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.     

Psychosocial factors related to parental restraint of pre-school children in motor vehicles

While the use of safety restraints effectively reduces the risk of death or injury in accidents, many children still travel unrestrained in motor vehicles. Compulsory seat belt legislation in Australia increased rates of adult use dramatically, but did not have the same impact with children. In order to understand why levels of children's restraint use remain low, it is necessary to investigate parental factors related to use and non-use of restraints. This study assessed the rates of safety restraint use of parents and their pre-school children, and the sociodemographic, attitudinal and belief characteristics of parents which relate to children's restraint use, using the Health Belief Model as a basis for investigation. Restraint use for adults was substantially higher than for pre-school children. Children were more likely to be restrained if their parents were wearing seat belts, were married, were of high socioeconomic status, did not smoke, engaged in certain other preventive health behaviors on their children's behalf, traveled longer distances to pre-school and provided child seats for their children. In terms of the Health Belief Model, parents of restrained and unrestrained children differed in their evaluation of the "costs" and "benefits" of using restraints for their children, and in health locus of control. Parents of unrestrained children perceived the "costs" of restraint use, in terms of nuisance value, installation difficulty and financial cost, to be high. They were also less likely to believe that they could play a significant role in preventing injury to their children. Implications of these findings for safety restraint campaigns are discussed.     

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.     

Responsibility allocation for child injury: victim age and positive vs. negative framing of manufacturer's safety policy

Two experiments examined allocation of responsibility in the context of a fictitious, but realistic, product-use scenario in which a young girl suffers serious brain injury after consuming a product with a non-obvious hazard (marshmallows). The research investigated whether the responsibility allocated to the various parties would depend on the age of the child and whether the manufacturer took, or failed to take, precautions. Scenarios given to participants stated the age of the girl as 1½ years, 4 years, 8 years, or 16 years and had positive, negative, or no supplemental information about the manufacturer and its safety practices. Both experiments showed that the parents were considered most responsible for a young child's injury, but the allocation decreased with the older child. When negative information about the manufacturer's safety practices was given, allocations of responsibility for the girl's injury to the manufacturer increased significantly. In Experiment 2, the presence of warnings in the positive supplemental information condition reduced the manufacturer's responsibility for the oldest (16-year old) child. Negative impressions due to poor safety practices by manufacturers can lead to increased levels of responsibility allocated for injury. Primary caretakers are responsible for the safety of young children, but as they get older, children are viewed as being more responsible for their own safety. These results have implications for product-development decisions including labelling. They also point out a role for human factors professionals before and during product-related forensic litigation.     

Injuries to belted older children in motor vehicle crashes

Context

The American Academy of Pediatrics and the National Highway Traffic Safety Administration currently recommend that, unless they are under 57 in. in height, 8–12-year-old children use seat belts and all should ride in the rear seats of vehicles. These recommendations assume that the vehicle seat belt should provide adequate protection for these older children in the event of a crash.

Objectives

To describe characteristics of older children in the rear seat using seat belts in crashes, to estimate their risk and body region distribution of injury, and to identify risk factors for injury.

Methods

A representative sample of 6680 seat belt-restrained occupants, 8–12 years of age, seated in the rear seat during crashes involving insured vehicles in 16 US states between December 1998 and December 2007. A telephone interview was conducted with the driver of each vehicle. The main outcome was the parent-reported injury defined as Abbreviated Injury Scale (AIS) 2 or greater injuries.

Results

The risk of injury for belted 8–12 year olds in the rear seat was 1.3%. Head injury was the most common injury (60%), followed by injuries to the face (9%), upper extremity (9%) and abdomen (9%). One out of five (21%) 8–12 year olds either did not use the shoulder portion of the vehicle seat belt or placed it incorrectly behind their back or under their arm. Bivariate analyses indicated a higher risk of injury for these children (1.8%) as compared to children using both the lap and shoulder portions of the seat belt (1.1%). However, this difference was not statistically significant when other risk factors such as crash severity and characteristics of the driver were considered.

