Observed child restraint misuse in a large, urban community: Results from three years of inspection events

The influence of video prompting with embedded safety checks to teach child passenger safety restraint skills

Motor vehicle collisions are among the leading causes of unintended injury-related deaths among children under the age of 14. The primary cause of these deaths is the improper use of child passenger safety restraints (CPSRs). Correctly installed CPSRs can decrease the risk of fatal injury by 45% to 95%. To date, no studies have used video prompting with embedded safety checks to teach correct CPSR installation and harnessing in the absence of researcher-delivered instruction and feedback. We used a concurrent multiple-baseline-across-participants design to evaluate the efficacy of a video-prompting procedure with embedded safety checks to teach four prospective parents and caregivers CPSR installation and harnessing skills. All participants learned to perform these skills, and these effects maintained for 4 weeks. Furthermore, this training improved all participants' performance of an untrained installation position, vehicle, and harnessing skill, and these effects were largely maintained for 4 weeks.

Acceptability of virtual restraint fitting to extend the reach of child restraint fitting services: A pilot randomized controlled trial

OBJECTIVE

Incorrect use of child restraints is a long-standing issue, limiting the protection offered by child restraints in the event of a crash. Child restraint fitting services are a measure to reduce incorrect use but have limited reach and availability to underserved populations. Virtual child restraint fitting services have the potential to increase the reach and availability, but as with any digital intervention, need to be acceptable to users to be effective. The acceptability of such interventions has not been studied before.

METHODS

Using a three-arm randomized controlled trial, this study evaluated the acceptability of: (1) a video with child restraint fitting advice (Control), (2) a traditional in-person child restraint fitting service (In-person), and (3) a virtual child restraint fitting service (Virtual). Additionally, the effectiveness in reducing incorrect use was evaluated.

RESULTS

There was a significantly higher level of overall acceptability for the in-person service, and significantly fewer errors in child restraint use in this group compared to the control. There were no significant differences in overall acceptability or errors between the virtual service and the control. However in-depth analysis of the constructs of acceptability demonstrated participants in the in-person and virtual service groups held similar views on four of the seven constructs including the usefulness of the services and the impact of the service on comprehension of key information for correct restraint use. Areas where the views differed between these groups included perceived burden, appropriateness, and opportunity costs. Qualitative feedback suggested these negative perceptions on the virtual service may be remediated with some improvements to the technology.

CONCLUSIONS

Overall, child restraint fitting services provided virtually show promise as an alternative to in-person but attention to how services are provided via this technology, together with technology improvement, might be needed to fully realize its potential.

User-driven instructions reduce errors in child restraint use: a randomised controlled trial in Sydney, Australia

BACKGROUND AND OBJECTIVES

Crash injury risk is reduced when a child correctly uses an appropriate restraint; however, incorrect restraint use remains widespread. The aim of this study was to determine whether product information developed using a user-driven approach increases correct child restraint use.

METHODS

We conducted a two-arm double-blinded parallel randomised controlled trial in New South Wales, Australia 2019-2021. Participants were current drivers who were either an expectant parent or a parent of at least one child residing in the greater Sydney metropolitan area who were interested in purchasing a new child restraint. The intervention was user-driven product information consisting of instructions printed on an A3 sheet of paper, swing tags with key reminders and a video accessed via Quick Response codes printed on the materials. The control group received a postcard summarising legal child restraint requirements. The primary outcome was the correctness of child restraint use observed during home visit approximately 6 months after restraint purchase. Correct use was defined as no serious error or <2 minor errors. The secondary outcome was a count of observed errors.

RESULTS

427 participants were recruited. Home visits were conducted for 372 (190 intervention and 182 control). Correct use was more common in the intervention group (37.4%) compared with the control group (24.2%, p=0.006). Participants receiving the intervention were 1.87 times more likely to correctly use their restraint than those in the control group (95% CI 1.19 to 2.93).

CONCLUSIONS

The results provide evidence for the effectiveness of user-driven instructions as a countermeasure to restraint misuse.

TRIAL REGISTRATION NUMBER

ACTRN12617001252303.

Differences in participant characteristics and observed child restraint use between population-based and restraint fitting service samples

OBJECTIVE

To compare characteristics and restraint use between a population-based and fitting service sample of child restraint users.

METHOD

Characteristics of the two samples were compared using chi-squared tests. Differences in errors in restraint use observed in the two samples were modeled using logistic regression.

