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Motor vehicle crashes are a leading cause of death for youth. Appropriate occupant protection significantly reduces these preventable injuries. Secondary field observation survey records were studied to identify populations that would most likely benefit from youth occupant protection programs. Multivariate regression analysis showed that drivers of youth between 4 and 14 years were in need of programs promoting youth and driver occupant restraint use. When these drivers were using seat belts, it was 35 times more likely they had youth occupants in safety restraints. A focus on pickup truck drivers may also give these programs greater efficacy in increasing youth restraint use. This study was limited to a single state, but the approach should be transferable to other jurisdictions where youth occupant protection field observation studies are conducted.

Background: State laws regarding child passenger protection vary substantially., Objectives: The objective of this study was to develop a scoring system to rate child passenger safety laws relative to best practice recommendations for each age of child., Methods: State child passenger safety and seat belt laws were retrieved from the LexisNexis database for the years 2002-2015. Text of the laws was reviewed and compared to current best practice recommendations for child occupant protection for each age of child., Results: A 0-4 scale was developed to rate the strength of the state law relative to current best practice recommendations. A rating of 3 corresponds to a law that requires a restraint that is sufficient to meet best practice, and a rating of 4 is given to a law that specifies several options that would meet best practice. Scores of 0, 1, or 2 are given to laws requiring less than best practice to different degrees. The same scale is used for each age of child despite different restraint recommendations for each age. Legislation that receives a score of 3 requires rear-facing child restraints for children under age 2, forward-facing harnessed child restraints for children aged 2 to 4, booster seats for children 5 to 10, and primary enforcement of seat belt use in all positions for children aged 11-13. Legislation requiring use of a "child restraint system according to instructions" would receive a score of 1 for children under age 2 and a 2 for children aged 2-4 because it would allow premature use of a booster for children weighing more than 13.6 kg (30 lb)., Conclusions: The scoring system developed in this study can be used in mathematical models to predict how child passenger safety legislation affects child restraint practices.

This paper assesses the effectiveness of child safety seat laws in the United States. Over the past 35 years, these laws have steadily increased mandatory child safety seat restraint ages. We exploit state-year level variation in the age until which children are required to ride in child safety seats to estimate triple difference models using Fatality Analysis Reporting System (FARS) data from 1975 to 2011. Our findings show that increasing the age thresholds is effective in increasing the actual age of children in safety seats. Across the child-age distribution, restraint rates increase by between 10 and 30 percentage points or by between 50 and 170 percent, in the long run. We also estimate the impact of the child safety seat laws on the likelihood that a child dies in a fatal accident. We find that the laws saved up to 39 children per year. Finally, we find that the laws primarily induce compliant parents to switch from traditional seatbelt use to child safety seat use, with only small effects among parents who do not restrain their children.

Problem: Motor-vehicle crashes are a leading cause of death for American Indian/Alaska Natives (AI/AN) including AI/AN children. Child safety seats prevent injury and death among children in a motor-vehicle crash, yet use is low among AI/AN children., Methods: To increase the use of child safety seats (CSS; car seats and booster seats), five tribal communities implemented evidence-based strategies from the Guide to Community Preventive Services during 2010-2014. Increased CSS use was evaluated through direct observational surveys and CSS event data. CSS events are used to check the installation, use, and safety of CSS and new CSS can be provided., Results: CSS use increased in all five programs (ranging from 6% to 40%). Four out of five programs exceeded their goals for increased use. Among the five communities, a total of 91 CSS events occurred resulting in 1417 CSS checked or provided., Conclusions and Practical Applications: Evidence-based child passenger safety interventions are both feasible in and transferable to tribal communities., (Published by Elsevier Ltd.)

Campaigns advocating behavioural changes often employ social norms as a motivating technique, favouring injunctive norms (what is typically approved or disapproved) over descriptive norms (what is typically done). Here, we investigate an upside to including descriptive norms in health and safety appeals. Because descriptive norms are easy to process and understand, they should provide a heuristic to guide behaviour in those individuals who lack the interest or motivation to reflect on the advocated behaviour more deeply. When those descriptive norms are positive - suggesting that what is done is consistent with what ought to be done - including them in campaigns should be particularly beneficial at influencing this low-involvement segment. We test this proposition via research examining booster seat use amongst parents with children of booster seat age, and find that incorporating positive descriptive norms into a related campaign is particularly impactful for parents who report low involvement in the topic of booster seat safety. Descriptive norms are easy to state and easy to understand, and our research suggests that these norms resonate with low involvement individuals. As a result, we recommend incorporating descriptive norms when possible into health and safety campaigns., (Copyright © 2016. Published by Elsevier Ltd.)

