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Observed child restraint misuse in a large, urban community: Results from three years of inspection events
Journal of Safety Research 56 (2016) 17–22
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Observed child restraint misuse in a large, urban community: Results from three years of inspection events Shelby L. Bachman, a Garrett A. Salzman, a Rita V. Burke, a,b Helen Arbogast, a Pearl Ruiz, a Jeffrey S. Upperman a,b,⁎ a b
Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
a r t i c l e
i n f o
Article history: Received 12 December 2014 Received in revised form 22 September 2015 Accepted 18 November 2015 Available online 2 December 2015 Keywords: Car seat Child passenger safety Child restraint system Installation Misuse
a b s t r a c t Problem: Child restraints (CRs) are vital for optimizing child passenger safety and reducing the risk of pediatric injury and fatality in motor vehicle crashes. However, most CRs are installed improperly. Methods: This present study was an assessment of observed instances of CR misuse. Participants were recruited through advertisements for CR inspection events in Los Angeles County, California. Child Passenger Safety Technicians collected information about each child passenger, vehicle, and aspects of CR selection and installation. Results: Of 693 CRs installed upon arrival, only 3.8% were used with no instances of misuse. The most common misuses were inappropriate use of the top tether and failure to secure the seatbelt in locked mode. Conclusions: The majority of observed CRs were installed with instances of misuse. CRs in newer vehicles were less likely to be installed in front of airbags and more likely to have the seatbelt routed inappropriately compared to those in older vehicles. Older children were more likely to be prematurely restrained in the front vehicle seat. Practical Applications: The majority of CRs are installed improperly. We identified specific instances of CR misuse that are common in a large, urban community and present recommendations to improve child passenger safety practices and education. © 2015 National Safety Council and Elsevier Ltd. All rights reserved.
1. Introduction Motor vehicle crashes (MVCs) are the leading cause of unintentional morbidity and mortality in children in the United States (Centers for Disease Control and Prevention, 2007). Between 2001 and 2010, 20,448 children ages 14 and under died from MVC-related injuries, and another 2,074,550 were treated in the emergency department for injuries sustained in MVCs (Centers for Disease Control and Prevention, 2013). Each year, MVC-related injuries and fatalities in children account for more than $825 million in medical expenditures (Centers for Disease Control and Prevention, 2013). Child restraints (CR) are well-documented for protecting children from MVC-related injury and fatality (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). When chosen and installed correctly, CRs have been demonstrated to significantly reduce the risk of injury and death in children of all ages (Rice & Anderson, 2009; Ma, Layde, & Zhu, 2012). Despite their protective value, the majority of CRs continue to be used improperly (Koppel & Charlton, 2009; Rogers, Gallo, Saleheen, & Lapidus, 2012; Klinich et al., 2013; Koppel, Charlton, & Rudin-Brown, 2013; Nie, Colunga, McCoy, Stephens-Stidham, & Istre, 2013; Mathieu, Peter, Yvan, & Philippe, 2014). Improper use of CRs, including the use of age- or weight-inappropriate CRs, places a ⁎ Corresponding author at: 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA, USA 90027. Tel.: +1 323 361 7078; fax: +1 323 361 7305. E-mail address: [email protected] (J.S. Upperman).
http://dx.doi.org/10.1016/j.jsr.2015.11.005 0022-4375/© 2015 National Safety Council and Elsevier Ltd. All rights reserved.
child passenger at elevated risk for MVC-related injury and fatality (Kapoor et al., 2011; Ma et al., 2012). According to recent assessments of CR use, the most common instances of misuse include harness strap errors, seatbelt errors, missing or incorrect use of locking clips, tether errors, CR placement in vehicle errors, and infant placement in CR errors (Koppel & Charlton, 2009; Rogers et al., 2012; Koppel et al., 2013). Many factors have been shown to be associated with CR misuse, including certain CR and vehicle features, having multiple children in a vehicle, and a child's resistance to being restrained. Further, parents and caregivers with lower education and income levels are more likely to use CRs improperly or not at all (Keay et al., 2013; Oliveira et al., 2012; Rogers et al., 2012; Yanchar, Kirkland, LeBlanc, & Langille, 2012). Child passenger age has been shown to be associated with premature placement in the front seat and premature graduation to seatbelt (Macy & Freed, 2012). Finally, misuse and nonuse of CRs have been reported as more common among non-white compared to white parents (Macy & Freed, 2012; Rogers et al., 2012; Macy, Cunningham, Resnicow, & Freed, 2014). While these studies have revealed a variety of factors associated with CR misuse, few have examined which specific instances of misuse are associated with demographic characteristics of drivers and passengers. Recently, Macy and Freed (2012) examined racial/ethnic associations with CR use, being unrestrained, and sitting in the front seat, but did not examine more specific aspects of CR use. Further, several recent studies assessing the prevalence of CR misuse have relied on parent selfreports rather than direct observation of CR use by nationally certified
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child passenger safety technicians (Arbogast, Durbin, Morris, & Winston, 2000; Macy et al., 2012; Macy et al., 2014; Raman et al., 2013). Comparisons of observational and self-report methodologies have shown that observational techniques were more accurate in assessing true use of CRs (Quistberg, Lozano, Mack, Schwartz, & Ebel, 2010; Snowdon et al., 2010). By using reliable methods to understand which specific aspects of misuse are the most common among certain populations, assessments of CR misuse can be used to inform policy, education, and outreach efforts. In the present study, we aimed to provide an up-to-date assessment of the prevalence of many specific instances of CR misuse in the diverse, urban community of Los Angeles County, California. Here, the term “misuse” was used to describe CR use not consistent with best practice recommendations outlined by the American Academy of Pediatrics (AAP) in the United States (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). We sought to determine whether three factors – vehicle age, child passenger age, and child passenger weight – predicted specific aspects of CR misuse. We expected that CRs observed in older vehicles would more commonly have inappropriate seatbelt routing, snugness of CR fit to seat, and locking of seatbelt. We also expected that older children would be more likely to be prematurely restrained in the front seat and prematurely graduated to a vehicle seatbelt. 2. Materials and methods 2.1. Study design The present study is a retrospective analysis of CR inspection data gathered through an inspection program conducted in Los Angeles County, California, between 2011 and 2013. The study was approved by the supervising hospital's Institutional Review Board. 