RESULTS

There were significant differences in child age (p < 0.001), and restraint types (p < 0.001) between the two samples, with more younger children in the fitting service sample. Controlling for differences in restraint type, the odds that adult participants were female were 61% less in the fitting service sample than in the population-based sample (OR 0.39, 95%CI 0.21-0.71). The odds that adult participants perceived a large risk associated with restraint misuse (OR 3.62, 95%CI 1.33-9.84), had a household income in the highest bracket (OR 3.89, 95%CI 1.20-12.62) and were living in areas of highest socioeconomic advantage (OR 2.72, 95%CI 1.22-6.06) were approximately three times higher in the fitting service sample. Overall, more participants had errors in restraint use in the population-based sample (p = 0.021). However, after controlling for restraint type, securing errors were three times more likely (OR 3.34, 95%CI 1.12-10.2), and serious installation errors were almost twice as likely (OR 1.91, 95% CI 1.09-3.39) in the fitting service sample.

CONCLUSIONS

While less resource intensive, convenience and/or fitting service samples may be less representative than population-based samples. Given the need for efficiency, methods that combine randomized population-based invitations to participate in restraint fitting check day events across geographically representative areas may be useful for ongoing surveillance of child restraint use.

The use of car safety seats for children in China: A questionnaire survey based on the theory of planned behavior

OBJECTIVE

The purpose of this study was to analyze the psychological characteristics underlying Chinese parents' behaviors in using child car seats and to understand their decision-making processes. Based on the theory of planned behavior (TPB), three extended variables of perceived accident severity, perceived benefits, and perceived barriers were introduced. From the perspective of social psychology, the psychological factors that influence parents' use of child car seats and their interrelationships were explored.

METHODS

A questionnaire was designed to collect data, including information on demographic characteristics, basic components of the TPB, and relevant extension variables. Using on online survey, 585 valid questionnaires were collected. Structural equation modeling was used to calibrate the data, and multiple group analysis was performed on the demographic variables.

RESULTS

The extended TPB can effectively explain and predict parents' behaviors when using children's car seats. The results of the model show that parents' positive attitudes toward child safety seats (CSSs), others' recognition of their own use and perceptual control of the use of CSSs increase their willingness to use CSSs. Parents' willingness to use has a positive impact on the use of CSSs. Additionally, for the three extended variables introduced, perceived benefit significantly promoted parental intention and behavior to use CSS for children; perceived barriers significantly reduced parental use of CSS; and perceived accident severity had no significant effect on parental use of CSS.

CONCLUSIONS

This study established the validity of the extended TPB model in predicting parents' behaviors in using car seats for their children. In addition, the current findings may provide a theoretical basis for policy development to promote CSS use.

Building an optimal pediatric trauma program

In this brief review, I suggest a framework for the ideal pediatric trauma program. I provide a trauma program construct devised by the American College of Surgeons. I expand on this design by offering some concepts around how trauma programs can maximize their effectiveness in care, education, and research. This review was a preamble for a minisymposium focused on pediatric hemorrhagic shock and resuscitation.

Adequacy of Emergency Department Documentation of Child Restraint Use After a Motor Vehicle Crash

OBJECTIVES

There are limited data on how often providers collect and document adequate restraint information in children seen in the emergency department (ED) after motor vehicle crashes (MVCs). The objectives of this study are to determine (1) how often adequate child restraint information to determine age-appropriate use is documented after MVC; (2) the frequency of incorrect use of the child restraint when adequate details are documented; and (3) for those discharged from the ED with identified incorrect use, the frequency of provision of information on child passenger safety (CPS).

METHODS

Retrospective chart review of visits of children younger than 13 years with an International Classification of Diseases, Tenth Revision code for MVC to an urban, academic, level 1 pediatric trauma center, from October 2015 to September 2018. Adequate documentation of child restraint use was defined as identification of location of the child in the car (front vs rear row), type of restraint used, and forward or rear facing for children 24 months or younger.

RESULTS

A total of 165 visits qualified for inclusion. There was adequate documentation in 46% of visits. Of those, incorrect child restraint use was identified in 49%. Of discharged patients with incorrect use, 10% had documentation of provision of CPS information.

CONCLUSIONS

Adequate details to determine proper age-appropriate restraint use are documented in only half of ED visits for MVC. Very few are given CPS instructions on discharge, even when incorrect use has been identified. Identification of incorrect restraint use in the ED is an opportunity for a teachable moment that is being underused.

Child restraint headrest and belt routing design features and their association with child passenger behavior and restraint misuse

OBJECTIVES

Ergonomic design of child restraint systems (CRS) may facilitate optimal travel behavior and crash protection of child passengers during motor vehicle trips. However there have been few studies examining the relationship between CRS design and child passenger travel behavior. The aim of this study was to examine whether associations between CRS design features and child passenger behavior exist during real-world, everyday vehicle trips.

