Method

RECRUITMENT PROCEDURES

All hospital births occurring in Columbia, Missouri (population 79 000) are published free of charge in the local newspaper, based upon information routinely provided to the newspaper by the city's two hospitals. Investigators used these newspaper reports to create a database containing the names, dates of birth, and phone numbers (when available) of all children born locally between January 1994 and April 1999 (n = 2842). Participants were randomly recruited by phoning the families of every fifth child whose birth announcement was contained in the database. Only mothers of children at least 6 months of age (that is, old enough to use a walker) were contacted. The resulting sample was also stratified to reflect approximately the same proportion of births during each year in the community as a whole. Through these procedures, 294 mothers were reached by telephone, of which 264 (89.8%) agreed to participate and completed the baby walker interview.

In addition to the 264 participants recruited by telephone, 65 mothers completed the baby walker interview in person (bringing the total sample to 329). These mothers, who also had children born between 1994 and 1999, were invited to complete the interview while participating in another injury project being conducted concurrently in our laboratory (see footnote at end of paper). All mothers asked to participate in the face-to-face interviews agreed to do so. Once these interviews were completed, participant names were deleted from the birth announcement database to avoid rerecruitment by telephone.

PARTICIPANTS

The 329 participating mothers were caregivers for a total of 463 children about whom they provided data for the present study. Of these children, 223 were female and 236 were male (four were missing gender data). Demographic comparisons between those interviewed by telephone and the 65 mothers recruited in person were made with a series of t tests and χ² values, and revealed no significant differences between the two groups with regard to race, education, occupational status, or socioeconomic status. The majority of all participants were white (96%), with the remaining 4% being of various minority groups. Fewer than 1% of mothers had less than a seventh grade education, 1.5% graduated from junior high school, 12% graduated from high school, 22.5% completed some college, 46.4% graduated from college, and 16.9% reported obtaining a graduate degree. The mean socioeconomic status of the sample, computed using the Hollingshead four factor index (Hollingshead AB. Four factor index of social status. Unpublished manuscript, Yale University 1975) was 48.98 (SD = 11.26, range 17.5–66.0). This suggests that a broad range of socioeconomic strata was represented, but that the average family was of an upper middle class.

INTERVIEWING PROCEDURES

The interview itself consisted of eight components assessing: (1) age and sex of all children in the home age 5 and younger; (2) whether a baby walker or exersaucer had been used with each child; (3) frequency of baby walker use; (4) reasons for using or not using baby walkers; (5) reasons for using exersaucers; (6) knowledge of walker risks; (7) where and when baby walker hazard information was acquired (if applicable); and (8) demographic information. To reduce potential reactivity to the questions about baby walkers, all questions were embedded within a larger interview about mothers' use of other baby furniture items, such as playpens and changing tables.

One clinical psychology graduate student and three psychology undergraduates conducted the interviews. Project coordinators trained interviewers until they were determined to be proficient. Training involved script rehearsal and the completion of several practice interviews that were audiotaped and evaluated before actual data collection. As noted, mothers recruited by birth announcements were contacted and interviewed by telephone; interviews with the remaining participants were conducted face-to-face. All procedures for this study received prior approval from the University of Missouri Institutional Review Board.

Results

BABY WALKER AND EXERSAUCER USE

Of the 329 mothers interviewed, 48.9% reported using baby walkers with at least one child in the family. Inquiries about walker use revealed that 45.6% of all children born during the six year time period had been placed in a walker on at least one occasion. The frequency of walker use varied among these children, with 14.1% having used a walker “once or twice”, 16.5% “once in a while”, 15.5% “a few times a month”, 5.3% “on a weekly basis”, and 48.5% daily.

Regarding exersaucers, 51.7% of mothers reported using them with at least one child in the family. Altogether 47.1% of all children in the sample had been placed in an exersaucer on at least one occasion. Frequency of use data for exersaucers were not obtained.

