’s name] is a [age]
year old [boy/girl] who
weighs [weight] pounds.
[He/she] is riding in a
[current incorrect seat
type]. You decided not to
use [correct seat] because
[barrier].
Stage 4: Decided not
to use
Tailor on self-efficacy and
barriers
Decide today to get a
[correct seat] at [store
or safety center]
Link to resources
Think about getting a
[correct seat] at [store
or safety center] today
Link to resources
Link to resources
It’s not too late to make a
safer decision and commit
to getting a [correct seat]
at [store or safety center]
Link to resources
Put your planning into
action and get a [correct seat] at [store or
safety center] today
Stages 1–7
Mechanics of how [correct seat] provides protection (brief description)
Link to resources
Great job keeping [child]
safe. Check in with a
car seat technician
when you think
[child’s name] is ready
for a [next seat type]
Stages 6,7
Knowing that [he/she] is
in the right type of car
seat should make you
and [social influence]
feel good about keeping [child’s name] safe
in the car.
Way to go! That’s the
best seat for [child’s
name]’s age and size.
[Child’s name] is a [age]
year old [boy/girl]
who weighs [weight]
pounds. [He/she] is
riding in a [current
correct seat type].
[Child’s name] is a [age]
year old [boy/girl]
who weighs [weight]
pounds. [He/she] is
riding in a [current incorrect seat type].
It’s great that you’re
planning to use
[correct seat]
Stages 6,7: Acting or
maintenance
Tailor on reinforcement
and social influence
Stage 5: Planning
to use
Tailor on self-efficacy
and barriers
Stages 3–5
Low self-efficacy for avoiding an accident: can’t always control when an accident
will happen; [correct seat] is best protection
High self-efficacy for avoiding an accident: accidents can happen to good drivers;
crashes leading cause of death; [correct seat] best protection
Stage 3
Stages 4,5
Getting and using a car seat is easy; [Barrier] tailored
Social Influence: That’s
specific message
why [child’s names]’s
doctor wants him/her
to ride in [correct seat]
There are many reasons
to decide to have child
ride in [correct seat
type]
Stages 1,2,3
[Child’s name] is a [age] year old [boy/girl] who weighs
[weight] pounds. [He/she] is riding in a [current
incorrect seat type].
Stage 3: Have not
decided
Tailor on self-efficacy
and social influence
Introduction
Message
elements
Stages 1,2: Unaware or unengaged
Tailor on risk
perception
Theoretical constructs for message content
Table II. Template for creating stage-tailored communication to parents about using the correct CRDs
A. C. Gielen et al.
App for child passenger safety: theory to practice
Fig. 1. Screen shot of sample assessment item.
This same template is used for each of the remaining three behavioral components, with information
specific to the behavior being addressed (data not
shown; available upon request).
Safety in seconds app
Displaying the feedback is critically important to the
potential impact of these carefully constructed messages. A template for this purpose was also created.
Several screen shots from the app illustrate how our
assessment items and tailored feedback are communicated (Figures 1–3). In addition to the visual
appeal elements of the layout, the actual app is
also colorful although the figures are shown in
black and white here.
Discussion
This work offers new information on at least two
important health communication challenges. First,
Fig. 2. Screen shot of sample summary feedback.
how best to educate parents about proper and consistent CRD use has remained elusive. Our app is
grounded in two well-established behavior change
theories, ELM and PAPM, which should increase
the likelihood of success. The use of computer tailoring made it feasible to disentangle the specific
behavioral components of ‘proper and consistent’
CRD use and provide specific messages efficiently.
The success of other tailored programs bodes well
for this one. Second, although the steps in creating
tailored communication have been well described
[23], our article describes how a specific theory
was used to systematically construct tailored messages. Creators of tailored communication interventions must spend substantial time determining both
informational content and persuasive appeals, and
they must be sensitive to issues of literacy. The template we created and the work we described here
helped systematize this process, and should be
689
A. C. Gielen et al.
Fig. 3. Screen shot of sample tailored feedback.
useful to others interested in creating theory-based,
tailored messages.
With increased interest in m-health, it is important to consider the rationale for using a smartphone app to address any given health problem.
In our case, the rational was multifaceted. The
interactive nature of such a program allows for
repeated contact with participants and the delivery
of multiple tailored messages. The greater effects
of multiple tailored interactions as compared with
single tailored or untailored interactions have
been demonstrated in other behavioral interventions [57, 58]. The portability of the app makes it
ideal for repeated interaction and reinforcement of
information and behavioral changes. When introduced in a clinical setting, smartphone apps (as
well as other computer-based programs) can address identified barriers to the delivery of patient
education. They minimize the patient education
690
burden on clinical staff by replacing or supplementing the clinician’s counseling. With electronic health records, the information shared by
the patient on the app can efficiently be sent to
the health record for access by the clinician, who
can then provide reinforcement of the app’s messages. Apps also provide a constructive activity
for patients during wait time, and once the infrastructure is in place, operational costs likely
decline.
There are some limitations to consider in the work
described here. In the absence of the intervention
trial, which is now underway, we do not know the
app’s efficacy. Second, we needed to create a package of information that was comprehensive but not
exhaustive. To be efficient and effective, we limited
our assessment and our content to the most important and most changeable aspects of proper and consistent car seat use. The app encourages visiting a
CPST who can identify and correct other important
use/misuse challenges not included in our app. In
addition, we also created a ‘parent portal’ that directs parents to additional information on CRD’s.
The technical expertise and other resources needed
to fully develop and pilot test a complicated app
such as ours may be prohibitive for other programs.
Finally, resources are also required to ensure that the
app is updated with any changes in best practices
over time. Therefore, a long-term perspective and
dynamic approach to program operation is key.
Although the efficacy of this smartphone app will
not be known until completion of our ongoing randomized controlled trial, there is great potential for
similar intervention development approaches to be
applied in other populations and to address other
important public health problems with complicated
educational messages and behavioral goals.
Funding
This work was supported by a grant from the
National Institute of Child Health and Human
Development, National Institutes of Health, (Grant
No. 1R01HD069221).
App for child passenger safety: theory to practice
Conflict of interest statement
17.
None declared.
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