METHODS

Video from a naturalistic driving study (NDS) was analyzed in this study. Families drove an instrumented study vehicle for approximately two weeks with at least one child aged between one and eight years traveling in their own forward-facing (FF) CRS or belt positioning booster (BPB). Video for one child passenger was randomly selected from each trip for analysis. Video was coded for five-second epochs at nine time points (5%, 17%, 25%, 30%, 50%, 53%, 75%, 89% and 95% of trip length). Two types of child passenger travel behaviors were identified by manual review of the video and audio recordings: (i) optimal/suboptimal head position and (ii) correct/incorrect use of the internal harness/shoulder belt. Video screenshots were used to characterize CRS design features. Random effects logistic regression models were used to examine the associations between specific CRS design features and the travel behaviors of interest, whilst accounting for clustering of data by child and trip.

RESULTS

Suboptimal head position was associated with the absence of a height adjustable headrest and a narrow headrest wing width in FFCRS. Incorrect harness use in a FFCRS was associated with the absence of an adjustable headrest, in addition to headrest features such as wing width and depth. In BPBs, a reduction in suboptimal head position was associated with the absence of a sash belt guide, however no restraint design features were associated with incorrect shoulder belt use.

CONCLUSIONS

Some CRS design features may influence undesirable child passenger travel behavior. These early findings support enhanced and user-centric CRS design as a likely important mechanism to improve child passenger safety.

A study of students' use of restraint systems in school transportation services in primary and secondary schools in northern Iran: an observational study

Background

Traffic accidents are one of the leading causes of death and severe injury among child occupants of vehicles in most countries. This has led to the consideration of how to use restraint systems for students in school buses. The purpose of the present study was to determine the percentage of students’ use of restraint systems in school transportation services in 2020.

Methods

In the present cross-sectional observational study, seatbelt use was assessed in 400 students in school transport vehicles using a checklist. The observation team sat at their vehicle, at the nearest location on one of the three sides of the school’s entrance: they had by manually registering the variable in the checklist. They focused on exactly the first vehicle parked next to the school entrance. There were two other observers to validate the observations. Data were analyzed by SPSS software (version 21).

Results

The rate of using restraint systems was 11.3%, use of restraint systems in the Sport Utility Vehicles (SUVs) was significantly higher (P < 0.03), in areas with medium income (P < 0.009) and low income (p < 0.012) as well as when the students were sitting in the rear seats, using the seatbelt were significantly lower (P < 0.001). Seatbelt use in students was less in services driven by drivers over the age of 40 (P < 0.01) and more in vehicles driven by female drivers (P < 0.003) and newer vehicles (p < 0.001).

Conclusion

School authorities must enforce traffic safety rules for school transportation services. These rules should be taught to drivers, families, and students. A restraint system must be mandatory for all students. School officials must equip their buses with seatbelts and employ school bus assistants to encourage wearing seatbelts and prevent students from standing.

The effectiveness of booster seat use in motor vehicle collisions

BACKGROUND

Alberta remains the only province in Canada without booster seat legislation. To date, analyses of booster seat effectiveness compared with seatbelt only use have demonstrated mixed findings using observational data.

METHODS

This study uses Alberta police collision report data for the years 2010-2016, inclusive. Using a case-control study design, children aged four to eight years, who were reported by police to be injured (cases), were compared with uninjured controls for restraint use (seatbelt, booster seat or no restraint). Logistic regression was used to estimate the relation between booster seat use and injury with adjusted odds ratios (aORs) and 95% confidence intervals (CI), stratified by collision types.

RESULTS

There were 12,922 children involved in collisions, of whom 570 were injured. Approximately 62% of all children included in the analysis were in a booster seat or safety seat at the time of collision. Crude analysis indicates higher odds of injury for seatbelt wearers compared with booster seat use (OR = 1.21; 95% CI: 1.02-1.44). Front-end vehicle-vehicle collisions, demonstrated higher odds of injury for seatbelt wearers relative to those in booster seats (aOR = 1.46; 95% CI: 1.03-2.07).

CONCLUSION

This analysis indicates a protective effect of booster seats that varies depending on the type of collision and impact location. These regionally-specific injury data may encourage and inform policy on the use of booster seats. Moreover, stratification by collision type may be necessary to inform analyses on booster seat effectiveness.

The rate of child restraint system use among children aged under six years in China

AIMS

The child restraint system (CRS) for vehicles is designed to provide specialized protection for children in the event of a crash. The aim of the study was to investigate the rate of CRS use and analyze the factors associated with CRS use among children aged under six years in China, and to provide further insight into developing strategies for promoting public health education.

METHODS

This is a cross-sectional study. The study sites were 36 primary healthcare institutions in 12 provinces across China, and the participants were 34,503 guardians of children aged 0-6 years. Guardians who owned private cars were included and completed surveys about their experience using CRS. Odds ratios and 95% confidence intervals were calculated using multivariate logistic regression models.

