Evaluation of a child passenger safety class in increasing parental knowledge

Background

Child passenger restraint systems have been found to greatly reduce the risk of injury and death among child passengers. However, nearly half of the children who died in 2009 as a result of motor vehicle crashes were completely unrestrained. Our global hypothesis is that parents and other caregivers failed to restrain children due to a lack of child passenger seat education and practice. In this report, we postulate that a car seat class will improve the basic understanding of child passenger safety. The objective of the study was to evaluate the effectiveness of a car seat class in increasing parental knowledge about child passenger safety.

Methods

Car seat classes were held at a Level 1 pediatric trauma center every other Tuesday for ten months. The curriculum consisted of: child passenger safety laws discussion, a 21-min video on the use of child safety seats followed by a 15-min discussion about the video, 15 min of discussing the different types of car seats, and hands-on training on how to properly install and use child restraints. Free car seats were provided to eligible parents. The pre-test was administered at the beginning of class and the post-test at the end of the class. McNemar's test and a paired t-test were used to compare pre- and post-test scores. Test scores were also stratified by language spoken.

Results

Forty-four classes were held and a total of 491 parents/caregivers attended the classes. An increase in knowledge was found for all survey questions. Mean knowledge score for the post-test was 3.10 points higher compared to the mean knowledge score from the pre-test. Mean difference in knowledge scores for English-speaking participants were higher than Spanish-speaking participants.

Conclusion

Lack of knowledge and low risk perception have frequently been cited as barriers for the use of child passenger restraints. Our intervention attempted to eliminate these barriers. We found that this intervention was effective at increasing parental knowledge about child passenger safety. The results of this study may be used to design and implement future interventions in multicultural settings.     

Child restraint seat use behavior and attitude among Japanese mothers

OBJECTIVES: The purpose of the study was to assess associations between child restraint seat use and attitudes among Japanese mothers. MATERIALS AND METHODS: Mothers whose children were under 6 years of age were recruited through 11 kindergartens located in Kanagawa prefecture, Japan. Questions were developed based on the Health Belief Model and the Theory of Reasoned Action. Past use and future intentions to use, perceived risk of injury, knowledge of safety, attitudes toward use, subjective norms, and safety values related to safety seats were asked. RESULTS: A total of 552 complete questionnaires was obtained. Of 500 car owning households, 54.2% used child restraint seats inconsistently on short drives, and 36.4% did so on long drives. Three variables were associated with inconsistent use on short drives: frequent child resistance to sitting in a restraint seat; mothers' feeling hassled by child restraint seat use; and, mothers' agreement with the lack of need to use a restraint seat when another adult is in a car. Two variables were associated with inconsistent use on long drives: lower subjective norm of husband and frequent child resistance. CONCLUSIONS: In-car environmental modification and parent education need to be considered to increase child restraint seat use among Japanese households.     

Parental survey of beliefs and practices about bathing and water safety and their children: guidance for drowning prevention

Drowning represents the second leading cause of unintentional injury death in children less than 19 years. In children less than 5 years, many of these deaths occur in bathtubs. The objective of this study was to describe parental beliefs and practices regarding bathing their children and general water safety to aid in improving anticipatory guidance for drowning prevention. We distributed a written survey about parental beliefs and practices concerning their children's bathing and general water safety to a convenience sample of caregivers. One hundred and thirty-six caregivers participated in the survey providing data for a total of 209 children. Overall, 85% of respondents reported using baby bathtubs, and 46% reported using bath seats when bathing their children. Some caregivers reported leaving a 6-12 months old child unsupervised in the tub, either alone or with a sibling. About half of respondents (52%) indicated that pediatricians discussed water safety and supervision with them, and 36% indicated discussing the proper use of bathing aids with their child's pediatrician. In conclusion, the survey found the majority of caregivers use bathing aids, and caregivers reported some risky behaviors of unsupervised bathing of infants, either alone or with siblings. Better water safety anticipatory guidance is needed for caregivers.     

A longitudinal study of the effectiveness of a multi-media intervention on parents’ knowledge and use of vehicle safety systems for children

Motor-vehicle crashes are the leading cause of death and serious injury for children under the age of 14 in Canada and in the United States despite mandatory use of vehicle restraints since 1977. Using a pre- and post-test design, the present study tests the effectiveness of a multi-media intervention study on parents’ knowledge of car safety seat use for children (0-12 years). The sample included 201 parents from four Ontario cities. Results indicate that parents’ knowledge of when to accurately and safely transition a child to the appropriate car safety seat based on child's age, weight and height was retained at the 1 year post-test for children 4-8 years of age. The rates of correct use of safety seats significantly increased 1 year following the intervention program. Other factors that influenced parent's knowledge included being a parent versus non-parents, gender, income, education, sources of information, and regional location. The results of this study can help guide the development and implementation of future intervention programs and injury prevention policy.     