Objectives: We sought to identify the program fidelity factors associated with successful implementation of the Buckle-Up Safely program, targeting correct use of age-appropriate child car restraints., Methods: In 2010, we conducted a cluster randomized controlled trial of 830 families with children attending preschools and long day care centers in South West Sydney, New South Wales, Australia. Families received the Buckle-Up Safely program in the intervention arm of the study (13 services). Independent observers assessed the type of restraint and whether it was used correctly., Results: This detailed process evaluation showed that the multifaceted program was implemented with high fidelity. Program protocols were adhered to and messaging was consistently delivered. Results from multilevel and logistic regression analyses show that age-appropriate restraint use was associated with attendance at a parent information session hosted at the center (adjusted odd ratio [AOR]=3.66; 95% confidence interval [CI]=1.61, 8.29) and adversely affected by the child being aged 2 to 3 years (AOR=0.14; 95% CI=0.07, 0.30) or being from a family with more than 2 children (AOR=0.34; 95% CI=0.17, 0.67)., Conclusions: Findings highlight the importance of parents receiving hands-on education regarding the proper use of age-appropriate child restraints.

In order to test stereotypes that mothers are more safety conscious than fathers, this study aimed to explore differences in restraint patterns, front-row seating and injury for children in crashes when driven by fathers versus mothers, both when driving alone and with other adults. From 15 January 2003 to 30 November 2007, data were collected via insurance claims records and telephone surveys on a weighted sample of 10,715 child passengers in crashes. When riding with children and no other adults, father drivers in crashes were more likely than mother drivers to transport children <9 years old unrestrained or suboptimally restrained (35.0% vs 26.1%, p=0.001) and to seat children <13 years old in the front row (23.7% vs 14.3%, p<0.001). For children <16 years, no statistically significant difference in injury risk was noted for father versus mother drivers, regardless of adult passenger presence. Further improvements in child passenger safety might be gained with campaigns directed at both fathers and mothers., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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.

Aim: The purpose of this study is to determine how children are transported to and from hospital, and to understand caregivers' car restraint knowledge base., Method: A convenience sample of 200 inpatients in five wards at Starship Children's Hospital. Parents or caregivers underwent a short interview, asking: the usual restraint used by their child; how the child was transported to hospital; their plans for transporting the child home; their knowledge of current New Zealand legislation and best practice recommendations regarding child car restraints., Results: In their normal car travel, 95% children younger than 5 years were reported to be using a car seat all the time, versus 34% children aged 5 to 9 years. In their journey to hospital, 8% (7/91) of children younger than 5 years were not in a child car seat; 27% (3/11) of children younger than 5 years transported to hospital in a taxi, were not in car seats (one was held in the parent's lap). Responses about the planned trip home showed nine children (7%) were at immediate risk of being transported in an unsafe way, without a child restraint. Questions about awareness of correct child restraint use showed 68% of the families with children aged 5 to 9 were unaware that it was important to continue to use a child restraint for their child., Conclusion: There is an opportunity for child health professionals to provide support to families with children in hospital by collaborating with established child restraint rental agencies and making best practice child restraint advice and products more readily available. New Zealand law should be updated to require the use of child car restraints beyond a child's fifth birthday.

Objective: This study aimed to evaluate the impact of a computer kiosk intervention on parents' self-reported safety knowledge as well as observed child safety seat, smoke alarm use, and safe poison storage and to compare self-reported versus observed behaviors., Methods: A randomized controlled trial with 720 parents of young children (4 months to 5 years) was conducted in the pediatric emergency department of a level 1 pediatric trauma center. Enrolled parents received tailored safety information (intervention) or generic information (control) from a computer kiosk after completing a safety assessment. Parents were telephoned 4 to 6 months after the intervention to assess self-reported safety knowledge and behaviors; in-home observations were made 1 week after the telephone interview for a subset of 100 randomly selected participants. Positive and negative predictive values were compared between the intervention and control groups., Results: The intervention group had significantly higher smoke alarm (82% vs. 78%) and poison storage (83% vs 78%) knowledge scores. The intervention group was more likely to report correct child safety seat use (odds ratio, 1.36; 95% confidence interval, 1.05-1.77; P = 0.02). Observed safety behaviors were lower than self-reported use for both groups. No differences were found between groups for positive or negative predictive values., Conclusions: These results add to the limited literature on the impact of computer tailoring home safety information. Knowledge gains were evident 4 months after intervention. Discrepancies between observed and self-reported behavior are concerning because the quality of a tailored intervention depends on the accuracy of participant self-reporting. Improved measures should be developed to encourage accurate reporting of safety behaviors.

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., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Child safety restraints can reduce risk of death and decrease injury severity from road traffic crashes; however, knowledge about restraints and their use in Kuwait is limited. A cross-sectional, self-administered survey about child car safety was used among a convenience sample of parents of children aged 18 years or younger at five Kuwaiti university campuses. Of 552 respondents, over 44% have seated a child in the front seat and 41.5% have seated a child in their lap while driving. Few parents are aware of and fewer report using the appropriate child restraint; e.g., 36% of parents of infants recognised an infant seat and 26% reported using one. Over 70% reported wearing seat belts either "all of the time" (33%) or "most of the time" (41%). This new information about parents' knowledge and practice regarding child car seat use in Kuwait can inform interventions to prevent child occupant injury and death.

Seatbelts and child restraints can reduce deaths resulting from road traffic crashes, and are one of the risk factors being targeted by the Road Safety in 10 Countries project in Mexico. This study quantifies the prevalence of restraint use in two of the intervention sites (Guadalajara-Zapopan and León) and one comparison site (Cuernavaca). Three rounds of roadside observations were conducted between November 2010 and January 2012. The overall prevalence of seatbelt use was 45.0% (95% CI = 44.3-45.7) amongst all occupants ≥10 years of age in the three cities. Child restraint use in children <5 years of age ranged from 7.9 to 17.4%. Two rounds of surveys were administered to all road traffic injury (RTI) victims presenting at a tertiary hospital in each city; RTI victims had lower seatbelt use than the general population (31% vs 42%, p = 0.037). This study demonstrates the need for further targeted intervention to increase use of these highly efficacious safety devices in Mexico.

Motivating parents to take certain safety precautions when traveling with their children remains challenging for advocates. Caregivers of booster-aged children are particularly difficult to reach because they do not consider their children to be of "safety-seat" age and have inherently low perceptions of vulnerability to crash injury. Unfortunately, most booster seat programs fail to adequately motivate their intended population because they are primarily informational in nature and rely on caregivers to seek out and attend to the information. In this article, interventions using threat appeal tactics and progressive dissemination methods are recommended to effectively target participation and perceptions of vulnerability among this population. Recent research on risk communication indicates that threat appeals are supported when they contain high threat and high efficacy components. Threat appeal tactics are particularly desirable when perception of vulnerability is low, as is the case with parents of booster-aged children. In addition to theoretical arguments for more aggressive intervention approaches, a case example is presented wherein such techniques were used to promote booster seat use. The intervention resulted in significant increases in knowledge, risk-reduction attitudes, sense of efficacy, and observed booster seat use. Through use of progressive dissemination methods, the intervention has reached an audience of 431,600 people and counting.

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., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To describe child car safety practices among children aged 0-8 years. Eight schools from two local government areas (LGAs) were selected by simple random sampling. Passenger cars were observed for child seating position and restraint use at each selected school as children were being dropped off in the morning., Results: Observed child restraint use was very low, as was the rate of appropriate restraint for age (10.8% and 4.2%, respectively, in Eti-Osa, and 7.0% and 1.8% in Ikeja). Child restraint use decreased with increasing age group from 25% in those below 1 year, to 12% in those aged 1-3 years, and 7.4% in those aged 4-8 years. A large proportion of restrained passengers were inappropriately restrained in a seatbelt alone. Front seating among observed child passengers was not as high as in studies from similar environments (9.4% and 17.5% in Eti-Osa and Ikeja, respectively). Factors associated with child restraint use were number of child passengers in car, and whether or not the driver wore a seatbelt. Seating position of the child was significantly associated with the relationship of the driver to the child, and driver's gender., Conclusion: The level of child restraint use observed in this study is unacceptably low. The relatively low prevalence of front seating while riding in cars should however be further reduced. The study recommends the enactment of specific country legislation on the use of child restraints, accompanied by multifaceted intervention programmes to improve the availability and use of child car safety seats and booster seats.

Little is known about child passenger safety practice in China. This study aims to describe child passenger seating and restraint practice in Shanghai. Information on 970 children enrolled in five randomly selected kindergartens in the Songjiang and Pudong districts of Shanghai was collected from a parental survey during 2008-2009. The adjusted rate ratios for optimal (rear-seated alone) versus suboptimal seating position (including front-seated or sitting in adult laps) and restraint use versus non-use of restraints among child passengers were evaluated using multivariate binomial regression. Suboptimal seating position (16.9%) and non-use of restraints (60.8%) was common among child passengers. Younger age (≤4 years) and having parents who are licensed drivers decreased the likelihood of being rear-seated alone; whereas having a tertiary-educated mother increased the likelihood of a child being seated optimally. Compared with unlicensed parents, guardian parents who have a driver's licence were more likely to use restraints for their child passengers. This study suggests restraint non-use and suboptimal seating position are common for child passengers in the Songjiang and Pudong districts of Shanghai, and identifies risk factors influencing restraint use and seating position choice for child passengers. There is an urgent need to improve child passenger safety in China and these findings indicate potential targets for educational interventions in the absence of child restraint laws.

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., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

This study evaluated the effectiveness of the NSW Restraint Fitting Station Network in preventing incorrect use of rearward facing and forward facing child restraints. The way children used restraints was observed randomly as they arrived at observation sites during a cross-sectional ecological study across New South Wales, Australia. Trained researchers examined restraint system installation once the child left the vehicle. A structured interview was also conducted with the driver. Logistic regression was used to examine the association between parental report of ever having the restraint checked at a Restraint Fitting Station and whether or not the restraint was used correctly, while controlling for potential confounders and accounting for the complex sample design. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The results demonstrated that children of respondents who did not use Restraint Fitting Stations were 1.8 times more likely to be incorrectly using their restraints (95% CI 1.1-2.8) than children of Restraint Fitting Station users. Regardless of whether or not a Restraint Fitting Station had been used, there was a trend towards a greater likelihood of incorrect restraint use as the length of restraint ownership increased (OR 1.3 95% CI 1.0-1.7). These results are important for developing strategies aimed at reducing child occupant casualties by reducing the rate of incorrect restraint use, and support programs encouraging the use of Restraint Fitting Stations and similar services as a countermeasure to incorrect use., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

As the number of vehicles in China rapidly increases and there is no child safety seat law, the issue of road safety for children is a growing concern. The purpose of this study was to examine parents' use and knowledge of car safety seats in Beijing, China. Using a convenience sample of 843 parents, survey results showed that only 64.8% of parents used a safety restraint for their children; the remaining 35.2% of children, of which most were toddlers or school-aged children, travelled unrestrained in vehicles. Among parents who used a safety restraint, only 24.2% were using it correctly based on the child's age (for infants), weight and height. Common reasons for not using a safety seat included difficulty finding safety seats (56.6%), cost (26.1%), and a preference to hold the child (18.1%). Moreover, a large proportion of parents prematurely transitioned their child from a safety seat to seat belt. The results highlight the need to develop injury prevention interventions that communicate the benefits and encourage the use of child safety restraints in China.

This study examines safety seat use among Canadian children and evaluates child safety seat use relative to the national policy for child occupant safety, Road Safety Vision 2010. Using a probability sample, roadside observations of car safety seat use were collected from May to October of 2006 for 13,500 children aged from birth to 9 years in 10,084 vehicles at 182 sites in nine Canadian provinces and one territory. Observations revealed that 89.9% of Canadian children were restrained in some type of restraint. However, only 60.5% of these children were restrained in the correct safety seat. When comparing rates of correct use across provinces, results were not significantly different in provinces with booster seat legislation and those without this legislation. This data may be useful for healthcare practitioners and policy makers to develop interventions aimed at increasing appropriate car safety seat use for children in Canada.