RESULTS

The overall rate of CRS use among children aged under six years in China was 17.3%. Multivariate logistic regression analysis revealed that living in an urban area, low age of the child, guardians having higher education and being looked after by parents had a significant positive association with CRS use among children aged under six years.

CONCLUSIONS

This study confirms that there is a low rate of CRS use among children aged under six years in China, highlighting the considerable need for CRS use education, advocacy and promotion of increasing use.

An Adapted Child Safety Seat Hassles Score Is Associated With Suboptimal Child Passenger Safety Behaviors Among Parents

OBJECTIVE

We modified the Child Safety Seat (CSS) Hassles Scale to characterize CSS hassles in a diverse population and test for associations between hassles and caregiver-reported child passenger safety behaviors.

METHODS

Secondary analysis of a 2-site survey of caregivers seeking emergency care for their ≤10-year-old child in 2015. Caregivers answered questions regarding CSS hassles, child passenger safety behaviors, and demographics. Size-appropriate restraint use was defined by the American Academy of Pediatrics (AAP) 2011 Guidelines for Child Passenger Safety. We tested for associations between the number of hassles and adherence to AAP guidelines (including the consistent use of a size-appropriate CSS, travel in a back seat, and never traveling unrestrained).

RESULTS

There were 238 caregivers included in analyses. Overall, caregivers endorsed a median of 5 hassles (interquartile range 2, 8). Half (50.8%) of caregivers endorsed child passenger safety behaviors that were nonadherent to AAP guidelines. Compared with caregivers reporting no hassles, there was an increased odds of not adhering to AAP child passenger safety guidelines for each additional hassle reported (adjusted odds ratio [aOR] 1.11; 95% confidence interval [CI] 1.03, 1.19). In addition, a higher number of hassles was associated with the inconsistent use of a size-appropriate CSS (aOR 1.15; 95% CI 1.06, 1.25) and as sometimes traveling unrestrained (aOR 1.13; 95% CI 1.03, 1.23).

CONCLUSIONS

Caregivers who reported more CSS hassles were more likely to report behaviors that were not adherent to AAP guidelines. Addressing CSS hassles may provide solutions for nonadherence of AAP child passenger safety guidelines.

So much nuance: A qualitative analysis of parental perspectives on child passenger safety

OBJECTIVE

To explore barriers and facilitators to optimal child restraint system (CRS) use for diverse parents of newborn infants and to obtain input from parents on the use of technology-assisted remote car seat checks as tools for promoting optimal CRS use.

METHODS

Parents were recruited using purposive sampling. Interviews were conducted with English- or Spanish-speaking parents with a full term newborn and regular access to a car. Interviews were conducted by phone, and recorded and transcribed verbatim. Interviews were conducted until thematic saturation was reached. Data were organized for analysis using Atlas.ti, and codes grouped by theme using constant comparison.

RESULTS

30 parents were enrolled. Barriers and facilitators to optimal CRS use were classified into three themes, as were thoughts on the pros and cons regarding remote car seat checks. Themes on barriers and facilitators included motor vehicle and CRS features (such as age and size of the motor vehicle and presence of the Lower Anchors and Tethers for Children LATCH system), resources (availability, accessibility, and accuracy of resources), and parental factors (parental emotions and characteristics). Themes related to pros and cons of remote car seat checks included the ability (and challenge) of remote car seat checks to identify and correct errors, the potential use of remote car seat checks in certain situations (such as CRS transitions and periods of growth), and convenience of remote car seat checks (including increased availability and ease of access). Subthemes with further detail were arranged within each theme identified.

CONCLUSION

From a parent perspective, there are several identified barriers and facilitators of optimal CRS use. Although car seat checks were identified as a resource, in-person accessibility was an issue, and there were mixed opinions on technology-assisted remote car seat checks. These results provide a foundation for additional study on targeted interventions, including remote interventions for which there is an increased need due to the COVID-19 pandemic.

The perspectives of young people on barriers to and facilitators of bicycle helmet and booster seat use

BACKGROUND

Mandatory bicycle helmet and booster seat laws for children are now common across Canada and the United States. Previous research has found that despite legislation, child compliance is often low. Our objectives were to identify and compare children's perspectives on barriers to and facilitators of their use of bicycle helmets and booster seats.

METHODS

Eleven focus groups were conducted with a total of 76 children; five groups of children between the ages of 4 and 8 years discussed booster seats and bicycle helmets, and six groups of children between the ages of 9 and 13 years discussed bicycle helmets. Efforts were made to include diverse participants from a variety of ethno-cultural and socioeconomic backgrounds.

RESULTS

Poor fit and physical discomfort were most often described as barriers to bicycle helmet use. Helmet appearance was a barrier for some children but acted as a facilitator for others. Booster seat facilitators included convenient features such as drink cup holders and being able to sit higher up in order to have a better view, while barriers included fear of being teased, and wanting to feel and be seen as more mature by wearing a seatbelt only.

