The three main findings of this study are (1) knowledge on infant safety was good as three-quarters of the items had good responses, (2) self-reported practices on infant safety were poor as almost half had poor responses and (3) knowledge on infant safety was not translated to practice in one-third of the tested significant associations. In this study, although better knowledge on safety was associated with better safety practices, there were more caregivers who did not practice safety despite answering the corresponding safety practice in three of the items correctly.
The knowledge of caregivers on infant safety was good. There were two items that were poorly answered and the worst was on the misconception that ‘infant walkers promote independent walking in infants’. Infant walkers are dangerous and had been shown to be related to unintentional injuries . A study in Singapore had also shown that baby walkers did not accelerate independent walking but led to a delay in motor development . In our study, a total of 73.2% of participants agreed that infant walkers promote independent walking in infants. This is similar in the United States where 72% of caregivers believed that walkers promoted walking and this was one of the reasons for walkers use . Another study in Dublin showed that 75% of parents who used walker believed that walker was good for their infants but only 10% of parents who do not use walker viewed the use of infant walkers as beneficial . Furthermore, 66% of parents who used walker felt that walker was safe, albeit only 5% of parents who do not use walker felt infant walker was safe . Thus, education is important to reduce the rate of infant walker use so that injuries related to it can be prevented.
The other item with poor responses was on the best way for infants to pillion ride on a motorcycle. Most countries do not allow infants to ride on motorcycles but in countries that do, a safety seat must be used . In Malaysia, sidecars and child safety seats for motorcycles are not easily available and there is no legislation prohibiting children from riding on motorcycles. Thus, some caregivers perceived that the safest way to ride was by squeezing the infant between two adult riders. However, it would be safer to use public transport rather than risking injury due to motorcycle accidents.
Overall self-reported safety practices in infants were poor; half of the 19 safety practices had poor responses. The worst self-reported practices were on the use of baby cots, infant walkers and sarong cradles. Very few (13.8%) caregivers used a baby cot, although it has been advocated to prevent falls and sudden infant death syndrome [4, 5, 17]. A study in the United States showed that the use of baby cots was high and the rate of usage increased with the infants’ age. More than 80% of infants were put to sleep in a baby cot from the age of 9 months . The difference in the rate of use of baby cot may be due to cultural practice as bed sharing is common in Asian countries [19, 20]. Another reason could be financial constraints. We have shown that only 25.6% of caregivers placed the baby in a supine sleep position. This rate is much lower than that observed in other studies [18, 20]. We did not examine the reason for this practice in this study, but a possible contributing factor could be the older mean age of the infants, which was 13 months. A study in the United States showed that the rates of placing the infant in a supine position reduced in older infants .
We found the use of infant walkers was high despite danger associated with their use . Poor knowledge among caregivers on the use of infant walkers was reflected in their practice as a high proportion of them used infant walkers. This was similar to the findings of a study in the United States . Studies in the United Kingdom and Dublin showed that the rate of the use of walker was around 50% [9, 21]. Some caregivers used walkers because they felt that walkers were good for their infants . Other reason for the use were previous experience (an older sibling had used it), caretaker’s perception that infants were happy in walkers and having received walkers as a present . Educational counselling to discourage the use of infant walker among parents has been shown to be effective to reduce the use and possession of infant walker [22, 23]. Significant reduction in the use of infant walker has been shown to decrease injuries related to it [14, 24]. Thus, more education programmes are needed to discourage the use of infant walker.
We also found a high number of caregivers used sarong cradles. There is a lack of studies looking at the use of sarong cradles since the use is unique to the South East Asian region. Sarong cradle is a traditional baby hammock made from cloth and is suspended above the ground anchored with a spring. All injuries sustained with the use of sarong cradle involved the head including serious injuries such as extradural haematoma and skull fracture .
The use of sarong cradles and walkers should be discouraged to reduce injuries related to it [6, 24, 25]. The Canadian government has banned the sale and use of walkers since 2004 . Similarly, the American Association of Pediatrics had also recommended banning the use of infant walkers . Thus, a similar ban on the sarong cradle and infant walker could be effective to reduce their usage in Malaysia.
It was encouraging to find that 96.3% of caregivers used child safety seats properly. This was much higher than the rate of 27.4% found in another local study in 2004 . The higher rate found in this study may be due to an increased awareness of child safety seats from recent national campaigns and a difference in the socio-demographic characteristics of the two study populations.
Association between knowledge and self-reported practice
This study has shown that better safety knowledge was associated with better safety practices. This indicates that education plays an important role in influencing safety practices of caregivers. A systematic review had shown that education was effective in reducing injuries at home, improved the use of home safety equipment and increased safety practices . Initiatives from public health and clinical authorities are, therefore, recommended to address this issue.
However, it was appalling to note that there were items in which better knowledge was not translated to safe practices. Almost two-thirds of the caregivers answered that a baby cot was the safest sleep location, and yet they did not use a baby cot. Similarly, more than half of the caregivers who used a sarong cradle knew that the use of a sarong cradle could lead to serious head injuries. In addition, more than half of the caregivers used infant walkers despite knowing that their use did not accelerate independent walking. We did not explore the reasons for these discrepancies in knowledge and practice but possible reasons could be financial or cultural . This should be explored in future studies.