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.     

Restraint use legislation: Its prospects for increasing the protection of children in cars

Very few children traveling in cars—even fewer than adults—are restrained, and effective ways need to be found to increase their crash protection. One potential mechanism for accomplishing this goal is through laws requiring restraint use. Unfortunately, seat belt use laws have tended to exempt children, and the increases in restraint use and decreases in occupant fatalities that have resulted from some of these laws have not been shared by children. Empirical evidence from several countries indicates that children can be protected by seat belts, and thus they should be included in belt use legislation. Several Australian states have now extended restraint use legislation to children less than eight years old, requiring them to use seat belts or child restraints. In the United States, Tennessee has a law in force requiring use of child restraints by children less than four years old. Present child restraint laws have major gaps and shortcomings that limit their potential effectiveness, and the data available at this writing indicate that the effects of the laws have, at best, been slight. It is more likely that significant advances in protecting children in cars can be achieved through implementation of measures that provide protection automatically to virtually all the people for whom they are available, whether children or adults.     

Use of booster seats by Michigan children 4-8 years of age

This study reports the results of a statewide survey of restraint use by 4–8-year-old children in Michigan conducted between July 13 and 29, 2004. In this study, 3420 4–8-year-old children were observed traveling in passenger cars, vans/minivans, sport-utility vehicles, and pickup trucks. Restraint use was estimated for children traveling in all vehicles combined, as well as for each vehicle type separately. Children's restraint use was also calculated by the sex, age, and belt use of the driver. Separate estimates were also made of the restraint use of 4–8-year-old children by the combination of sex and belt use of the driver. Overall, 8.6 ± 5.9% of 4–8-year-old children were seated in a booster seat, 48.8 ± 10.3% were wearing a safety belt, 5.1 ± 3.4% were seated in a child safety seat, and the remaining 37.5 ± 11.5% were traveling completely unrestrained. When examining the rates by vehicle type, booster seat use was highest among children riding in sport-utility vehicles and lowest for those in pickup trucks. Surprisingly, children riding in passenger cars were more likely to be completely unrestrained than those in any other type of vehicle. While the sex of the driver did not seem to influence the restraint use of target-aged children, the driver's age did seem to have an effect. Booster seat use was quite low (0.6%) for children traveling with a driver over the age of 60, compared to 7.0 and 9.1% for those riding with drivers 16–29 and 30–59 years of age, respectively. The safety belt use of the driver also had a substantial influence on children's restraint use. Irrespective of driver sex, children riding with belted drivers were traveling in booster seats about 10% of the time, while those riding with unbelted drivers were only in booster seats 1–2% of the time.     

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.     

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.     

Injuries to children in automobiles in relation to seating location and restraint use

Findings in this study are based on 26,971 passengers less than 15 years of age in reported crashes in 1967 and later model year automobiles in North Carolina during calendar years 1973 and 1974. (1) Children least likely to be injured in crashes are restrained and in the back seat; those most likely to be injured are unrestrained and are in the front seat. Unrestrained children in the front right seat have the highest injury rate. (2) More than 90% of the children in the surveyed crashes were found unprotected by restraints—paralleling earlier findings for those in cars in general. (3) Back seat location reduced the injury rate by 28% among unrestrained children and 18% among restrained children. Use of restraints reduced the injury rate by 39% in the front seat and 31% in back. (4) Among unrestrained children, back seat location is advantageous for both males and females, for both younger and older children, and in automobiles of various sizes. The advantage of back seat location is most pronounced in frontal impacts.     

Restraint use and seating position among child car passengers: an observational study in Shanghai

Child passenger restraint practices in China are poorly characterized and few direct observational studies have been performed. This study aims to describe child passenger restraint use and to investigate factors influencing the restraint practices. A cross-sectional observational study was conducted at toll-gates in Shanghai during an 11-day period in June in 2009. A pro-forma observation checklist was used to collect data related to restraint use by child passengers aged ≤12 years, restraint use by drivers, and the number of child passengers traveling in passenger cars registered in Shanghai. Adjusted risk ratios (RR) comparing those children who were properly rear seated with those in other positions (front seat, on adult's lap) and any restraint use with no restraint use were evaluated using multivariate binomial regression with robust variance estimation. Among 967 children observed, 44.1% of children were in suboptimal seating positions (i.e., 12.2% in the front seat and 31.9% in adult laps) and 93.9% were unrestrained. Children aged ≤4 years (RR: 0.35, 95% Confidence Interval: 0.28–0.44), and those who were the only child in a car (RR: 0.84, 95% confidence interval: 0.74–0.96) had a lower likelihood of being properly rear seated. Children traveling with unrestrained drivers (RR: 0.09, 95% confidence interval: 0.01–0.60) were less likely to be restrained. This study demonstrates low restraint use and common suboptimal seating positions for child passengers in China and relates these to driver restraint use. These findings support the need for targeted programs to improve child restraint practices in China.     

Studies of child safety restraint use in motor vehicles--some methodological considerations

Despite the effectiveness of safety restraints in reducing the risk of death or injury in motor vehicle accidents, many children still travel unrestrained. Two methodological issues related to child restraint studies which had not been adequately addressed were identified: firstly, the accuracy of parental self-reports of restraint use with their children; and secondly, the consistency of observational data over time. These issues were investigated in the present research. The data indicate that parents' report is inaccurate, suggesting that if self-report measures are used, there is a need to compare them with direct observational measures to obtain information on reporting bias. A single observation of a child's restraint use appears to provide an accurate reflection of restraint use on other occasions in the same setting.     

Driver seat belt use indicates decreased risk for child passengers in a motor vehicle crash

Study objective

We examined the association between driver restraint use and child emergency department (ED) evaluation following a motor vehicle crash (MVC).

Methods

This cohort study included child passengers aged 0-12 years riding with an adult driver aged 21 years or older involved in a MVC in Utah from 1999 to 2004. The 6 years of Utah MVC records were probabilistically linked to statewide Utah ED records. We estimated the relative risk of ED evaluation following a MVC for children riding with restrained versus unrestrained drivers. Generalized estimating equations were used to calculate relative risks adjusted for child, driver, and crash characteristics.

Results

Six percent (6%) of children riding with restrained adult drivers were evaluated in the ED compared to twenty-two percent (22%) of children riding with unrestrained adult drivers following a MVC (relative risk 0.29, 95% confidence interval 0.26-0.32). After adjusting for child, vehicle, and crash characteristics, the relative risk of child ED evaluation associated with driver restraint remained significant (relative risk 0.82, 95% confidence interval 0.72-0.94). Driver restraint use was associated with child restraint use, less alcohol/drug involvement, and lower relative risk of severe collision types (head-on, rollover).

Conclusions

Driver seat belt use is associated with decreased risk of ED evaluation for child passengers in the event of a MVC.     

The actual threat posed by unrestrained rear seat car passengers

A statistical analysis of the threat posed by unrestrained rear seat car passengers to restrained drivers and front seat passengers was published in 2002. This was based on Japanese accident data from 1995 to 1999, and the conclusions have been checked using corresponding accident data from Great Britain. The law in respect of the use of seat belts and other restraint systems was less strict in Japan than in Great Britain between 1995 and 1999, so an earlier period had to be studied. The results suggest that the risk of death to a front seat car occupant is increased by about three-quarters by the presence of an unrestrained rear seat passenger behind them, a much smaller increase than was claimed by the Japanese researchers.     

Comparison of motor vehicle occupant injuries in restrained and unrestrained 4- to 14-year-olds.

This study compares injuries of restrained and unrestrained 4- to 14-year-olds in nine emergency rooms and the Coroner's office in Orange County, California from 1983 to 1989. Analyses were performed separately for 4- to 9- and 10- to 14-year-olds because of differences related to the fit of the seat belt. Significantly fewer intracranial injuries and a significantly lower mean Injury Severity Score (ISS) were seen between the restrained and unrestrained for 10- to 14-year-olds in the front passenger and back seats; but for 4- to 9-year-olds in the back seat only. These same differences were noted between restrained 4- to 9-year-olds in the back compared with those in the front passenger seat. Except for 4- to 9-year-olds in the front passenger seat, our findings are consistent with similar studies of occupants of all ages. Our results suggest that lap-shoulder belts (primary restraint in front seat) may provide less protection for 4- to 9-year-olds than for 10- to 14-year-olds and adults.     

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.     

Seat belt use among 13-15 year olds in primary and secondary enforcement law states

CONTEXT: Coverage and enforcement provisions of safety belt use laws vary by state. Most laws cover drivers and passengers age 16 and above. "Primary" enforcement laws allow police to stop and ticket a motorist for a safety belt law violation. With "secondary" enforcement laws, ticketing can only occur in the presence of another traffic infraction. Given the lower rates of restraint use among teen drivers and their passengers, the effect of primary enforcement laws on the restraint use of young teen passengers is of particular interest. OBJECTIVE: To compare restraint use by 13-15 year olds passengers in motor vehicle crashes in states with primary versus secondary enforcement safety belt laws. METHODS: Cross-sectional study of 3953 crashes involving 5372 children, representing 54,226 children aged 13-15 years in 41,198 crashes of insured vehicles in 16 states and Washington, DC between December 1, 1998 and December 31, 2004, with data collected via insurance claims records and a telephone survey. RESULTS: Non-use of restraints by 13-15 year olds was 7.2% (95% CI 4.3-10.1%) greater in secondary enforcement states (10.8%) as compared to states with primary enforcement laws (3.6%). After controlling for driver's age and restraint status and the seating row of the occupant, a 13-15 year olds was over twice as likely to be unrestrained in a secondary enforcement state as compared to a primary enforcement state (adjusted RR=2.2, 95% CI 1.5-3.1). CONCLUSIONS: States considering primary enforcement provisions to their restraint laws should consider the potential benefits these laws may have to all occupants in the vehicle, particularly young adolescents who are nearing driving age.     

Seat back and head restraint response during low-speed rear-end automobile collisions

Automobile seat backs and head restraints play a key safety role during low-speed rear-end collisions, yet few studies have explored the effect of collision variables on seat response. In this study, the effects of vehicle speed change and seat belt use on dynamic seat back and head restraint response during low-speed rear-end automobile collisions were examined. Four human subjects were repeatedly exposed to vehicle-to-vehicle rear-end collisions with speed changes of 2, 4, 6 and 8 km/h. Seat back force and deflection, and head restraint force were measured. The point of application of the resultant force applied to the seat back and head restraint were determined. The magnitude and time of peak kinematic and kinetic response parameters were used in a two-way repeated-measures analysis of variance (ANOVA) for speed change and seat belt use. The results showed that 20 of the 24 seat back and head restraint response parameters varied with speed change and none of the parameters varied with seat belt use. Head restraint forces, seat back forces and seat back deflections increased approximately linearly with speed change, whereas time to peak response, direction and moment arm of the forces remained either constant or varied only slightly over the range of speed changes tested.     

Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia—A population-based study

Objectives

To determine discrepancies between knowledge and practice of childhood motor vehicle restraints (CMVRs) and vehicle seating position amongst parents within the province of Nova Scotia.

Design

Random telephone survey.

Setting

The Canadian province of Nova Scotia.

Subjects

Four hundred and twenty-six households with at least one child under the age of 12 years, totaling 723 children.

Main outcome measures

The proportion of parents whose children who should be in a specific stage of CMVR and sitting in the rear seat of the vehicle, and who demonstrate correct knowledge of that restraint system and seating position, yet do not use that restraint system/seating position for their child (demonstrate practice discrepant from their knowledge).

Results

Awareness of what restraint system to use is good (>80%). However, knowledge of when it is safe to graduate to the next stage is low (30–55%), most marked for when to use a seatbelt alone. Awareness of the importance of sitting in the rear seat of a vehicle was universal. Discrepancies between knowledge and practice were most marked with booster seats and rear-seating of older children. Factors influencing incorrect practice (prematurely graduated to a higher-level restraint system than what is appropriate for age and weight) included lower household income, caregiver education level, and knowledge of when to graduate from forward-facing car seats and booster seats. Incorrect practice was also more commonly observed amongst children of weight and/or age approaching (but not yet reaching) recommended graduation parameters of the appropriate CMVR.

Conclusions

Discrepancies between knowledge and practice are evident through all stages of CMVRs, but most marked with booster seats. The roles of lower socioeconomic status and gaps in CMVR legislation, in influencing discrepant practice, must be acknowledged and suggest the need for targeted education concurrent with development of comprehensive all-stages CMVR policies.     

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.     

Community-based programs to promote car seat restraints in children 0-16 years -- a systematic review

STUDY OBJECTIVE: Community-based models for injury prevention have become an accepted part of the overall injury control strategy. This systematic review of the scientific literature examines the evidence for their effectiveness in reducing injury due to inadequate car seat restraint use in children 0-16 years of age. METHODS: A comprehensive search of the literature was performed using the following study selection criteria: community-based intervention study; target population was children aged 0-16 years of age; outcome measure was either injury rates due to motor vehicle crashes or observed changes in child restraint use; and use of community control or historical control in the study design. Quality assessment and data abstraction was guided by a standardized procedure and performed independently by two authors. Data synthesis was in tabular and text form with meta-analysis not being possible due to the discrepancy in methods and measures between the studies. RESULTS: This review found eight studies, that met all the inclusion criteria. In the studies that measured injury outcomes, significant reductions in risk of motor vehicle occupant injury (33-55%) were reported in the study communities. For those studies reporting observed car seat restraint use the community-based programs were successful in increasing toddler restraint use in 1-5 year aged children by up to 11%; child booster seat use in 4-8 year aged children by up to 13%; rear restraint use in children aged 0-15 years by 8%; a 50% increase in restraint use in pre-school aged children in a high-risk community; and a 44% increase in children aged 5-11 years. CONCLUSION: While this review highlights that there is some evidence to support the effectiveness of community-based programs to promote car restraint use and/or motor vehicle occupant injury, limitations in the evaluation methodologies of the studies requires the results to be interpreted with caution. There is clearly a need for further high quality program evaluation research to develop an evidence base.     

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.     

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.