2.2. Study population and recruitment The studied population included children of parents and caregivers that responded to advertisements for free CR inspection events sponsored by a freestanding Level I Pediatric Trauma Center. Advertisements were displayed at the pediatric tertiary hospital, childcare centers, churches, community centers, schools, and grocery stores. Inspection events were conducted at locations throughout Los Angeles County, California, USA, an ethnically and socioeconomically diverse urban community, by nationally certified Child Passenger Safety Technicians (CPSTs). CR inspections and child passenger safety education were provided free-of-charge to all participants, and all inspections were overseen by a certified Child Passenger Safety Technician Instructor (CPSTI). There were no child age or weight restrictions for participation in the inspection events. 2.3. Instrument and measurements Inspection data were recorded on an inspection instrument developed by a CPSTI. The instrument was created based on existing child restraint inspection tools from SafetyBeltSafe USA, Safe Kids Worldwide, Cincinnati Children's Hospital Medical Center, and California Highway Patrol. During each inspection, an inspection form was completed by a certified CPST after observation of each restrained child passenger. For inspections in which multiple child passengers arrived in a single vehicle, each child and his or her CR was inspected separately. Information collected during each inspection included vehicle make, model, and year of manufacture, as well as age, weight, and ethnicity of the child passenger. Children were weighed at the time of inspection by CPSTs. Information regarding CR position within vehicle, expiration date, recall date, ownership, and involvement in a crash were also recorded on the inspection form. For assessment of CR use, the inspection form included a checklist of 13 items regarding restraint installation and
selection. For each item, the responding CPST selected “Yes” to indicate appropriate use, “No” to indicate misuse and/or use not consistent with best practice recommendations outlined by the AAP (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011), or “N/A” if the item was not relevant. For instance, harness clip and LATCH information was not considered to be relevant for inspected booster seats. Information collected from inspection forms for the purposes of analyses, including the 13 studied aspects of CR use, is presented in Table 1. In most cases, child passenger and vehicle information were selfreported by participants. These fields were completed by a CPST in the event they were left uncompleted by participants.
2.4. Data analysis Relevant inspection data were reviewed and coded onto a spreadsheet by members of the research team. Data were stored on a secure, password-protected network requiring invitation for access. Analysis was conducted with SAS v9.2 (Cary, NC). Inspections in which all relevant data (vehicle year, child age, child weight, and aspects of CR use) were missing were excluded from all analyses. Additionally, in some inspections, certain aspects of use were not relevant; these “N/A” responses were excluded from all analyses. Because ethnicity data were collected for less than half of all inspections and the studied sample included primarily participants of Hispanic ethnicity, differences in the CR use among ethnic groups were not investigated. Summary statistics (frequencies) were used to describe characteristics of the studied sample and the frequency of each inspected aspect of CR use. Univariate logistic regression analyses were conducted to determine whether vehicle year, child age, and child weight were associated with specific instances of CR misuse. Logistic regression analyses were performed for each of three predictor variables (vehicle year, child age, child weight) as both categorical and continuous variables. For these analyses, categories for child age and weight (see Table 2) were established in accordance with standards of the National Highway Traffic Safety Association (NHTSA) in the United States for ease of comparison with existing misuse and crash data (Glassbrenner, 2009). Categories for vehicle year (presented in Table 2) were established based on two milestones of child passenger safety-related policies and standards in the United States: the mandate of lockable seatbelt systems in vehicles manufactured after September 1995 and the introduction of the Lower Anchors and Tethers for Children (LATCH) system in vehicles manufactured after September 2002. Results of the categorical analysis were less informative than those of the continuous analysis and are not included in the current report. Table 1 Information collected on child restraint inspection forms. Child passenger information
Age Weight Ethnicity
Vehicle information CR information
Year of manufacture CR facing correct direction CR not in front of airbag CR in rear vehicle seat Harness straps snug Harness retainer clip present Harness retainer clip at armpit level Harness retainer clip threaded properly LATCH anchor used properly Top tether used properly Safety belt routed properly Safety belt/LATCH holding CR tightly Safety belt in locked mode Child within CR height/weight limits
CR = child restraint; LATCH = Lower Anchors and Tethers for Children system.
S.L. Bachman et al. / Journal of Safety Research 56 (2016) 17–22 Table 2 Sample characteristics by child age, child weight, ethnicity, and vehicle year.
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Table 3 Observed instances of CR misuse.
N (%) Child Age (years) 0–3 4–5 6–7 8–10 N10 Missing
588 (53.3) 239 (21.6) 136 (12.3) 83 (7.5) 5 (0.5) 53 (4.8)
Child weight (pounds) 0–20 21–40 41–60 N60 Missing
149 (13.5) 548 (49.6) 250 (22.6) 73 (6.6) 84 (7.6)
Ethnicity Asian African–American Hispanic Non-Hispanic White Other Missing
28 (2.5) 56 (5.1) 377 (34.1) 11 (1.0) 40 (3.6) 592 (53.6)
Vehicle year b1996 1996–2002 N2003 Missing
71 (6.4) 377 (34.1) 413 (37.4) 243 (22.0)
CR correct direction CR not in front of airbag CR in rear vehicle seat Harness straps snug Harness clip present Harness clip at armpit level Harness clip threaded properly LATCH anchor used properly Top tether used properly Seatbelt routed properly Seatbelt/LATCH holding CR tightly Seatbelt in locked mode Child within height/weight limits of CR
Yes
No
Na (%)
Na (%)
590 (91.5) 647 (97.7) 647 (98.2) 308 (65.7) 333 (78.4) 227 (57.2) 251 (62.0) 176 (68.5) 54 (41.2) 301 (74.3) 274 (54.4) 194 (42.9) 294 (75.4)
55 (8.5) 15 (2.3) 12 (1.8) 161 (34.3) 92 (21.7) 170 (42.8) 154 (38.0) 81 (31.5) 79 (58.8) 104 (25.7) 230 (45.6) 258 (57.1) 96 (24.6)
Note: N values reflect number of inspected CRs for which each aspect of use was relevant. CR = child restraint; LATCH = Lower Anchors and Tethers for Children system.
3.3. CR misuse by vehicle year Vehicle year was found to be a significant predictor of two instances of misuse (Table 4). CRs in newer vehicles were significantly less likely to be installed in front of airbags as compared to older vehicles (OR = 0.89; 95% CI = 0.79–1.0). In addition, CRs in newer vehicles were significantly more likely to have the safety belt routed incorrectly as compared to those in older vehicles (OR = 1.1; 95% CI = 1.0–1.1).