Table 1 depicts the percentage of children who were placed in walkers and exersaucers each year from 1994 to 1999. Walker use rates declined from a high in 1994 of 65.9% to a low in 1999 of 21.1%. Conversely, exersaucer use was lowest in 1994 (19.0%) and highest in 1997 (62.2%), with rates remaining at comparable levels for 1998 and 1999. Analysis of these patterns using Mantel-Haenszel χ² tests revealed a significant downward trend for baby walker use (χ² (1) = 17.97, p<0.001) from 1994 to 1999, and a concomitant upward trend for exersaucer use (χ² (1) = 36.98, p<0.001) during the same six year time frame. A point-biserial correlation revealed a significant negative relationship between baby walker and exersaucer use across the six years (r = −0.42, p<0.001), suggesting that caregivers tended to use either walkers or exersaucers with children.

KNOWLEDGE OF WALKER RISKS

At the time of the study 88.8% of all mothers reported having some knowledge of the hazards associated with baby walkers. When asked to name the sources from which they acquired this information, 72.9% cited print or broadcast media; 20.1% cited a child care professional (for example, a physician); 19.8% learned of the hazards from a friend or relative; 11.8% reported that a previous experience with an injury or near injury had taught them about the hazards; 8.6% cited common sense; 8.3% cited formal education; 3.8% cited walker warning labels; and 4.2% gave other sources.

Remarkably, 38.2% of mothers reported using walkers with one or more children, despite being aware of the associated risks at the time of use. To explore whether this trend was related to specific demographic characteristics, one way analyses of variance and χ² tests were conducted on several variables. These analyses revealed no differences in socioeconomic status, ethnicity, or education between mothers who used walkers with knowledge of walkers hazards and those who used walkers but had no knowledge of the associated risks.

REASONS FOR WALKER AND EXERSAUCER USE

All mothers who reported using walkers were asked about their motivations for doing so. In all, 48.3% cited perceived benefit to children (e.g., as a source of entertainment) as a factor in their decision to use walkers; 35.5% cited access (e.g., receiving one as a gift or having one left over from an older sibling); 29.4% believed that walkers fostered their child's development (e.g., to help children learn to walk); 21.8% reported parental convenience (e.g., to keep children occupied while the parent does housework); and 4.7% cited a perception that the home environment was safe for baby walker use (e.g., there are no stairs in the home).

Mothers who had never used walkers with their children also provided reasons for their decisions. Concern about safety issues (e.g., the child could fall down stairs) was by far the most common reason (78.7%). The second most common reason was a conscious decision to use exersaucers instead of walkers (10.8%). A lack of access to a walker and perceived detriment to children's motor development (e.g., damaging children's leg muscles) were cited by 8.8% and 8.0% of mothers, respectively.

Finally, all participants were asked to report advantages of (i.e., reasons for) exersaucer use. Safety concerns (e.g., exersaucers are safer than baby walkers) and child entertainment were cited as advantages of exersaucers by 64.4% and 44.3% of mothers respectively; 36.4% cited perceived benefit to child development (e.g., opportunity to exercise leg muscles), and 28.5% cited parental convenience (e.g., as a means to occupy the child while a parent does housework).

Discussion

To date, the primary strategies for discouraging walker use have been educational in nature, involving public awareness campaigns and the use of warning labels. Several investigations predating these campaigns showed little indication that parents perceived walkers to be dangerous.^2,7,13 In contrast to these earlier studies, our finding that almost 89% of mothers were aware of walker hazards suggest that efforts to educate the public have been rather successful. It is also encouraging to note that 79% of mothers who did not use walkers specifically cited injury risk as the reason for their decision.

Despite these encouraging findings, 38% of those who reported having knowledge of walker dangers nevertheless decided to use these devices. This is consistent with other findings that many caregivers whose children are injured by walkers were aware of the dangers beforehand, and that a substantial proportion of these individuals continued walker use even after an injury.⁸ Thus, it appears that although risk information is sufficient to convince some caregivers to abstain from walker use, another segment of the population is not deterred from use by educational interventions, or even by the occurrence of an injury.

When asked about reasons for walker use, 22% of participants specifically cited caregiver convenience as a factor in their decision (e.g., “It frees me up to do housework” or “It's easier to supervise her while she's in the walker”). This figure is probably an underestimate given that those who cited other factors, such as child entertainment, may also perceive ease of supervision as a beneficial byproduct of walker use. Although it is easy to see why occupying a child in a walker could prove useful to a busy parent, the possibility that caregivers use walkers as a substitute for close supervision is concerning, for even the briefest lapse in supervision (e.g., answering the telephone or doorbell, glancing at the television) may be long enough for a mishap to occur.¹⁷

Our data indicate that walkers may be quite appealing to many caregivers. Most walker users reported several perceived advantages associated with using the devices. Walkers also tended to be relied on often, with nearly half (48.5%) of these children using them daily. As suggested by prominent health behavior theories (e.g., the Heath Belief Model^18,19), greater success in discouraging walker use might be achieved by providing caregivers with an alternative course of action that is both readily available and provides the same benefits as walkers. Our data showed that participants perceived many of the same reasons for use associated with both walkers and exersaucers. Furthermore, like mobile walkers, exersaucers are reasonably priced and are readily available alongside walkers in stores. For these reasons, exersaucers appear to represent an appealing, accessible, and presumably safe alternative to traditional walkers.

Regarding preferences for exersaucers versus walkers, the present study suggests that some parents may already be forgoing mobile walkers in favor of stationary playstations. Nearly two thirds of mothers who used exersaucers specifically cited safety issues as a factor motivating their decision. Our examination of the trends was certainly consistent with these individual reports. These analyses showed a significant inverse relationship between walker and exersaucer use for the period 1994 to 1999. That is, the fairly steady decline in mobile walker use was mirrored by a concurrent upsurge in exersaucer use over the six year time period. Our correlational analysis also supported a significant negative relationship between walker and exersaucer use. It appears, then, that caregivers tend to use one or the other, but not both, devices with their children.

Limitations of this study should be noted. One potential problem concerns the limited data from children born during 1999, which suggested a decrease in walker use compared with previous years. This finding may be misleading due to the small number of participants from that year (n = 19), and the fact that some children had not completely passed through walker using age by the time of data collection. Less opportunity for these children to be exposed to walkers may have contributed to the lower rates for 1999. Second, although our sample contained participants with a range of characteristics on some demographic variables, the extent to which they represent the broader population of parents who may use baby walkers is unknown. A more diverse sample in terms of geographic location, ethnicity, and socioeconomic status could improve the generalizability of findings. Finally, as with all survey research, participant reports may have been affected by expectation biases.

Implications for prevention

Results of this study have several implications for the prevention of walker related injuries. First, future interventions should target the sizable minority of caregivers who use walkers despite having knowledge of the associated risks. For these individuals, general risk knowledge appears insufficient to evoke a change in individual walker use. This type of “optimistic bias”, involving an underestimation of personal risk, has been well documented in the adult literature and may pose a barrier to the discontinuance of walker use.^20,21 As suggested by the Health Belief Model,¹⁸ interventions should challenge individuals' perceptions of invulnerability to walker injuries by reinforcing the notion that even vigilant supervision does not guarantee protection against injury.

Ultimately, however, persuasive techniques alone may be insufficient to achieve maximum reductions in walker use. These approaches should be augmented with the presentation of practical and appealing alternatives to traditional walkers. The present data show trends in recent years away from walker use in favor of safer stationary playstations. Future interventions could capitalize upon these trends by actively promoting exersaucers. In the end—and in the absence of a legislative ban on walkers—a twofold approach that addresses issues of personal vulnerability to walker injuries and informs caregivers of safe, accessible alternatives may prove to be the most fruitful prevention strategy.