Conclusions

Injuries to the head, face, abdomen and upper extremity are the most common injuries to target for improved protection among 8–12 year olds in seat belts. Driver and crash characteristics are important risk factors for injury. A recent federal motor vehicle safety standard requiring lap and shoulder belts in all rear seat positions has the potential to further decrease the risk of injury to older children using seat belts.     

Managing children's risk of injury in the home: Does parental teaching about home safety reduce young children's hazard interactions?

Past research confirms that parents extend much effort to teach their young children about safety, but little is known about this process. The present study examined mothers’ use of teaching as a strategy to manage young children's risk of home injury and how this impacts children's hazard interactions. Mothers of three-year-olds completed an in-home room-by-room interview in which they identified injury hazards that concern them, reported on use of teaching to manage risk of injury from these hazards, rated children's understanding of these safety issues and compliance with behavioral guidelines regarding these safety issues, and reported on children's recent interactions with these hazards. They also completed questionnaire measures of how difficult the child is to manage and the child's typical level of risk taking. Results revealed that children's understanding of safety impacted both their compliance and hazard interactions, moderating the impact of risk taking on compliance and also the impact of children's difficult-to-manage score on hazard interactions. These findings demonstrate that teaching strategies need to effectively enhance children's understanding of the safety issue in order to reduce children's risk of hazard interactions.     

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.     

Are SUVs dangerous vehicles?

This study was a population cohort study of all licensed passenger vehicles in New Zealand in the years 2005–2006. The objective of the study was to evaluate the effect on road safety of sports utility vehicles (SUVs) compared to other passenger vehicle types. Statistical models were fitted to the population of 2,996,000 vehicles of which 17,245 were involved in an injury crash. Controlling for distance driven, vehicle and owner characteristics, SUVs were found to be relatively safe vehicles in terms of injury crash involvement and in terms of the injury rate of their own occupants or other road users into which they crashed. Current research on SUV safety clearly shows them to be a road safety concern, but only once a collision occurs. The present study shows that SUVs in New Zealand have relatively few collisions compared to other passenger vehicle types, allowing for factors such as distance driven, some allowance for the type of driving exposure (via the owners’ addresses) and for owner age and gender. Overall, the vehicle type implicated most frequently in injury crashes and involving the highest rate of road injuries was sports cars, causing clearly the most harm per licensed vehicle. Instead of concerning themselves primarily with SUVs, the focus of road safety agencies should be on the relatively high crash risk of sports cars, which are clearly a road safety concern. Their high crash involvement rate and injury rate is likely to be largely due to the way they are driven rather than to inherent characteristics of the vehicles themselves.     

Rollover crashes: predicting serious injury based on occupant, vehicle, and crash characteristics

The purpose of this research was to determine occupant, vehicle, and crash characteristics predicting serious injury during rollover crashes. We compared 27 case occupants with serious or greater severity injuries with 606 control occupants without injury or with only minor or moderate injury. Odds ratios (OR) for individual variables and logistic regression were used to identify predictive variables for serious injury associated with rollovers. Cases more often had thorax, spine, or head injury compared to controls that more often had extremity injuries. Intrusion (especially roof rail or B-pillar intrusion) at the occupant's position, the vehicle interior side and roof as sources of injury, and improper safety belt use were significantly associated with serious injury. Even when safety belt use or proper use was controlled for, occupants with greater magnitude of intrusion at their seat position were about 10 times more likely to receive serious injury. Although prevention of rollover crashes is the ultimate goal, it is important to develop safer vehicles and safety systems to better protect occupants who are involved in rollover crashes. This also requires improvement in data collection systems documenting these types of crashes.     

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.     

A statewide analysis of child safety seat use and misuse in Michigan.

This study was designed to determine frequency of child safety seat use for children under the age of 4 years in Michigan, as well as to determine types of misuse. No state has previously conducted such a statewide survey. A two-stage sampling plan was used with data collected through direct observation at a sample of 88 child-care centers and pediatric clinics throughout the state. Misuse data were collected at a subset of the sites through driver interview and visual and hands-on inspection. The study results indicate that 74.5% of children under 4 years of age in Michigan are in safety seats with use highest in vehicles driven by belted drivers, females, and drivers under 60 years of age. Some degree of seat misuse was found in 88.5% of the inspections. The most common types of misuse were related to snugness of fit (both in installing the seat into the vehicle and in securing the child), use of the safety belt locking clip, and the harness positioning clip. Drivers who had a high occurrence of misuse, as compared with drivers with lower misuse, had lower educational levels, removed the seat frequently from their vehicle, were not the parent of the child, and had children who were both younger and smaller. The results show that efforts to encourage people to use child safety seats have been successful.     

Perceived risk among parents concerning the travel situation for children with disabilities

The aim of this study was to describe perceived risk among parents concerning the travel situation for children with disabilities, in addition to their self-reported knowledge of regulations and standards. The results from the present questionnaire study showed that entering and exiting the vehicles often required manual assistance and, thus, was perceived as risky, creating worry among parents. Parents were also worried about professional drivers' lack of knowledge about the child, incautious driving behaviour and lack of adequate safety measures. A poor postural sitting position was a problem in all vehicles. Half of the parents lacked knowledge about the regulations and standards for school transportation and Special Transport Systems. Lack of information seems to be one underlying reason for the parents' worries. Comprehensive information, focused on the special needs of children with disabilities in their transportation, would probably reduce the parents' worries significantly.     

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.     

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.     

The influence of vehicle damage on injury severity of drivers in head-on motor vehicle crashes

Data from crashes investigated through the Crash Injury Research and Engineering Network (CIREN) Program were used to assess differences in injury patterns, severity, and sources for drivers, protected by safety belts and deploying steering wheel air bags, in head-on frontal impacts. We studied whether exterior vehicle damage with a different distribution (wide vs. narrow) across the front vehicle plane influenced injury characteristics. Drivers from both impact types were similar on the basis of demographic characteristics (except age), restraint use, and vehicle characteristics. There were significant differences in the type of object contacted and intrusion into the passenger compartment at the driver's seat location. The mean delta V (based on the kilometers per hour change in velocity during the impact) was similar for drivers in both (wide vs. narrow) impact types. There were no significant differences in injury patterns and sources except that drivers in wide impacts were almost 4 times more likely (odds ratio (OR)=3.81, 95% confidence limits (CL) 1.26, 11.5) to have an abbreviated injury scale (AIS) 3 serious or greater severity head injury. Adjusted odds ratios showed that drivers in wide impacts were less likely (OR=0.54, 95% CI 0.37, 0.79) to have severe injury (based on injury severity score (ISS)>25) when controlling for intrusion, vehicle body type, vehicle curb weight, age, proper safety belt use, and delta V. Drivers with intrusion into their position or who were driving a passenger vehicle were almost twice more likely to have severe injury, regardless of whether the frontal plane damage distribution was wide or narrow. Our study supports that the type of damage distribution across the frontal plane may be an important crash characteristic to consider when studying drivers injured in head-on motor vehicle crashes.     

How important is vehicle safety in the new vehicle purchase process?