3.4. CR misuse by child passenger age and weight 3. Results 3.1. Population characteristics
Child passenger age and weight were also significant predictors of several instances of CR misuse. Child age was inversely associated with CRs being installed in the incorrect direction (OR = 0.82; 95%
One thousand one hundred four CRs were inspected. Child age was collected in 95.2% (n = 1051) of inspections, child weight in 92.4% (n = 1020) of inspections, vehicle year in 78.0% (n = 861) of inspections, and child ethnicity in 46.4% (n = 512) of inspections. CRs were inspected for children aged b17 years and weighing b 135 lb. Child passenger and vehicle characteristics are presented in Table 2.
Table 4 Univariate logisitic regression model for vehicle year, child passenger age, and child passenger weight as predictors of specific instances of CR misuse.
3.2. CR use and misuse In 37.2% (n = 411) of inspections, no data on CR use were collected because the vehicle either arrived without a CR or the CR was present but not installed. Of the 693 inspections in which a CR was present and installed, 3.8% (n = 26) were installed with no observed instances of misuse and were consistent with best practice recommendations outlined in the 2011 update of the AAP Guidelines for Child Passenger Safety (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). The most commonly observed instance of CR misuse was failure to use the top tether correctly. Among inspected CRs for which tether use was recommended, 58.8% of inspected CRs had a tether used inappropriately or were missing the recommended tether altogether. Other frequently observed instances of misuse included failure to secure the seatbelt in locked mode (57.1%), safety belt/LATCH not holding the restraint tightly in vehicle (45.6%), harness retainer clip not at armpit level (42.8%), improper threading of the harness retainer clip (38.0%), and loose harness straps (34.3%). Frequencies of each instance of CR misuse are provided in Table 3. The different N values listed for each aspect of installation reflect the fact that not all scenarios were relevant for each inspected CR. For instance, for CRs initially installed with the LATCH system as opposed to the seatbelt system, seatbelt-related aspects of installation were irrelevant and not inspected.
Vehicle year
Child age
Child weight
OR
OR
OR
(95% CI)
(95% CI)
(95% CI)
1.0 1.0 (0.93–1.1)
1.0 0.82⁎ (0.70–0.96)
1.0 0.98 (0.96–1.0)
CR position relative to airbag Appropriate 1.0 Inappropriate 0.89⁎ (0.79–1.0)
1.0 0.97 (0.76–1.2)
1.0 1.0 (0.98–1.1)
CR position within vehicle Appropriate (rear) Inappropriate (front)
1.0 1.2⁎
1.0 1.0 (1.0–1.0)
Direction of CR Appropriate Inappropriate
LATCH lower anchor usage Appropriate Inappropriate
Seatbelt routing through CR Appropriate Inappropriate
1.0 1.0 (0.99–1.1)
(1.0–1.5)
1.0 1.0 (0.92–1.0)
1.0 1.3⁎⁎ (1.1–1.5)
1.0 1.0⁎⁎ (1.0–1.1)
1.0 1.1⁎⁎ (1.0–1.1)
1.0 1.0 (0.87–1.1)
1.0 1.0 (0.98–1.0)
Note: The table includes only those instances of CR misuse for which child age, child weight, and/or vehicle year were significant predictors. CI = confidence interval; CR = child restraint; LATCH = Lower Anchors and Tethers for Children; OR = odds ratio. ⁎ p b 0.05. ⁎⁎ p b 0.01.
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CI = 0.70–0.96). In other words, younger children were more likely to be riding in CRs facing the incorrect direction. Older children were significantly more likely to be prematurely restrained in the front seat of a vehicle (OR = 1.2; 95% CI = 1.0–1.5). CRs of older children were significantly more likely to be installed with improper use of LATCH lower anchors (OR = 1.3; 95% CI = 1.1–1.5). 4. Discussion Consistent with previous assessments of CR use, we found that only a small fraction (3.8%) of inspected CRs were installed with no observed instances of misuse and consistent with best practice recommendations of the AAP (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). The most frequently observed instance of misuse was improper use of the top tether, which has been identified in previous studies as a frequently problematic component of CR installation (Klinich et al., 2013; Koppel & Charlton, 2009). It should be noted that for many of the inspected CRs, including rear-facing CRs and booster seats, top tether use was not relevant and therefore not inspected, which is reflected in the low sample size for this aspect of installation. Other instances of misuse we observed have been observed as common errors in past assessments of CR misuse. These include failure to secure seatbelt in locking mode, CR not restrained tightly in vehicle seat, improper threading of harness retainer clip, and loose harness straps (Klinich et al., 2013; Koppel & Charlton, 2009; Rogers et al., 2012). 4.1. CR misuse by vehicle year CRs installed in older vehicles were significantly more likely to be installed in front of airbags compared to those installed in newer vehicles. This finding is consistent with our hypothesis that older vehicles would have more errors in the use of CRs. Due to crash testing and retrospective analyses of crash data, the risk of placing CRs in front of airbags has been emphasized over the past decade (Glass, Segui-Gomez, & Graham, 2000; Kamerling, 2002). As a result, newer vehicles include more airbag warnings designed to make drivers aware of this risk. Additionally, airbag warning signs may be less abundant or more difficult to decipher in older vehicles. CRs in newer vehicles were significantly more likely to have the seatbelt routed incorrectly. We predicted that CRs in older vehicles would more often have the seatbelt routed incorrectly since newer vehicles in the United States have mandated locking systems that facilitate ease of installation of CRs (National Highway Traffic Safety Administration, 1993). Instead, we observed that newer vehicles had more instances of inappropriate seatbelt routing, which may be explained by differences in seatbelt structure in older compared to newer vehicles. While lap-and-shoulder belt systems are typically found in all rear seats of newer vehicles, older vehicles often lack lap-and-shoulder belt systems, especially in the rear middle seating position. This difference in newer vehicles may complicate installation for CRs that require differential routing of the lap-and-shoulder belts. For instance, many infant-only CRs require the lap and shoulder belts to be routed independently, creating additional opportunities for inappropriate installation of CRs in newer vehicles. Overall, our findings are partially consistent with our original hypothesis that CRs in older vehicles would have more errors installation compared to those in newer vehicles. The rationale for this hypothesis was two-fold. First, older cars are more likely to be registered in lowincome areas, where misuse of CRs and lack of CPS knowledge are abundant (Murakami & Young, 1997; Goldberg, 2001; Oliveira et al., 2009; Oliveira et al., 2012; Keay et al., 2013). Secondly, changes in vehicle manufacture policies have been implemented over time in the United States to promote child passenger safety and the installation of CRs. In 1993, NHTSA issued a federal requirement that all vehicles manufactured after September 1995 have lockable seatbelt systems to tightly secure CRs without the use of locking clips or other devices