CONCLUSIONS

The main barriers to usage of bicycle helmets and booster seats identified by young people were modifiable and fit within a theory of planned behaviour framework that includes subjective norms, child attitudes towards safety equipment and perceived behavioural control of its usage. Recommendations were made regarding how these elements can be utilized in future injury prevention campaigns.

Reducing child restraint misuse: national survey of awareness and use of inspection stations

OBJECTIVE

Research indicates that hands-on instruction on installation and use of child restraint systems (CRSs) is an effective method to reduce misuse. However, use of these services is low. The objective of the Awareness and Availability of Child Passenger Safety Information Resources (AACPSIR) Survey was to estimate the degree of awareness caregivers have of CRS inspection stations. The survey also evaluated the relationships among caregiver confidence and risk perceptions as well as potential barriers and facilitators to inspection station use.

METHODS

The AACPSIR was a web-based cross-sectional survey targeting a nationally representative sample of adults who drove with children aged 0-9 at least twice a month. An address-based sample was selected using a cluster sample design. Caregivers who reported driving frequently with child passengers answered questions on awareness and use of inspection stations, confidence related to CRS use, and barriers and facilitators to inspection station use.

RESULTS

Data were collected from 1,565 households. In all, 66.9% of respondents were aware of inspection stations, but only 44.2% reported that they had used these services. Most caregivers indicated that they were confident (91.7%) that the car seat was installed correctly. A quarter of the respondents indicated a reason that might prevent them from using an inspection station was that they "don't think it's necessary". A long wait time (66.5%), distance (65.2%), and schedule conflicts (63.9%) were also frequently indicated as potential barriers. Conversely, among inspection station users, most did not need to make an appointment (73%), and over half indicated that the station was five miles or less from their home and within a 15-minute drive.

CONCLUSIONS

The AACPSIR Survey results suggest a segment of caregivers share a positive safety culture, including knowledge of CPS services and use of those services. Of concern are caregivers who did not access an inspection station because they indicated it was not necessary, they already knew how to install the CRS, or pointed to other inconveniences. Future intervention programs that target caregivers unfamiliar with inspection stations or believe that the services are not necessary have the potential to improve child passenger safety.

A Process Evaluation Protocol for Examining the Impact of Instructions for Correct Use of Child Car Seats Designed through a Consumer-Driven Process and Evaluated in a Field-Based Randomised Controlled Trial

The incorrect use of child car seats is common, with significant negative effects on crash protection for child passengers. There is currently little evidence for effective, practical countermeasures for incorrect use. The provision of clear and comprehensible materials on correct use supplied with restraints at the point of sale could be highly cost-effective and achieve similar benefits to restraint-fitting services or hands-on training; however, routinely supplied instructions in their current form are frequently difficult to understand. We are conducting a randomised controlled trial of the consumer-driven redesign of instructional materials, consisting of an instruction sheet, swing tags and online training videos. This paper presents the protocol that will be used in an innovate process evaluation that will use the primary outcome of overall serious misuse assessed at six months, together with a survey and semi-structured interviews to determine fidelity, dose and outcomes for all intervention participants. The study will assess intervention delivery and external factors that may impact the effectiveness of the intervention, including experience, health literacy, confidence and attitudes. When it has been conducted, this process evaluation will provide enhanced understanding of the mechanisms through which the intervention works or not, aspects of the implementation process key to success of the intervention and insight into how external factors influence the success of the intervention.

Study protocol: a randomised non-inferiority trial using interactive virtual presence to remotely assist parents with child restraint installations

BACKGROUND

Motor vehicle crashes are the third-leading cause of death to American children aged 1-5 years. When installed correctly, child restraints (car seats) reduce risk of serious injury and death. However, most restraints are installed incorrectly. The current gold standard for correct installation is systematic car seat checks, where certified technicians help parents, but car seat checks are highly underused due to barriers in access, scheduling and resources.

METHODS

The present study protocol describes plans to evaluate use of interactive virtual presence technology (interactive merged reality)-joint, simultaneous remote verbal and visual interaction and exposure to the same 3D stimuli-to assist remotely located parents installing child restraints. If effective, this technology could supplement or replace in-person checks and revolutionise how government, industry and non-profits help parents install child restraints properly. Building from preliminary studies, we propose a randomised non-inferiority trial to evaluate whether parents who install child restraints while communicating with remote expert technicians via interactive virtual presence on their smartphones achieve installations and learning not inferior in safety to parents who install restraints with on-site technicians. We will randomly assign 1476 caregivers at 7 US sites to install child restraints either via interactive virtual presence or live technicians. Correctness of installation will be assessed using objective checklists, both following installation and again 4 months later.

