Correct and incorrect use of child restraints: Results from an urban survey in New Zealand

Child restraint systems: Understanding confidence in proper use and addressing the need for education

Objective

To quantify the extent of proper local child restraint system (CRS) use and to better understand changes to the level of self-reported confidence with increased CRS installations. With the goal being to improve safety for children travelling in personal vehicles across London, ON and the region.

Methods

Public CRS clinics were initiated by Injury Prevention staff after they obtained the Child Passenger Safety Technician certification. Additionally, an online survey was commissioned targeting Ontario parents who had installed at least one CRS in the last five years.

Results

From September 2018 to September 2019, 96 comprehensive CRS checks were performed, with 29% of systems found to be installed correctly. Survey results showed a high level of reported confidence with CRS installation (N = 514, 70% female, 43% one child). Parents who had installed only one CRS reported higher confidence in their first install, compared to parents who had installed two or more systems.

Conclusions

The error rate with CRS installation and use seen in London, Ontario and the region, is similar to that reported in previous research. Survey results showed high levels of self-reported confidence in CRS use, especially for parents who have installed only one CRS. There presents a need to better understand the root cause of the discrepancy between level of confidence and proper CRS use and to expand our understanding of CRS knowledge retention and transferability to subsequent systems.

Knowledge, attitudes, and behaviors related to child safety restraint in citizens of Shenzhen Municipality, China, and the associations between these factors

OBJECTIVE

A child safety restraint (CSR) is an effective measure to reduce the risk of child injury from traffic collisions. This study aims to explore knowledge, attitudes, and behaviors regarding CSRs in a Chinese population.

METHODS

A cross-sectional survey regarding CSR use was conducted from April to May 2014 in Shenzhen municipality. Respondents were parents who had at least one child 0 to 6 years of age and owned a car. These parents provided a self-report of demographic characteristics as well as information about their knowledge, attitudes, and behaviors toward CSR use.

RESULTS

Most respondents had a fair level of knowledge about CSRs, with higher mean knowledge scores demonstrated among the respondents who were male, had an advanced degree, had a higher income, owned an expensive car, had an older child, drove frequently with children, and routinely drove greater distances with children. In addition, most respondents had a more positive attitude toward CSR use, with a higher mean attitude score among those who had an advanced degree, owned an expensive car, drove frequently with children, and routinely drove greater distances with children. However, some myths regarding CSR use also existed (e.g., parents can effectively protect their children in a car collision by holding them, they are not required to purchase the CSR for child safety if there is no mandatory provision by law, among others). Among 3,768 respondents who had at least one child and a car, 27.8% (1,047) had a CSR and 22.9% (864) used the CSR. A logistic regression model showed the likelihood of CSR ownership to be higher if respondents drove frequently or greater distances and was dependent on both the education level of the respondents and the age of the children. The frequency of CSR use increased as the age of children decreased (P = .0274). Respondents who owned a CSR and those who frequently used CSRs had higher mean knowledge and mean attitude scores.

CONCLUSIONS

This observational study found that although the majority of respondents had fair levels of knowledge and positive attitudes, they had lower rates of CSR ownership and use. Therefore, efforts at developing opportunities to expand public awareness of CSR use should be made to improve child passenger safety practices and eliminate child injury caused by traffic collisions.

Child Passenger Restraint System Misuse in Rural Versus Urban Children: A Multisite Case-Control Study

OBJECTIVES

Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population.

METHODS

A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions.

RESULTS

Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02).

CONCLUSIONS

In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified.

Child restraint use and parental perceptions of comfort

OBJECTIVE

Suboptimal child restraint use includes incorrect and/or inappropriate restraint use and increases the risk of injury. Comfort has been suggested as an important factor impacting on optimal use of restraints by children. This article aims to examine the relationships between parent reported comfort and restraint misuse and age-appropriate restraint choice.

METHODS

This is an analysis of data from a cross sectional observation study of child restraint use in New South Wales. Logistic regression was used to model the relationship between parent-reported comfort and restraint misuse and age-appropriate restraint choice.

RESULTS

There was no significant relationship between either parent-reported comfort and restraint misuse or parent-reported comfort and age-appropriate restraint choice.

CONCLUSIONS

Parent perceptions of comfort of children in child restraints do not appear to be associated with incorrect child restraint use or age appropriate restraint choice. It is possible that the actual comfort of the child may be related to incorrect use but this remains to be tested. Further investigation of the relationship between parent-perceived comfort and the actual comfort of the child, as well as the impact of child comfort on optimal child restraint use is warranted.

Buckle up safely (shoalhaven): a process and impact evaluation of a pragmatic, multifaceted preschool-based pilot program to increase correct use of age-appropriate child restraints

OBJECTIVE

To conduct a process and impact evaluation of a multifaceted education-based pilot program targeting correct use of age-appropriate restraints in a regional setting with a high proportion of Aboriginal and Torres Strait Islander families.