(National Highway Traffic Safety Administration, 1993). Additionally, in 1999, NHTSA mandated that all vehicles manufactured after September 2002 have a LATCH system (National Highway Traffic Safety Administration, 1999). Designed to improve the ease of installing CRs, the LATCH system offers dedicated attachment points within a vehicle for CR installation as opposed to using the adult seatbelt system (Arbogast & Jermakian, 2007). As a consequence, most newer vehicles are manufactured with features that may simplify installation of CRs, while older vehicles may lack such features. Based on these trends regarding income and legislation, we expected that specific instances of CR misuse would be more likely in older compared to newer vehicles. However, it should also be noted that changes in vehicle design may affect the difficulty of CR use and installation regardless of income level. That being said, care should be taken to understand how to better educate all parents regarding specificities of older and newer vehicle features and their relationship to CR use and installation. 4.2. CR misuse by child passenger age and weight When examining child age and weight as a predictor of errors in the use of CRs, we found that CRs of older, heavier children were more likely to be installed with errors in LATCH lower anchor usage. This finding is consistent with our original hypothesis, which was based on findings that child passenger age is positively associated with restraint misuse and risk of MVC-related injury (Snowdon, Polgar, Patrick, & Stamler, 2006; Yaghoubian et al., 2011; Macy & Freed, 2012; Stewart, Baiden, & Theall-Honey, 2013). This finding may be partially explained by the existence of upper weight limits for usage of the LATCH system, which are specified both by CR and vehicle manufacturers. These weight limits vary among CRs and vehicles but generally encourage children weighing more than 40 lb to ride in CRs installed with a seatbelt rather than LATCH. In our investigation, we observed that many instances of inappropriate LATCH usage involved child passengers exceeding restraint- or vehicle-specified LATCH weight limits. This finding highlights the importance of emphasizing LATCH guidelines and weight limits to parents and caregivers particularly of older, heavier children. Older children were also significantly more likely to be restrained in the front seat of a vehicle. We observed that many of these children were restrained by vehicle seatbelt alone despite requiring CRs by California law. This finding is consistent with several studies demonstrating that child age is positively associated with restraint misuse, likely due to premature graduation to seatbelt (Snowdon et al., 2006; Stewart et al., 2013), which is a prevalent problem and places children at elevated risk for spine and abdominal injury (Snowdon et al., 2006; Yaghoubian et al., 2011; Macy & Freed, 2012; Macy et al., 2014). Our results build upon existing findings, supporting the notion that premature exit from a CR and placement in the front vehicle seat are problematic practices that should be addressed by the public health community. We also found that CRs of younger children were more likely to be facing the incorrect direction compared to those of older children. This result may be explained by the fact that older children more commonly ride in combination or booster seats, for which only one seat direction is possible. In contrast, parents and guardians may be more likely to confuse the intended direction of convertible and rear-facing CRs occupied by younger children. Based on our findings, we offer recommendations to health educators and child passenger safety technicians around the world for optimal assessment and promotion of CR use (Table 5). One can see that some of these practices involve more specified behaviors within the installation process (e.g., proper tether use and seatbelt routing), while others are more reliant on knowledge and reception of public health messaging (e.g., premature restraint in front seat and airbag placement). 4.3. Limitations In interpreting the findings of the present investigation, several limitations must be taken into account. First, selection bias in the study
S.L. Bachman et al. / Journal of Safety Research 56 (2016) 17–22 Table 5 Recommendations based on study findings for clinicians, health educators, and child passenger safety technicians to promote best practices of child passenger safety. Emphasize to all parents and caregivers the importance of: • Using the top tether correctly • Proper routing of seatbelt through the child restraint • Securing the child restraint tightly to the vehicle seat Especially in older vehicles, check that child restraints are: • Not installed in front of an airbag • Installed with the seatbelt routed correctly Ensure that older, heavier child passengers are not: • Prematurely restrained in the front seat • Riding in restraints with errors in use of the Lower Anchors and Tethers for Children system.
sample should be noted, as the participants in this study were those who responded to advertisements in the community about free CR inspection events. It may have been the case that these participants were more concerned about problems in CR installation, but the specific motivation of these participants is unknown. Likewise, those who did not respond to the advertisement may have confidence in their own installation, whether proper or not. Therefore, selection bias exists and should be taken into account upon interpretation of the present findings. Secondly, the majority of the child passengers for whom we collected ethnicity data were Hispanic, preventing us from analyzing ethnicity as a predictor of errors in CR installation. Though ethnicity data were not formally collected until halfway through the data collection period, the majority of families who participated in all the included CR inspection events were Hispanic. Previous studies have demonstrated that African American and Hispanic children are more likely to be unrestrained or restrained inappropriately (Yaghoubian et al., 2011; Macy & Freed, 2012; Rogers et al., 2012; Keay et al., 2013). The present assessment is novel in that it examines specific instances of CR misuse that were particularly common among a largely Hispanic population living in the urban community of Los Angeles County, California. Thus the recommendations made may be particularly applicable for tailoring child passenger safety education and outreach in communities with Hispanic populations. A final limitation is that child passenger age and weight data collected during inspections could not be verified. As Macy and Freed explained, caregivers may overestimate age and weight of a child passenger if he or she had prematurely graduated to a CR designed for older, heavier children (2012). Additionally, in each inspection, CPSTs attempted to verify vehicle age data by inspecting the vehicle itself but in some cases had to rely on potentially inaccurate driver reports of vehicle year. 5. Conclusions In the present study, we have provided an up-to-date assessment of CR misuse in a diverse, urban community. The findings of this study, in conjunction with those of past assessments of CR use, demonstrate a significant need to improve the state of child passenger safety practices. Only 3.8% of inspected CRs were installed with no instances of misuse, which warrants significant future investigation through prospective studies and innovative educational methods. Previous studies have examined fewer specific aspects of misuse, relied upon self-reported versus observed CR use information, and/or quantified CR use dichotomously as either correct or incorrect. These approaches limit the applicability of findings and do not allow for a detailed understanding of the present state of CR misuse. We found that child age, child weight, and vehicle year were significant predictors of specific instances CR
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misuse and should be considered when conducting inspections and addressing deficiencies in CR use. Given the ability of child passenger safety educational interventions to improve proper restraint use, tailored educational interventions are important for reducing the risk of MVC-related injuries and fatalities (Agran & Hoffman, 2008; Keay et al., 2013; Koppel et al., 2013; Snowdon, Hussein, Purc-Stevenson, Follo, & Ahmed, 2009), and other innovative methods should be developed to reduce CR misuse. In the present study, we have taken a further step to understand CR misuse and inform future in child passenger safety investigations and interventions. Future studies should continue to understand why CR misuse persists, and other interventions must be designed to equip parents with the knowledge, skills, and confidence to use CRs consistently and correctly.