Whilst there has been a significant increase in the amount of consumer interest in the safety performance of privately owned vehicles, the role that it plays in consumers’ purchase decisions is poorly understood. The aims of the current study were to determine: how important vehicle safety is in the new vehicle purchase process; what importance consumers place on safety options/features relative to other convenience and comfort features, and how consumers conceptualise vehicle safety. In addition, the study aimed to investigate the key parameters associated with ranking ‘vehicle safety’ as the most important consideration in the new vehicle purchase. Participants recruited in Sweden and Spain completed a questionnaire about their new vehicle purchase. The findings from the questionnaire indicated that participants ranked safety-related factors (e.g., EuroNCAP (or other) safety ratings) as more important in the new vehicle purchase process than other vehicle factors (e.g., price, reliability etc.). Similarly, participants ranked safety-related features (e.g., advanced braking systems, front passenger airbags etc.) as more important than non-safety-related features (e.g., route navigation systems, air-conditioning etc.). Consistent with previous research, most participants equated vehicle safety with the presence of specific vehicle safety features or technologies rather than vehicle crash safety/test results or crashworthiness. The key parameters associated with ranking ‘vehicle safety’ as the most important consideration in the new vehicle purchase were: use of EuroNCAP, gender and education level, age, drivers’ concern about crash involvement, first vehicle purchase, annual driving distance, person for whom the vehicle was purchased, and traffic infringement history. The findings from this study are important for policy makers, manufacturers and other stakeholders to assist in setting priorities with regard to the promotion and publicity of vehicle safety features for particular consumer groups (such as younger consumers) in order to increase their knowledge regarding vehicle safety and to encourage them to place highest priority on safety in the new vehicle purchase process.     

Vehicle deformation patterns in New Zealand road accidents

This paper presents partial results of a study undertaken by the University of Auckland in cooperation with the Ministry of Transport in New Zealand, into vehicle damage characteristics in typical road accidents. The overall objective of the study was to evaluate the likely effect of vehicle damage on child restraint systems installed in vehicles in common use on New Zealand roads. The results presented here, relate specifically to vehicle deformation and encroachment as recorded at the accident scenes by traffic officers over a 3 month period. It would appear from the results of the study involving 406 vehicles, that the likelihood of encroachment into the passenger compartment as a result of an accident, is considerably less for the centre back seat position. This confirms the widely accepted view that it represents the most desirable location for a child safety restraint system with regard to possible injury caused by vehicle deformation.     

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.     

Parents’ attitudes,knowledge and behaviours relating to safe child occupant travel

This study investigated parents’ attitudes, knowledge and behaviours relating to safe child occupant travel following new Australian legislation regarding child restraint system (CRS) and motor vehicle restraint use for children aged 7 years and under. A questionnaire exploring attitudes, knowledge and behaviours regarding general road safety, as well as safe child occupant travel, was completed by 272 participants with at least one child aged between 3 and 10 years residing in the Australian state of Victoria. Responses to the questionnaire revealed that participants’ attitudes, knowledge and behaviours towards road safety in general were fairly positive, with most participants reporting that they restrict their alcohol consumption or do not drink at all while driving (87%), drive at or below the speed limit (85%) and ‘always’ wear their seatbelts (98%). However, more than half of the participants reported engaging in distracting behaviours ‘sometimes’ or ‘often’ (54%) and a small proportion of participants indicated that they ‘sometimes’ engaged in aggressive driving (14%). Regarding their attitudes, knowledge and behaviours relating to safe child occupant travel, most participants reported that they ‘always’ restrain their children (99%). However, there was a surprisingly high proportion of participants who did not know the appropriate age thresholds’ to transition their child from a booster seat to an adult seatbelt (53%) or the age for which it is appropriate for their child to sit in the front passenger seat of the vehicle (20%). Logistic regression analyses revealed that parents’ knowledge regarding safe child occupant travel was significantly related to their attitudes, knowledge and behaviours towards road safety in general, such as drinking habits while driving and CRS safety knowledge. Based on the findings of this study, a number of recommendations are made for strategies to enhance parents’ attitudes, knowledge and behaviours relating to safe child occupant travel, as well as for future research.     

Parental attitudes and behaviours concerning helmet use in childhood activities: Rural focus group interviews

Previous research demonstrates the importance of parents in ensuring that their children practice proper helmet use. Parents encourage helmet use by setting an example when they wear helmets, as well as establishing rules that the children are expected to follow. Research in the area of helmet use predominantly focuses on bicycle helmets, but there are a number of childhood activities for which a helmet is required. The purpose of this research was to examine rural parents’ attitudes toward helmet use and investigate when, and for what activities, they require their children to wear helmets. Rural parents were selected as there is evidence that helmet use is less frequent among children in rural settings.