METHODS

The program was delivered in 2010 in 3 early learning centers where 31 percent of the children were of Aboriginal and Torres Strait Islander descent. Each component of the program was assessed for message consistency and uptake. To measure program effectiveness, participating children were matched 1:1 by age, language spoken at home, and annual household income with 71 children from the control arm of a contemporaneous trial. The outcome measure in the control and program centers (a 4-category ordinal scale of restraint use) was compared using ordinal logistic regression accounting for age of the parent.

RESULTS

Process evaluation found that though program components were delivered with a consistency of message, uptake was affected by turnover of all staff at one center and by parents experiencing difficulty in paying for subsidized restraints at each of the centers. Impact evaluation found that children from the centers receiving the program had nearly twice the odds of being in a better restraint category than children matched from the control group (adjusted odds ratio [ORadj] = 2.06, 95% confidence interval [CI], 1.09-3.90).

CONCLUSIONS

This was a pragmatic study reflecting the real-life issues of implementing a program in preschools where 57 percent of families had a low income and turnover of staff was high. Despite these issues, impact evaluation showed that the integrated educational program showed promise in increasing correct use of age-appropriate restraints. The findings from this pilot study support the use of an integrated educational program that includes access to subsidized restraints to promote best practice child restraint use among communities that include a high proportion of Aboriginal and Torres Strait Islander families in New South Wales. Future trials in similar settings should consider offering more support in centers with high turnover of staff and offering alternative methods of payment when families experience financial difficulties in purchasing the subsidized restraints. If proven in larger trials, this approach could reduce death and injuries in child passengers in this vulnerable group.

The impact of new legislation on child restraint system (CRS) misuse and inappropriate use in Australia

OBJECTIVE

The current study aimed to investigate the incidence of child restraint system (CRS) misuse and/or inappropriate use of CRS through an Australian CRS inspection program conducted by CRS fitting specialists between October 2004 and October 2011 and to determine whether CRS misuse and/or inappropriate use of CRS changed following new Australian legislation regarding CRS and motor vehicle restraint use for children aged 7 years and under.

METHODS

Participants were recruited through an advertisement for free CRS inspections displayed at childcare centers, kindergartens, community centers, hospitals, and child expos. At each inspection, a CRS fitting specialist inspected each child in their CRS while in their vehicle and reported to the owner of the CRS on the installation of the child restraint(s) and/or system(s) and any fitting faults and/or concerns with the fitting and/or use of the child restraint(s) and or system(s).

RESULTS

Results are based on the inspection of 2674 CRS. Of all of the CRS inspected, the majority (79%) were reported as having at least one instance of misuse and/or inappropriate use. The most common forms of CRS misuse and/or inappropriate use observed were harness strap errors (twisted, poorly adjusted, and/or incorrectly positioned, 41%), seat belt errors (incorrectly routed, twisted, and/or incorrectly adjusted, 32%), and a missing or incorrect fitting of the gated buckle/locking clip (24%). Significant differences were found across the proportion of CRS misuse and/or inappropriate use across restraint types (infant restraint/forward-facing CRS/convertible [birth to 18 kg] CRS/convertible [8-26 kg] CRS/boosters [booster seat/cushion/booster with harness combination]), χ(2)(4) = 147.852, P < .001. CRS misuse and/or inappropriate use were most prevalent among convertible CRS (birth to 18 kg; 87%), forward-facing CRS (85%), and convertible CRS (8-26 kg; 81%), compared to infant restraints (73%) and booster seats (booster seats/cushions/boosters with H-harness combination; 65%). There was no significant difference in the proportion of CRS with misuse and/or inappropriate use across the pre- and post-legislation period (80% vs. 77%), χ(2)(1) = 1.545, P > .5.

CONCLUSIONS

Based on the findings of the current study, it was concluded that, despite the introduction of new, definitive CRS legislation, CRS misuse and/or inappropriate use remains widespread in Australia. The findings highlight the need for CRS education and legislation that include information on correct CRS use, as well as information on appropriate CRS use, in order to provide specialized protection for child vehicle occupants in the event of a motor vehicle crash.

Methodology of estimating restraint use in children: roadside observation or parking lot interview survey

OBJECTIVE

To compare the differences in Canadian national estimates of correct child restraint use obtained using the standard roadside observation method compared to a detailed parking lot interview.

DESIGN

A multi-stage stratified survey design was used to conduct roadside observational and interview data collection at 182 randomly selected sites across Canada. For each site, a roadside intersection location and a parking lot location were used for the roadside observational survey and the interview respectively. Weighted estimates of correct restraint use from both locations were compared.

RESULTS

Estimates of correct restraint use were significantly higher for all children under the age of 9 in the parking lot sample. The largest discrepancy between the two samples was in booster seat aged children (ages 4-8) where 29.1% versus 67.8% of children were observed to be correctly restrained using the roadside and the parking lot methodology respectively. There was a 67% participation refusal rate in the parking lot survey.

CONCLUSIONS

There are specific advantages and limitations to both survey designs. The purpose of the data collection must be considered when selecting the methodology. Parking lot surveys provide richer data regarding restraint use/misuse. Estimates of correct restraint use must be approached with caution due to the effect of consent bias resulting in over inflation of estimates. Roadside observation is adequate and appropriate for providing national estimates of correct restraint use.

Population-level estimates of child restraint practices among children aged 0-12 years in NSW, Australia

This cross-sectional study provides population-referenced data on the restraints used and the extent of incorrect restraint use, among child vehicle passengers aged 0-12 years in NSW, Australia. A multistage stratified cluster sampling plan was used to randomly select vehicles from baby/child health clinics, pre-schools/day care centres, and primary schools across NSW to undergo detailed inspection of restraints used by child occupants within those vehicles. Overall, there were very high restraint usage rates (>99% of sampled children) but fewer than one quarter of children were using the correct size-appropriate restraints. Incorrect use (51.4%) was as common as inappropriate use (51.2%). Incorrect use was highest among users of dedicated child restraint systems (OR 16.0, 95% CI 6.9-36.0), and was more likely among those using size-appropriate restraints than those using inappropriate restraints (OR 1.8 95% CI 1.1-3.2); and among convertible restraints than those designed for a single mode of use (OR 1.5 95% CI 1.2-1.7). As incorrect use substantially reduces the protection from injury that is offered by child restraints, it is important that future strategies to reduce casualties among child occupants target both inappropriate and incorrect use.

Vehicle child restraint usage for Pacific children aged 6 weeks to 4 years: findings from the Pacific Islands Families study

Child restraint systems (CRSs) for vehicles are designed to provide protection and prevent or reduce child mortality and morbidity in road traffic accidents. Overall, 90% of children under 5 years of age in New Zealand currently use CRSs. There is considerable regional variability in CRS usage, but little information exists on its ethnic variations or determinants. "Increasing the level of restraint use" is explicitly stated as one of the 13 priorities within the New Zealand Ministry of Transport's new road safety strategy. As such, understanding CRS prevalence, patterns and associates within different communities is essential in realising this priority. Utilising a large birth cohort of Pacific children (n=1376 mothers), this study aimed to report the prevalence of maternal self-reported car seat usage at the 6 weeks, 1-year, and 2 years postpartum measurement waves; car/booster seat usage at the 4 years postpartum measurement wave; and to identify important associates using generalised estimating equation (GEE) models. Car seats were not used by 161 (11.8%) Pacific children at the 6 weeks measurement wave, 71 (5.8%) at 1-year, and 44 (3.8%) at 2 years, while car/booster seats were not used by 139 (13.3%) at the 4 years wave. Multivariable GEE model results revealed that mothers with no formal education, high parity, who smoked tobacco, lower household income, who lacked English language proficiency, and had multiple births were all at higher odds of failing to use car seat/booster seats. Despite differential attrition being noted in mothers over time, a sensitivity analysis using multiple imputation methods yielded similar findings. Targeted initiatives and education programs focusing on these higher risk groups, in particular, is needed to increase uptake and use of CRS thereby decreasing Pacific children's exposure to injury risk. As New Zealand has a large and increasing proportion of Pacific, Maori and Asian people, there is a continuing need to understand cultural factors in traffic safety. Only when culturally appropriate initiatives and education programs have been developed and disseminated that meet the needs of New Zealand's different communities is the national priority likely to be realised.

Shoulder height labeling of child restraints to minimize premature graduation

OBJECTIVE

We hypothesized that parents and caregivers would make better judgments about child restraint fit if shoulder height labeling was used to communicate appropriate child restraint transition times.

METHODS

Participants were recruited at a shopping center in New South Wales, Australia, and were observed choosing restraints, with and without shoulder height labels indicating appropriate restraint fit, for each of 2 test mannequins (representing a 3-year-old child and a 5-year-old child). Demographic and child restraint use experience data also were collected. Generalized estimating equations were used to examine associations between labeling condition and participant's judgment of restraint appropriateness.

RESULTS

Participants (N=86) made significantly fewer errors in judging restraint appropriateness for the test mannequins when the restraints included shoulder height labels (P<.001). Depending on label format, the odds that a participant would always make the correct decision were 5.2 (95% confidence interval: 2.7-9.8) to 3.7 (95% confidence interval: 2.0-6.9) times greater when shoulder height labels were included than when they were not.

CONCLUSION

The use of shoulder height labels on child safety seats and booster seats is an effective means of communicating child restraint fit to parents and caregivers.

Evaluation of child safety seat checkpoint events

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Seatbelts and the law: how well do we protect Australian children?

About a thousand Australian children are seriously injured in motor vehicle accidents each year, despite 92% using seatbelts or child restraints. Premature graduation of children to adult seatbelts, misuse of seatbelts and use of lap-only belts increase the risk of injury or death. In Australia, use of a child restraint or booster seat is not mandatory for children aged > 1 year, while other countries mandate their use for children up to 5-12 years old. Australian parents are confused about the safest restraint and seating position, particularly for children aged > 2 years. Australian child restraint legislation needs to be reviewed to increase the rate of optimal restraint use.