References Agran, P. F., & Hoffman, B. (2008). Child passenger safety: Direction, selection, location, installation. Pediatric Annals, 37(9), 614–621. http://dx.doi.org/10.3928/0090448120080901-01. Arbogast, K. B., & Jermakian, J. S. (2007). Field use patterns and performance of child restraints secured by lower anchors and tethers for children (LATCH). Accident; Analysis and Prevention, 39(3), 530–535. http://dx.doi.org/10.1016/j.aap.2006.12.009. Arbogast, K. B., Durbin, D. R., Morris, S. D., & Winston, F. K. (2000). Assessing child restraint misuse by parental survey. Injury Prevention, 6(2), 145–147. http://dx.doi. org/10.1136/ip.6.2.145. Centers for Disease Control and Prevention (2007). Ten leading causes of death and injury charts: Causes of death by age group, causes of injury death: Highlighting unintentional injury. Retrieved from http://www.cdc.gov/injury/wisqars/leadingcauses.html Centers for Disease Control and Prevention (2013). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/ index.html Durbin, D. R., & Committee on Injury, Violence, and Poison Prevention (2011o). Child passenger safety. Pediatrics, 127(4), 788–793. http://dx.doi.org/10.1542/peds.2011-0213. Glass, R. J., Segui-Gomez, M., & Graham, J. D. (2000). Child passenger safety: Decisions about seating location, airbag exposure, and restraint use. Risk Analysis, 20(4), 521–527. http://dx.doi.org/10.1111/0272-4332.204049. Glassbrenner, D. (2009). The 2006 national survey of the use of booster seats—Methodology report. Washington DC: National Highway Traffic and Safety Administration. Goldberg, H. (2001). State and county supported car ownership programs can help lower-income families secure and keep jobs. Retrieved from http://www.cbpp.org/ archiveSite/11-8-01wel.pdf Kamerling, S. N. (2002). Airbags & children: Making correct choices in child passenger restraints. MCN: American Journal of Maternal Child Nursing, 27(5), 264–273. http://dx. doi.org/10.1097/00005721-200209000-00004. Kapoor, T., Altenhof, W., Snowdon, A., Howard, A., Rasico, J., Zhu, F., & Baggio, D. (2011). A numerical investigation into the effect of CRS misuse on the injury potential of children in frontal and side impact crashes. Accident; Analysis and Prevention, 43(4), 1438–1450. http://dx.doi.org/10.1016/j.aap.2011.02.022. Keay, L., Hunter, K., Brown, J., Bilston, L. E., Simpson, J. M., Stevenson, M., & Ivers, R. Q. (2013). Child restraint use in low socio-economic areas of urban Sydney during transition to new legislation. Accident; Analysis and Prevention, 50, 984–991. http://dx.doi. org/10.1016/j.aap.2012.08.002. Klinich, K. D., Flannagan, C. A., Jermakian, J. S., McCartt, A. T., Manary, M. A., Moore, J. L., & Wells, J. K. (2013). Vehicle LATCH system features associated with correct child restraint installations. Traffic Injury Prevention, 14(5), 520–531. http://dx.doi.org/10. 1080/15389588.2012.701030. Koppel, S., & Charlton, J. L. (2009). Child restraint system misuse and/or inappropriate use in Australia. Traffic Injury Prevention, 10(3), 302–307. http://dx.doi.org/10.1080/ 15389580902856392. Koppel, S., Charlton, J. L., & Rudin-Brown, C. M. (2013). The impact of new legislation on child restraint system (CRS) misuse and inappropriate use in Australia. Traffic Injury Prevention, 14(4), 387–396. http://dx.doi.org/10.1080/15389588.2012.700746. Ma, X., Layde, P., & Zhu, S. (2012). Association between child restraint systems use and injury in motor vehicle crashes. Academic Emergency Medicine, 19(8), 916–923. http://dx.doi.org/10.1111/j.1553-2712.2012.01403.x. Macy, M. L., & Freed, G. L. (2012). Child passenger safety practices in the U.S.: Disparities in light of updated recommendations. American Journal of Preventive Medicine, 43(3), 272–281. http://dx.doi.org/10.1016/j.amepre.2012.05.023. Macy, M. L., Clark, S. J., Freed, G. L., Butchart, A. T., Singer, D. C., Sasson, C., ... Davis, M. M. (2012). Carpooling and booster seats: A national survey of parents. Pediatrics, 129(2), 290–298. http://dx.doi.org/10.1542/peds.2011-0575. Macy, M. L., Cunningham, R. M., Resnicow, K., & Freed, G. L. (2014). Disparities in ageappropriate child passenger restraint use among children aged 1 to 12 years. Pediatrics, 133(2), 262–271. http://dx.doi.org/10.1542/peds.2013-1908. Mathieu, R., Peter, S., Yvan, C., & Philippe, L. (2014). National roadside survey of child restraint system use in Belgium. Accident; Analysis and Prevention, 62, 369–376. http://dx.doi.org/10.1016/j.aap.2013.08.021. Murakami, E., & Young, J. (1997). Daily travel by persons with low income. Retrieved from http://www-cta.ornl.gov/npts/1995/Doc/LowInc.pdf National Highway Traffic Safety Administration (1993). Federal Motor Vehicle Safety Standards No. 208; Occupant Crash Protection, Lockability Provision. 49 CFR 571.