CONCLUSION

We aim to demonstrate that child restraint installation is accurate (>90% correct) when conducted remotely, that such installations are not inferior to installation accuracy with live experts and that parents learn and retain information about child restraint installation.

A comparison of parent and child perspectives about barriers to and facilitators of bicycle helmet and booster seat use

To date, little work has compared similarities and differences between parent and young people's perceptions of barriers to and facilitators of bicycle helmet and booster seat usage. Our goal was to conduct such a comparison in order to inform future safety campaigns. Eleven focus groups with a total of 68 parents and 11 focus groups with a total of 76 young people were conducted. Recruitment was conducted and focus groups were held in diverse neighbourhoods to facilitate participation by families from a variety of cultural, linguistic, and socioeconomic backgrounds. Overall, parents and their children agreed on 50% of the barriers identified for bicycle helmet use and approximately 40% of the barriers for booster seats. Barriers common to both types of equipment for parents and children included comfort, style and design, and fear of teasing. Common facilitators included perceived safety, and comfort. While there was considerable overlap between the perspectives of parents and young people, there were also differences, underscoring the importance of addressing both perspectives. The barriers and facilitators identified were modifiable to a large extent; based on these, recommendations for future injury prevention campaigns were outlined.

Assessment of Caregiver-Targeted Interventions for Use of Motor Vehicle Passenger Safety Systems for Children: A Systematic Review and Meta-analysis

IMPORTANCE

Caregiver-targeted interventions to improve the use of child restraint systems (CRS) in motor vehicles are common and heterogeneous in their implementation. The effectiveness of these interventions is unknown.

OBJECTIVES

To quantify the effects of caregiver-targeted interventions using meta-analytic methods, assess the quality of published studies, and assess for publication bias.

DATA SOURCES

PubMed and PsychINFO (January 1, 2004, to April 1, 2019) were searched for English-language studies using a list of search terms. The search and screening process was completed between May 25, 2018, and April 1, 2019.

STUDY SELECTION

Studies met inclusion criteria if they included a caregiver-targeted intervention that focused on increasing CRS use for children (age, ≤9 years) and report the use of CRS before and after the intervention.

DATA EXTRACTION AND SYNTHESES

Cochrane and PRISMA guidelines were used for the meta-analysis and risk-of-bias review. Information was extracted on intervention type, setting, implementation, and attributes of the study independently between 2 coders. Data were pooled from independent samples, with 1 outcome measure from each intervention implementation or study.

MAIN OUTCOMES AND MEASURES

This study was an exploratory random-effects meta-analysis. Unadjusted odds ratios were calculated using the sample size and the observed number of children in incorrect or correct restraints in motor vehicles before and after the intervention to determine the odds of incorrect CRS use after completing an intervention. Setting, measurement method, randomization, use of vouchers, and types of restraint were tested as moderators. A funnel plot was used to assess for publication bias.

RESULTS

Of 1240 potential articles, 51 were deemed eligible for screening and 10 (8238 participants total) were included in the meta-analysis. Caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS (odds ratio, 0.51; 95% CI, 0.36-0.71; P < .001). Variance in the averaged effect size was driven by self-report methods (when removed from analyses, I2 = 61.8%; R2 change = 26.3; P = .02) and hospital settings (when removed from analyses, I2 = 70.7%; R2 change = 17.4; P = .002). Risk of bias was high in most studies; however, there was low evidence for publication bias.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS in motor vehicles; however, the methodological rigor of intervention studies should be enhanced.

Child passenger fatality: Child restraint system usage and contributing factors among the youngest passengers from 2011 to 2015

OBJECTIVE

Motor-vehicle crashes (MVC) remain a leading cause of preventable injury and death for children aged 0-3 in the United States. Despite advancement in legislation and public awareness there is continued evidence of inappropriate child restraint system (CRS) use among the youngest passengers. The current study focuses on appropriate CRS use from 2011 to 2015 using data from the Fatality Analysis Reporting System (FARS) for children aged 0-3.

METHODS

Child-, driver-, vehicle-, and trip-related characteristics were investigated within a sample of 648 children from 625 crashes over 5-years in which a child aged 0-3 was fatally injured while unrestrained or wearing an identified CRS type. Multivariable log-binomial regression was used to obtain relative risk.

RESULTS

Only 48% of the fatally injured children were appropriately restrained in a CRS. Premature transition to a booster seat and seat belt was evident. The largest proportion of rear-facing restraint use was reported in <1 year olds (40%), with less reported in 1 (11%) and 2 year olds (2%) and no usage in 3 year olds. Younger children were more likely to be in an appropriate CRS, while Black children, driver not restrained in a lap-shoulder belt configuration, and riding in a pickup truck were less likely to be restrained appropriately.

CONCLUSIONS

Evidence of inappropriate CRS use supports the use of more stringent legislation and parental interventions to communicate best practice recommendations and educate caregivers regarding appropriate child restraint methods. Practical applications: Public health campaigns focused on increasing appropriate restraint use in children are of great importance as optimally restrained children are less likely to sustain injuries, or require crash-related hospitalization compared to unrestrained children. Researchers and practitioners may find these surveillance findings essential when developing education and interventions targeting child-parent dyads at the greatest risk for a MVC-related fatality.

Evaluation of interventions to make top tether hardware more visible during child restraint system (CRS) installations

Objectives: The objective of the study is to determine whether specific child restraint system (CRS) or vehicle conditions improve top tether attachment rates during volunteer installations. Methods: A factorial randomized controlled trial was designed to evaluate 4 different experimental categories: (1) Color of tether adjuster casing (black or red), (2) labeling on tether adjuster casing (labeled with "Tether: Use for forward-facing" or unlabeled), (3) storage location of tether (bundled in a rubber band on the back of CRS or Velcroed over the forward-facing belt path), and (4) labeling in vehicle (labeled under head restraint and below anchor or unlabeled). Ninety-six volunteers were randomly assigned to one combination of conditions. One installation per volunteer was completed. The primary outcome measure was acceptable attachment of the top tether to the tether anchor. The secondary outcome measure was overall secureness of the installation. Pearson's chi-square tests were used to identify significant predictors of acceptable outcomes and logistic regression was used to investigate interaction effects. Results: A total of 66/96 subjects (68.8%) attached the top tether in an acceptable manner, with either zero errors (n = 50) or minor errors (n = 16). A total of 30/96 subjects (31.2%) had unacceptable tether outcomes, with either major errors (n = 10) or nonuse the tether at all (n = 20). None of the 4 experimental categories significantly affected tether outcomes. Subjects who opted to install the CRS with the lower anchors (LAs) had higher rates of acceptable tether attachment compared to subjects who installed using the seat belt or those who used both LA and seat belt together (χ² = 6.792, P = .034). Tether outcomes were not correlated with previous CRS experience, use of instruction manual(s), age, or sex. Only 15.6% of subjects produced overall correct and tight installations. Of those who used the seat belt in some manner, 70.2% neglected to switch the retractor into locking mode. Conclusions: Conditions in this study including tether color, tether labeling, storage location, and vehicle labeling did not significantly affect tether attachment rates. High rates of tether misuse and nonuse warrant further exploration to find effective solutions to this usability problem.

An assessment of child passenger safety levels of service in Michigan

Objective: The purpose of this article was to assess the match between child passenger safety resources (child passenger safety technicians [CPSTs], car seat checks, and child restraint system [CRS] distribution programs) and the child population in Michigan by utilizing geographic information systems approaches and to analyze the impact of Michigan's CPSTs on child passenger safety behaviors on departure from a seat check. Methods: Data were collected from administrative sources and a survey of CPSTs to determine the number and location of child passenger safety resources and children in Michigan. The main analyses used data from 2014. The child population ≤4 years old per county and per traffic safety region was determined from census data. CPST and car seat check locations were determined from a list from the Michigan Office of Highway Safety Planning (Mi-OHSP) and a survey of CPSTs who coordinate seat checks. Summary sheets from Mi-OHSP served as the data source for CRSs distributed through their occupant protection program. Data from child passenger safety checklists completed with seat checks were obtained from Safe Kids Michigan. Addresses were geocoded using Google Maps Geocoding API and then mapped at the county level using ArcGIS Desktop 10.3.1. Descriptive statistics were calculated and levels of service were determined at the county and regional levels. Results: In 2014, there were 570,929 children ≤4 years old in Michigan and 979 CPSTs who worked at 209 known seat check locations. An average of 6,854 seats was checked per year through Safe Kids Michigan Coalitions. All but 3 regions met an intermediate service level for seat check locations by offering one or more per 5,000 children ≤4 years old. There was at least one CPST in 80 of 83 counties (median 5; interquartile range, 2, 10.5). Assuming that an average Michigan CPST provides 10 h of service each year, all but 2 regions reached an intermediate service level of at least one technician hour per 90 children ≤4 years old. Fewer regions reached a basic level of service for the number of seat checks. Almost half (49.5%) of Safe Kids Michigan seat checks resulted in a change in child passenger safety behaviors. Conclusions: Child passenger safety resources in Michigan are not evenly distributed yet most regions and counties meet intermediate levels of service. Reallocating resources to areas that are providing basic levels of service could help reduce disparities in child passenger safety behaviors.

Factors Associated With Child Restraint Use in Motor Vehicle Crashes

Motor vehicle crashes (MVCs) are a leading cause of death among children. Multivariable analyses of age-appropriate child restraint system (CRS) use in the "booster-aged" population are needed. The current study identified factors associated with age-appropriate CRS use in fatal MVCs for children 4 to 7 years old, using 2011 to 2015 data from the Fatality Analysis Reporting System. Of 929 MVC fatalities, 32% of fatally injured children were in an age-appropriate restraint. While age-appropriate CRS use was higher for 4-, 5-, and 6-year-olds relative to 7-year-olds (adjusted relative risk [aRR] = 2.57, 2.51, and 2.18, respectively; p < .01 for each comparison), black children (aRR = 0.62; p < .01) relative to white children, and drivers who had not used a lap-shoulder belt (aRR = 0.40; p < .01) relative to belted drivers were associated with lower levels of age-appropriate CRS use. Our findings underscore the continued importance of communicating best practice guidelines on CRSs to caregivers of young children.

The impact of booster seat use on child injury and mortality: Systematic review and meta-analysis of observational studies of booster seat effectiveness

OBJECTIVE

To determine through systematic review and meta-analysis of observational studies if booster seats, compared to seatbelts alone, reduce injury and mortality from motor vehicle collisions among child passengers four to eight years of age.

METHODS

A comprehensive search of several data sources (including Medline, Embase, and PsycINFO) was conducted from inception to December 2016, to retrieve relevant publications in any language and from any geographic region. Data extraction was completed by two independent reviewers, capturing: study details, population characteristics, exposure (booster seat compared to seat belt use), outcomes (injury and fatality), and all associations reported between the exposure and outcomes. Risk of bias assessment was completed by two reviewers using the QUIPS tool. Meta-analysis of sufficiently similar studies was conducted using random effects models.

RESULTS

Eleven observational studies were included in qualitative syntheses. The systematic review and meta-analysis found no association between booster seat use, compared to seatbelts, and reduced injury (4 studies, OR 1.03; 95% CI 0.53-1.99) or fatality (2 studies, OR 0.91; 95% CI 0.73-1.13).

CONCLUSIONS

Evidence on booster seat effectiveness to protect against injury and mortality in real-world conditions is limited. This review identified the need for high quality studies assessing the effects of different models of booster seats on children of varying ages and weights.

Factors Associated With Poor Child Motor Vehicle Restraint on the USA-Mexico Border

Motor vehicle collisions (MVCs) are a significant cause of pediatric morbidity, particularly in low- to middle-income countries. We describe car seat use in children on the USA-Mexico border. A retrospective review was conducted for children 0-9 years old, admitted to the region's only Level I trauma center. Simultaneously, data were obtained from the SAFE KIDS database, a program that encourages car seat use through city checkpoints. There were 250 MVC admissions and nine fatalities in children 0-9 years old from 2010 to 2015. Nine percent of MVCs occurred in Mexico and 49% in El Paso, TX. Comparing trauma admissions to SAFE KIDS, there was some correlation between the location of MVCs and screening checkpoints (r = .50). There was a weaker correlation between injured children's neighborhoods and screening locations (r = .32). Only 37% of parents knew the crash history of the car seat and 3% were using a car seat previously involved in an MVC. While 96% of inspected children were placed appropriately in the backseat, 80% of children were found to be inappropriately restrained. Younger children more likely to be restrained (p < .05). Children from New Mexico and Mexico had the lowest rates of proper restraint and the highest injury severity scores. Proper use of car seats is a public health concern on the USA-Mexico border, and children are not properly restrained. Screening may be improved by focusing where at-risk children live and where most accidents occur. Restraint education is needed, particularly in New Mexico and Mexico.

Are mHealth Interventions to Improve Child Restraint System Installation of Value? A Mixed Methods Study of Parents

Childhood death from vehicle crashes and the delivery of information about proper child restraint systems (CRS) use continues to be a critical public health issue. Safe Seat, a sequential, mixed-methods study identified gaps in parental knowledge about and perceived challenges in the use of appropriate CRS and insights into the preferences of various technological approaches to deliver CRS education. Focus groups (eight groups with 21 participants) and a quantitative national survey (N = 1251) using MTurk were conducted. Although there were differences in the age, racial/ethnic background, and educational level between the focus group participants and the national sample, there was a great deal of consistency in the need for more timely and personalized information about CRS. The majority of parents did not utilize car seat check professionals although they expressed interest in and lack of knowledge about how to access these resources. Although there was some interest in an app that would be personalized and able to push just-in-time content (e.g., new guidelines, location and times of car seat checks), content that has sporadic relevance (e.g., initial installation) seemed more appropriate for a website. Stakeholder input is critical to guide the development and delivery of acceptable and useful child safety education.