Effectiveness of hands-on education for correct child restraint use by parents

This study evaluates whether a hands-on educational intervention makes a significant difference in the proper use of a child passenger restraint by a parent. The clinical trial design included a sample of 111 parents who were at least seven months pregnant and who were randomly assigned to one of two groups (56 intervention and 55 control). All participants received a free car seat and a standardized education session on the safety and use of child passenger restraints. The experimental group received an additional component consisting of a hands-on demonstration and return demonstration of correct installation and use in their own vehicle. Follow-up observation for correctness of use was done after birth using a standardized tool.A total of 24 (22%) parents correctly used the car seat; of these, 18 (32%) were in the intervention group and 6 (11%) were in the control group. The intervention group was four times more likely to have correct use than the control group (odds ratio 4.3, p-value = 0.0074). The range for the number of errors per person was 0-7, with the majority (70%) having 0-2. The rate of errors was 33% less in the intervention group (ratio of 0.67). There were few serious errors in either group. No secondary variable (age, education, income, or help from others) had a significant effect on the outcome.The hands-on educational intervention made a significant difference in the proper use of a child passenger restraint by a parent. This study demonstrates the value of hands-on teaching for learning how to install and use a child car seat.     

Grandparents and child passenger safety

Purpose

This study compares child passenger safety (CPS) practices of grandparents versus parents and determines grandparents’ opinions on car safety seats (CSS), barriers to use, and ways to transport grandchildren safely.

Methods

Observational surveys were conducted on a convenience sample of drivers transporting children younger than sixteen years at 25 locations by certified child passenger safety technicians observing children in motor vehicles and recorded use of child passenger restraints. The drivers were surveyed on their knowledge, attitudes, beliefs, and practices regarding CPS. Data from drivers identifying themselves as grandparents were analyzed; also, three grandparent focus groups provided opinions on CPS practices.

Results

During the study 1758 parents transporting 2713 children and 284 grandparents transporting 391 grandchildren were included. While most drivers were restrained and used child occupant restraints, almost 25% of parents and grandparents chose the incorrect seat to transport the child, and greater than 68% had at least one harness error. Grandparents were more likely to have looser lower anchor straps or seat belts and have children younger than thirteen years in the front seat.The focus group-grandparents had a favorable attitude toward CSS. Grandparents acknowledged the need for CSS but opined that CSS were difficult to use. Physical barriers included arthritis, back pain, mobility, decreased strength, and vision problems.

Conclusions

Grandparents and parents were equally likely to use CSS and choose correct seats. Compared to parents, grandparents were more likely to travel with their grandchildren with CSS installed with looser harnesses or an installed CSS with looser seat belt or lower anchors. Additionally, grandparents were more likely to have a child younger than thirteen years in the front seat. The use of community resources such as permanent fitting stations could help grandparents improve a grandchild's travel safety.     

Evaluation of child safety seat checkpoint events

Objective

To determine the effectiveness of child safety seat checkpoints in generating change in child restraint practice to reduce the prevalence and extent of misuse.

Methods

Child safety seats underwent an initial checkpoint evaluation and participants received a training session. Participants were asked to return within 6–12 months to a checkpoint for follow-up evaluation. During each visit, a data collection sheet was used to assess the participants’ use of their child safety seat, and to subsequently calculate a restraint misuse score to characterize the child safety seat's usage before and after the intervention.

Results

During the period of study, 42 participants underwent both the initial and follow-up child safety seat check. Before the intervention, at least one misuse was identified in 100% of installed child safety seats. After the intervention, there was a significant reduction in the proportion of rear-facing child safety seats (18.8%) and forward-facing child safety seats (64.0%) that had at least one misuse (p < 0.001). Almost all (93.4%) of those using rear-facing child safety seats and the majority (64.0%) of those using forward-facing child safety seats improved their safety score as measured after the intervention.

Conclusions

Although misuse was universally observed, child safety seat checkpoint events were successful in improving usage practices.     

Keeping baby safe: A randomized trial of a parent training program for infant and toddler motor vehicle injury prevention

Motor vehicle crashes are responsible for much death and disability among infants and toddlers. This study evaluated Keeping Baby Safe In and Around the Car, a multimedia DVD designed to improve knowledge about car seat installation among parents of infants and toddlers. The randomized controlled trial was conducted with 195 parents of children aged 0–24 months. Effective car seat use was evaluated via a written knowledge quiz and car seat simulation. Results from analyses of covariance models show that posttest scores for the intervention condition were significantly higher than those of the control condition on both knowledge and car seat simulation measures. The results, consistent across outcome measures and regardless of child age, suggest that viewing the Keeping Baby Safe In and Around the Car DVD resulted in significant gains in parents’ car seat knowledge and their ability to discriminate the critical elements of correct car seat installation. Dissemination of engaging multimedia DVDs such as this program might reduce motor vehicle crash-related injuries to infants and toddlers.     

Accessory child safety harnesses: Do the risks outweigh the benefits?

Accessory child safety harnesses are available in some countries as alternative restraints for young children or as an accessory restraint used with booster seats. Their use, in Australia at least, is becoming more common. There have been concerns that the risk of misuse of these restraints outweighs any potential benefit this system might have over a retractable lap-shoulder belt system used with a booster seat. However to date there is no evidence to confirm or deny this. This study used laboratory simulated frontal crash tests to examine the performance of accessory child safety harness systems compared to the lap-shoulder belt when used alone and when used with two common designs of Australian booster seat. The performance of the child safety harness system when misused was also investigated. The results demonstrate that the correctly used child safety harness system performed no better than the lap-shoulder system, and in fact allows for a greater risk of submarining. Furthermore, one common form of child safety harness misuse, where the harness is over-tightened causing the lap belt to be positioned high over the abdomen, allowed extremely undesirable dummy motion. This involved gross submarining and direct contact between the harness system and the dummy's neck. These findings suggest that the risks associated with accessory child safety harness systems most likely outweigh any potential benefits, in frontal impacts at least.     

Impacts of culture on driver knowledge and safety device usage among Hispanic farm workers

This study examines Hispanic migrant farm workers' driving behaviors and knowledge of the laws. These laborers worked and drove in California's agricultural region up to 8 months a year. Results are based on 167 face-to-face interviews conducted in Spanish at five labor camps and 126 observations conducted at these same camps in California. Most drivers were male licensed drivers (79%), who learned to drive at ages 8-14 in Mexico (42%). Those licensed in Mexico versus the US received more citations and unlicensed drivers were rated with poor driving skills. Drivers reported 'always' using seat belts (86%), yet admitted not buckling up within the previous 2 months. Observational data showed that only 37% used belts and 55% of drivers riding alone were belted. Reasons for non-use reflected cultural and economic issues and lack of effective media safety campaigns for this group. Most (75%) drivers with children (< 4 years) said they used child safety seats and others with 1+ children (< 4 years) used no safety seats (20%) or only one seat (53%). Observations showed that regardless of the number of riders aged 0-4, the number of car seats never exceeded one. In 66% of the cars where a single child was carried and where two children were carried, no car seats were used. In all of these cases there were other passengers and drivers who were not belted.     

Premature graduation of children in child restraint systems: an observational study

This study investigated the use and misuse of child restraint systems (CRS) in Flanders (Belgium). Observations were conducted at a random sample of primary school and recreation areas. In total 1376 children were observed. A logistic regression model was constructed in order to determine the variables involved. The parameter-estimates of this model have shown that children are more often restrained when the driver buckles up, the ride takes less than 1h, the children are younger, the children sit in the front seat of the car, a recreational area is the destination of the trip and there are less than five children in the car. Also premature graduation to CRS was analysed. More than half of the children are not appropriately restrained, according to their age, weight or height. Improper shoulder belt use (putting the shoulder belt behind the back or under the arm) was observed in 8.99% of the children being restrained with high back booster seats, in 32.73% of the children being restrained with backless booster seats and finally in 19.07% of the children being restrained with seat belts. The risk of incorrectly using the shoulder belt increases when children are prematurely graduated in a CRS. The results are discussed in the light of other studies on this matter.     

Seat belt misuse among children transported in belt-positioning booster seats

Objective

Observe and report seat belt use among children transported in belt-positioning booster seats.

Design

We conducted a cross-sectional, observational survey of children transported in motor vehicles between 2006 and 2007. While drivers completed a survey reporting the child's age, weight and gender, and the driver's age, gender, race, income, education, and relationship to the child; a child passenger safety technician recorded vehicle seating location, restraint type, and use of the car safety seat harness or seat belt as appropriate for the child.

Setting

Twenty-five fast food restaurants and discount department stores throughout Indiana.

Participants

A convenience sample of drivers transporting children younger than 16 years.

Main exposure

Seat belt use among children transported in belt-positioning booster seats.

Outcome measure

Seat belt misuse.

Results

Overall, 1446 drivers participated, 2287 children were observed with 564 children in belt-positioning booster seats. At least one seat belt misuse was observed for 64.8% of the children transported. Common misuses were the shoulder belt being placed over the booster seat armrest (35.8%); shoulder belt not at mid-shoulder position (28.5%), seat belt was too loose (24.5%), and the shoulder belt was either behind the child's back (9.1%) or under their arm (10.0%).

Conclusion

There is a high frequency of seat belt misuses among children transported in booster seats. Advice to parents on appropriate car seat selection, and encouragement to parents to supervise seat belt use may decrease misuse.     

An evaluation of the effectiveness of forward facing child restraint systems

The objective of this study was to determine the effectiveness of forward facing child restraint systems (FFCRS) in preventing serious injury and hospitalization to children 12-47 months of age as compared with similar age children in seat belts. Data were obtained from a cross-sectional study of children aged 12-47 months in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. Effectiveness estimates were limited to those children between 12 and 47 months of age seated in the back row(s) of vehicles, restrained in FFCRS, regardless of misuse, or seat belts of all types and usage. Completed survey information was obtained on 1207 children, representing 12632 children in 11619 crashes between 1 December 1998 and 31 May 2002. Serious injuries occurred to 0.47% of all 12-47-month olds studied, including 1.72% of those in seat belts and 0.39% of those in child restraint systems. The risk of serious injury was 78% lower for children in FFCRS than in seat belts (odds ratio (OR) = 0.22, 95% confidence interval (CI) = 0.11-0.45, P = 0.001). The risk of hospitalization was 79% lower for children in FFCRS than in seat belts (OR = 0.21, 95% CI = 0.09-050, P = 0.001). There was no difference between the restraint types in preventing minor injuries. As compared with seat belts, CRS are very highly effective in preventing serious injuries and hospitalization, respectively. This effectiveness estimate is substantially higher than older estimates, demonstrating the benefits of current CRS designs. These results provide those educating parents and caregivers population-based data on the importance of child restraint use.     

Towards a structured understanding of caregivers’ safety behaviour in the domestic and driveway setting

Slow speed run-overs represent a major cause of injury and death among Australian children, with higher rates of incidents being reported in Queensland than in the remaining Australian states. Yet, little attention has been given to how caregivers develop their safety behaviour in and around the driveway setting. To address this gap, the current study aimed to develop a conceptual model of driveway child safety behaviours among caregivers of children aged 5 years or younger. Semi-structured interviews were conducted with 26 caregivers (25 females/1 male, mean age, 33.24 years) from rural and metropolitan Queensland. To enable a comparison and validation of findings from the driveway, the study analysed both driveway and domestic safety behaviours. Domestic safety behaviours were categorised and validated against driveway safety behaviours, uncovering a process of risk appraisal and safety behaviour that was applicable in both settings (the Safety System Model). However, noteworthy differences between the domestic and driveway setting were uncovered. Unlike in the domestic setting, driveway risks were perceived as shifting according the presence of moving vehicles, which resulted in inconsistent safety behaviours. While the findings require further validation, they have implications for the design and implementation of driveway run-over interventions.     

Factors influencing the use of infant car restraints

Over a six-week period 100 mothers in Dunedin, New Zealand obtained General Motors infant car seats from a rental scheme. In interviews conducted in the maternity hospital, before the seats had been used, the mother's perceptions of the comfort and ease of use of the seat were recorded. All mothers rated the seats as very safe. From details of 2,830 car trips undertaken by these mothers while their infants were 0-3 months old and from a further 687 journeys by 85 of those mothers when their infants were 4-6 months old we found that an infant car seat was used for only 72% of journeys with the younger infant compared to 91% of journeys with the older infant. Those mothers who had rated the seat--before ever using it--as appearing uncomfortable or difficult to use were less likely to make use of it. The seat was least likely to be used when the mother was going out for more than two hours in the evening for some purpose that involved only a short car journey.     

Factors associated with the premature graduation of children into seatbelts

This study investigated the factors associated with the premature graduation into seatbelts for Australian children aged 4-11 years. From 699 child restraint use questionnaires, 195 children were identified as meeting the booster seat height-weight criteria (height: 100-145 cm and weight: 14-26 kg). Of these children, 44% were correctly traveling in a booster seat, while 56% had been moved prematurely into a seatbelt. A multivariable logistic regression model showed that there were a number of key predictors associated with the premature graduation to seatbelts. For example, children who were moved prematurely into a seatbelt were more likely to be older, have other children travelling in the vehicle and have younger parents compared to children appropriately restrained in a booster seat. In addition, there was a significant interaction between vehicle type and parent's household income. Based on the findings of this study, a number of recommendations are made for strategies to enhance appropriate restraint use for this age group, as well as for future research.     

Factors influencing premature graduation from the use of child restraints in Japan

This study examined the association of child passenger restraint use by younger and older children taking into account situational factors and driver/child passenger characteristics. The Japanese national traffic accident data pertaining to children injured in rear-end collisions where the drivers were not-at-fault was analyzed, while applying the quasi-induced exposure method. Multivariate logistic regression analyses were conducted to examine the adjusted effects of predictors for proper restraint use by 0-5, 6-9, and 10-12-year-old children. Unbelted drivers, child's seating position, the number of total occupants, and the child's age were significantly associated with restraint use by both younger and older children. Riding in the rear seats was strongly associated with older SB-age children not being properly restrained, suggesting a link between the lack of booster seat-use requirements and the generally low restraint use rate in rear seats as well as the premature graduation from CRS use in general. The results were discussed in light of other international findings in this field.     

Modeling improvements in booster seat use: a discrete choice conjoint experiment

Automobile crashes are the leading cause of death in children aged 1–14 years. Many children, however, are not properly restrained in safety seats that reduce serious injury and death. This study used a discrete choice conjoint experiment to study factors influencing the decision to use booster seats. Parents of 1714 children aged 4–9 years from nine Canadian provinces completed choice tasks presenting experimentally varied combinations of 15 4-level booster seat promotion attributes. Latent class analysis yielded three segments of parents. The choices of the Benefit Sensitive segment (50%) were most sensitive to the injury prevention benefits of booster seats. The choices of parents in the Context Sensitive segment (33.5%) were more likely to be influenced by installation complexity, oppositional behavior, and the prospect that their child may be teased for riding in booster seats. Parents in the High Risk segment (16.5%) were younger, less educated, and less knowledgeable about vehicle safety legislation. They anticipated fewer benefits, expected more barriers and were less likely to use booster seats. Simulations suggest that consistent enforcement coupled with advertising focusing on injury prevention and the use of booster seats by other parents would increase adoption.     

The effect of seating location on the injury of properly restrained children in child safety seats

Properly restrained child passengers in the National Automotive Sampling System (NASS), General Estimates System (GES), were studied for the effect of seating position on the risk of injury. The analysis focused on children seated in a child safety seat in a rear seat location. A multiple logistic regression model was used to assess whether the center rear seat is a safer seating position than either of the outboard rear seats. Standard errors for the odds ratios (ORs) of injury for several correlates of injury including seating position were obtained using a jackknife procedure. This analysis of the data showed that the center rear seat is not a safer seating position than either of the outboard rear seats in terms of odds of injury (left seat OR = 0.88, 95% CI = 0.73-1.03; right seat OR = 1.03, 95% CI = 0.85-1.20). These results do not agree with those of previous studies that suggested the center rear seat is the safest position for parents to place a child safety seat.     

Evaluation of the Boost ‘em in the Back Seat Program: Using fear and efficacy to increase booster seat use

Objectives

Recent research supports the use of high-threat messages when they are targeted appropriately and designed to promote high efficacy as well as fear. This research examined the effectiveness of using a novel threat-appeal approach to encourage parents to place their children in booster seats and rear seats of vehicles.

Method

A 6-min video-intervention was created and evaluated at after-school/daycare centers via an interrupted time series design with similar control sites for comparison. Caregivers (N = 226) completed knowledge and practice surveys and fear and efficacy estimations related to childhood motor vehicle hazards. Researchers observed booster-seat and rear-seat use in study site parking lots.

Results

Compared to baseline and control assessments, the treatment groups’ child passenger safety knowledge, risk-reduction attitudes, behavioral intentions, sense of fear related to the hazard, and sense of efficacy related to the recommended behaviors increased significantly. Further, observed overall restraint use and booster-seat use increased significantly following the intervention.

Conclusions

Applying high-threat messages to child passenger safety interventions is promising and has the potential to be adapted to other health risk areas.