22
S.L. Bachman et al. / Journal of Safety Research 56 (2016) 17–22
208. Retrieved from http://www.fmcsa.dot.gov/rules-regulations/administration/ fmcsr/fmcsrruletext.aspx?reg=r49CFR571.208 National Highway Traffic Safety Administration (1999). Federal Motor Vehicle Safety Standards Final Rule; Child Restraint Systems, Child Restraint Anchorage Systems. 49 CFR 571 & 596. Retrieved from http://www.nhtsa.gov/cars/rules/rulings/UCRAOMB-J08/FinalRule.html Nie, C., Colunga, I., McCoy, M., Stephens-Stidham, S., & Istre, G. R. (2013). Impact of errors in age estimates on the classification of proper child occupant restraint use: An observational survey. Injury Prevention, 19(2), 130–133. http://dx.doi.org/10.1136/ injuryprev-2012-040581. Oliveira, S. R., Carvalho, M. D., Santana, R. G., Camargo, G. C., Luders, L., & Franzin, S. (2009). Child safety restraint use among children attending day care centers. Revista de Saúde Pública, 43(5), 761–767. http://dx.doi.org/10.1590/S003489102009005000052. Oliveira, S. R., Leone, C., Carvalho, M. D., Santana, R. G., Luders, L. E., & Oliveira, F. C. (2012). Child safety seat usage errors in under-4 s. Jornal de Pediatria, 88(4), 297–302. http:// dx.doi.org/10.2223/JPED.2189. Quistberg, D. A., Lozano, P., Mack, C. D., Schwartz, R., & Ebel, B. E. (2010). A comparison of self-report and direct observation of booster seat use in Latino families. Injury Prevention, 16(4), 225–229. http://dx.doi.org/10.1136/ip.2009.025338. Raman, S. R., Landry, M. D., Ottensmeyer, C. A., Jacob, S., Hamdan, E., & Bouhaimed, M. (2013). Keeping our children safe in motor vehicles: Knowledge, attitudes and practice among parents in Kuwait regarding child car safety. International Journal of Injury Control and Safety Promotion, 20(4), 358–367. http://dx.doi.org/10.1080/17457300. 2012.745578. Rice, T. M., & Anderson, C. L. (2009). The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005. American Journal of Public Health, 99(2), 252–257. http://dx.doi.org/10.2105/AJPH.2007. 131128. Rogers, S. C., Gallo, K., Saleheen, H., & Lapidus, G. (2012). Wishful thinking: Safe transportation of newborns at hospital discharge. Journal of Trauma and Acute Care Surgery, 73(4 Suppl 3), S262–S266. http://dx.doi.org/10.1097/TA.0b013e31826b0146. Snowdon, A. W., Hussein, A., Purc-Stevenson, R., Follo, G., & Ahmed, E. (2009). A longitudinal study of the effectiveness of a multi-media intervention on parents' knowledge and use of vehicle safety systems for children. Accident; Analysis and Prevention, 41(3), 498–505. http://dx.doi.org/10.1016/j.aap.2009.01.013. Snowdon, A. W., Polgar, J., Patrick, L., & Stamler, L. (2006). Parents' knowledge about and use of child safety systems. The Canadian Journal of Nursing Research, 38(2), 98–114 Retrieved from http://docserver.ingentaconnect.com/deliver/connect/mcgill/08445621/ v38n2/s10.pdf?expires=1418255749&id=80167937&titleid=6601&accname= University+of+Southern+California&checksum= F9BA34E01232D70E67CAE231F83A5FD5. Snowdon, A., Rothman, L., Slater, M., Kolga, C., Hussein, A., Boase, P., & Howard, A. (2010). Methodology of estimating restraint use in children: Roadside observation or parking lot interview survey. Accident; Analysis and Prevention, 42(6), 1545–1548. http://dx. doi.org/10.1016/j.aap.2010.02.020. Stewart, S. L., Baiden, P., & Theall-Honey, L. (2013). Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities. International Journal of Mental Health Nursing, 22(1), 56–68. http://dx.doi.org/10.1111/j.1447-0349.2012.00831.x. Yaghoubian, A., De Virgilio, C., Kaji, A. H., Putnam, B., Neville, A. L., Bricker, S., & Lee, S. L. (2011). Are there racial disparities in the use of restraints and outcomes after motor
vehicle collisions in Los Angeles County? The American Surgeon, 77(10), 1346–1348 Retrieved from http://docserver.ingentaconnect.com/deliver/connect/sesc/00031348/ v77n10/s16.pdf?expires=1418255465&id=80167919&titleid=11737&accname= University+of+Southern+California&checksum=47F71E15BF21C46D4E17459A92 706062. Yanchar, N. L., Kirkland, S. A., LeBlanc, J. C., & Langille, D. B. (2012). Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia—A population-based study. Accident; Analysis and Prevention, 45, 326–333. http://dx.doi.org/10.1016/j.aap.2011.07.020. Shelby L. Bachman, BS Ms. Bachman is a Program Assistant in the Trauma Program at Children's Hospital Los Angeles where she participates in research related to pediatric trauma and disaster preparedness, injury prevention outreach, and trauma registry. Ms. Bachman is a certified Child Passenger Safety Technician and has additional qualifications in transportation for children with special healthcare needs. Garrett A. Salzman, BA Mr. Salzman is a Program Assistant in the Trauma Program at Children's Hospital Los Angeles where he participates in research related to pediatric trauma and disaster preparedness, injury prevention outreach, and disaster preparedness planning. Mr. Salzman is a certified Child Passenger Safety Technician and a future medical student. Rita V. Burke, PhD, MPH Dr. Burke is an Assistant Professor of Research in the Division of Pediatric Surgery at Children's Hospital Los Angeles. She received her MPH and PhD in Epidemiology from UCLA. She supervises outcomes research related to acute surgical care and injury prevention interventions. Dr. Burke is a also certified Child Passenger Safety Technician. Helen Arbogast, MPH Ms. Arbogast is the Injury Prevention Manager at Children's Hospital Los Angeles. She has 17 years of public health experience in coordination of intervention programs, collection and analysis of data, development of educational materials, curriculum and presentation development through collaboration with federal, state and local agencies and community-based organizations in both the public and private sector. Ms. Arbogast leads the local Injury Free Coalition for Kids chapter and the local Buckle Up For Life Initiative. She is a certified Special Needs Child Passenger Safety Technician Instructor and serves on the National Child Passenger Safety Board. Pearl Ruiz, BA Ms. Ruiz is a Health Education Associate in the Injury Prevention Program at Children's Hospital Los Angeles. She coordinates the local Buckle Up for Life Initiative, organizes community car seat check events, and teaches car seat classes at Children's Hospital Los Angeles and throughout her community. Ms. Ruiz is a certified Child Passenger Safety Technician Instructor with additional qualifications in transportation for children with special healthcare needs. Jeffrey S. Upperman Dr. Upperman is the Trauma Medical Director at Children's Hospital Los Angeles and an Associate Professor at Keck School of Medicine of the University of Southern California. He is a board-certified pediatric surgeon and a fellow of both the American College of Surgeons and the American Academy of Pediatrics.
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Journal of Safety Research journal homepage: www.elsevier.com/locate/jsr
Observed child restraint misuse in a large, urban community: Results from three years of inspection events Shelby L. Bachman, a Garrett A. Salzman, a Rita V. Burke, a,b Helen Arbogast, a Pearl Ruiz, a Jeffrey S. Upperman a,b,⁎ a b
Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
a r t i c l e
i n f o
Article history: Received 12 December 2014 Received in revised form 22 September 2015 Accepted 18 November 2015 Available online 2 December 2015 Keywords: Car seat Child passenger safety Child restraint system Installation Misuse
a b s t r a c t Problem: Child restraints (CRs) are vital for optimizing child passenger safety and reducing the risk of pediatric injury and fatality in motor vehicle crashes. However, most CRs are installed improperly. Methods: This present study was an assessment of observed instances of CR misuse. Participants were recruited through advertisements for CR inspection events in Los Angeles County, California. Child Passenger Safety Technicians collected information about each child passenger, vehicle, and aspects of CR selection and installation. Results: Of 693 CRs installed upon arrival, only 3.8% were used with no instances of misuse. The most common misuses were inappropriate use of the top tether and failure to secure the seatbelt in locked mode. Conclusions: The majority of observed CRs were installed with instances of misuse. CRs in newer vehicles were less likely to be installed in front of airbags and more likely to have the seatbelt routed inappropriately compared to those in older vehicles. Older children were more likely to be prematurely restrained in the front vehicle seat. Practical Applications: The majority of CRs are installed improperly. We identified specific instances of CR misuse that are common in a large, urban community and present recommendations to improve child passenger safety practices and education. © 2015 National Safety Council and Elsevier Ltd. All rights reserved.
1. Introduction Motor vehicle crashes (MVCs) are the leading cause of unintentional morbidity and mortality in children in the United States (Centers for Disease Control and Prevention, 2007). Between 2001 and 2010, 20,448 children ages 14 and under died from MVC-related injuries, and another 2,074,550 were treated in the emergency department for injuries sustained in MVCs (Centers for Disease Control and Prevention, 2013). Each year, MVC-related injuries and fatalities in children account for more than $825 million in medical expenditures (Centers for Disease Control and Prevention, 2013). Child restraints (CR) are well-documented for protecting children from MVC-related injury and fatality (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). When chosen and installed correctly, CRs have been demonstrated to significantly reduce the risk of injury and death in children of all ages (Rice & Anderson, 2009; Ma, Layde, & Zhu, 2012). Despite their protective value, the majority of CRs continue to be used improperly (Koppel & Charlton, 2009; Rogers, Gallo, Saleheen, & Lapidus, 2012; Klinich et al., 2013; Koppel, Charlton, & Rudin-Brown, 2013; Nie, Colunga, McCoy, Stephens-Stidham, & Istre, 2013; Mathieu, Peter, Yvan, & Philippe, 2014). Improper use of CRs, including the use of age- or weight-inappropriate CRs, places a ⁎ Corresponding author at: 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA, USA 90027. Tel.: +1 323 361 7078; fax: +1 323 361 7305. E-mail address: [email protected] (J.S. Upperman).
http://dx.doi.org/10.1016/j.jsr.2015.11.005 0022-4375/© 2015 National Safety Council and Elsevier Ltd. All rights reserved.
child passenger at elevated risk for MVC-related injury and fatality (Kapoor et al., 2011; Ma et al., 2012). According to recent assessments of CR use, the most common instances of misuse include harness strap errors, seatbelt errors, missing or incorrect use of locking clips, tether errors, CR placement in vehicle errors, and infant placement in CR errors (Koppel & Charlton, 2009; Rogers et al., 2012; Koppel et al., 2013). Many factors have been shown to be associated with CR misuse, including certain CR and vehicle features, having multiple children in a vehicle, and a child's resistance to being restrained. Further, parents and caregivers with lower education and income levels are more likely to use CRs improperly or not at all (Keay et al., 2013; Oliveira et al., 2012; Rogers et al., 2012; Yanchar, Kirkland, LeBlanc, & Langille, 2012). Child passenger age has been shown to be associated with premature placement in the front seat and premature graduation to seatbelt (Macy & Freed, 2012). Finally, misuse and nonuse of CRs have been reported as more common among non-white compared to white parents (Macy & Freed, 2012; Rogers et al., 2012; Macy, Cunningham, Resnicow, & Freed, 2014). While these studies have revealed a variety of factors associated with CR misuse, few have examined which specific instances of misuse are associated with demographic characteristics of drivers and passengers. Recently, Macy and Freed (2012) examined racial/ethnic associations with CR use, being unrestrained, and sitting in the front seat, but did not examine more specific aspects of CR use. Further, several recent studies assessing the prevalence of CR misuse have relied on parent selfreports rather than direct observation of CR use by nationally certified
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child passenger safety technicians (Arbogast, Durbin, Morris, & Winston, 2000; Macy et al., 2012; Macy et al., 2014; Raman et al., 2013). Comparisons of observational and self-report methodologies have shown that observational techniques were more accurate in assessing true use of CRs (Quistberg, Lozano, Mack, Schwartz, & Ebel, 2010; Snowdon et al., 2010). By using reliable methods to understand which specific aspects of misuse are the most common among certain populations, assessments of CR misuse can be used to inform policy, education, and outreach efforts. In the present study, we aimed to provide an up-to-date assessment of the prevalence of many specific instances of CR misuse in the diverse, urban community of Los Angeles County, California. Here, the term “misuse” was used to describe CR use not consistent with best practice recommendations outlined by the American Academy of Pediatrics (AAP) in the United States (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). We sought to determine whether three factors – vehicle age, child passenger age, and child passenger weight – predicted specific aspects of CR misuse. We expected that CRs observed in older vehicles would more commonly have inappropriate seatbelt routing, snugness of CR fit to seat, and locking of seatbelt. We also expected that older children would be more likely to be prematurely restrained in the front seat and prematurely graduated to a vehicle seatbelt. 2. Materials and methods 2.1. Study design The present study is a retrospective analysis of CR inspection data gathered through an inspection program conducted in Los Angeles County, California, between 2011 and 2013. The study was approved by the supervising hospital's Institutional Review Board. 2.2. Study population and recruitment The studied population included children of parents and caregivers that responded to advertisements for free CR inspection events sponsored by a freestanding Level I Pediatric Trauma Center. Advertisements were displayed at the pediatric tertiary hospital, childcare centers, churches, community centers, schools, and grocery stores. Inspection events were conducted at locations throughout Los Angeles County, California, USA, an ethnically and socioeconomically diverse urban community, by nationally certified Child Passenger Safety Technicians (CPSTs). CR inspections and child passenger safety education were provided free-of-charge to all participants, and all inspections were overseen by a certified Child Passenger Safety Technician Instructor (CPSTI). There were no child age or weight restrictions for participation in the inspection events. 2.3. Instrument and measurements Inspection data were recorded on an inspection instrument developed by a CPSTI. The instrument was created based on existing child restraint inspection tools from SafetyBeltSafe USA, Safe Kids Worldwide, Cincinnati Children's Hospital Medical Center, and California Highway Patrol. During each inspection, an inspection form was completed by a certified CPST after observation of each restrained child passenger. For inspections in which multiple child passengers arrived in a single vehicle, each child and his or her CR was inspected separately. Information collected during each inspection included vehicle make, model, and year of manufacture, as well as age, weight, and ethnicity of the child passenger. Children were weighed at the time of inspection by CPSTs. Information regarding CR position within vehicle, expiration date, recall date, ownership, and involvement in a crash were also recorded on the inspection form. For assessment of CR use, the inspection form included a checklist of 13 items regarding restraint installation and
selection. For each item, the responding CPST selected “Yes” to indicate appropriate use, “No” to indicate misuse and/or use not consistent with best practice recommendations outlined by the AAP (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011), or “N/A” if the item was not relevant. For instance, harness clip and LATCH information was not considered to be relevant for inspected booster seats. Information collected from inspection forms for the purposes of analyses, including the 13 studied aspects of CR use, is presented in Table 1. In most cases, child passenger and vehicle information were selfreported by participants. These fields were completed by a CPST in the event they were left uncompleted by participants.
2.4. Data analysis Relevant inspection data were reviewed and coded onto a spreadsheet by members of the research team. Data were stored on a secure, password-protected network requiring invitation for access. Analysis was conducted with SAS v9.2 (Cary, NC). Inspections in which all relevant data (vehicle year, child age, child weight, and aspects of CR use) were missing were excluded from all analyses. Additionally, in some inspections, certain aspects of use were not relevant; these “N/A” responses were excluded from all analyses. Because ethnicity data were collected for less than half of all inspections and the studied sample included primarily participants of Hispanic ethnicity, differences in the CR use among ethnic groups were not investigated. Summary statistics (frequencies) were used to describe characteristics of the studied sample and the frequency of each inspected aspect of CR use. Univariate logistic regression analyses were conducted to determine whether vehicle year, child age, and child weight were associated with specific instances of CR misuse. Logistic regression analyses were performed for each of three predictor variables (vehicle year, child age, child weight) as both categorical and continuous variables. For these analyses, categories for child age and weight (see Table 2) were established in accordance with standards of the National Highway Traffic Safety Association (NHTSA) in the United States for ease of comparison with existing misuse and crash data (Glassbrenner, 2009). Categories for vehicle year (presented in Table 2) were established based on two milestones of child passenger safety-related policies and standards in the United States: the mandate of lockable seatbelt systems in vehicles manufactured after September 1995 and the introduction of the Lower Anchors and Tethers for Children (LATCH) system in vehicles manufactured after September 2002. Results of the categorical analysis were less informative than those of the continuous analysis and are not included in the current report. Table 1 Information collected on child restraint inspection forms. Child passenger information
Age Weight Ethnicity
Vehicle information CR information
Year of manufacture CR facing correct direction CR not in front of airbag CR in rear vehicle seat Harness straps snug Harness retainer clip present Harness retainer clip at armpit level Harness retainer clip threaded properly LATCH anchor used properly Top tether used properly Safety belt routed properly Safety belt/LATCH holding CR tightly Safety belt in locked mode Child within CR height/weight limits
CR = child restraint; LATCH = Lower Anchors and Tethers for Children system.
S.L. Bachman et al. / Journal of Safety Research 56 (2016) 17–22 Table 2 Sample characteristics by child age, child weight, ethnicity, and vehicle year.
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Table 3 Observed instances of CR misuse.
N (%) Child Age (years) 0–3 4–5 6–7 8–10 N10 Missing
588 (53.3) 239 (21.6) 136 (12.3) 83 (7.5) 5 (0.5) 53 (4.8)
Child weight (pounds) 0–20 21–40 41–60 N60 Missing
149 (13.5) 548 (49.6) 250 (22.6) 73 (6.6) 84 (7.6)
Ethnicity Asian African–American Hispanic Non-Hispanic White Other Missing
28 (2.5) 56 (5.1) 377 (34.1) 11 (1.0) 40 (3.6) 592 (53.6)
Vehicle year b1996 1996–2002 N2003 Missing
71 (6.4) 377 (34.1) 413 (37.4) 243 (22.0)
CR correct direction CR not in front of airbag CR in rear vehicle seat Harness straps snug Harness clip present Harness clip at armpit level Harness clip threaded properly LATCH anchor used properly Top tether used properly Seatbelt routed properly Seatbelt/LATCH holding CR tightly Seatbelt in locked mode Child within height/weight limits of CR
Yes
No
Na (%)
Na (%)
590 (91.5) 647 (97.7) 647 (98.2) 308 (65.7) 333 (78.4) 227 (57.2) 251 (62.0) 176 (68.5) 54 (41.2) 301 (74.3) 274 (54.4) 194 (42.9) 294 (75.4)
55 (8.5) 15 (2.3) 12 (1.8) 161 (34.3) 92 (21.7) 170 (42.8) 154 (38.0) 81 (31.5) 79 (58.8) 104 (25.7) 230 (45.6) 258 (57.1) 96 (24.6)
Note: N values reflect number of inspected CRs for which each aspect of use was relevant. CR = child restraint; LATCH = