Maintenance mechanisms of child restraint system use based on the health action process approach theory: Evidence from China

Adherence to the use of child restraint system (CRS) can greatly reduce child casualties in road traffic accidents. This study aims to develop the behavior maintenance model of CRS use based on the health action process approach (HAPA) theory to explore the maintenance mechanisms, suggesting appropriate intervention strategies.Adopting the multi-stage stratified cluster random sampling method, a cross-sectional survey for guardians recruited from kindergarten and primary school was conducted using the questionnaire developed based on the HAPA theory in Nanjing, China, and 1135 valid samples were finally obtained. Rigorous analysis procedures of the partial least squares structural equation modeling (PLS-SEM) method were applied by using SmartPLS3.3.2 software.The results confirmed that action self-efficacy (β = 0.479, P < 0.001) and negative outcome expectancy (β = -0.187, P < 0.001) were valid predictors of intention in the non-intentional stage, intention (β = 0.488, P < 0.001) and maintenance self-efficacy (β = 0.334, P < 0.001) contributed significantly to action planning in the intentional stage, while action planning (β = 0.470, P < 0.001) and recovery self-efficacy (β = 0.256, P < 0.001) jointly determined behavior maintenance in the action stage. It was also revealed that action planning fully mediated the relation between intention and behavior maintenance (β = 0.229, P < 0.001).Based on the above mechanisms, interventions aimed at the stages of non-intention, intention, and action should be designed and implemented, with the participation of the government, automobile dealers, and communities to promote the maintenance of improved CRS use behavior.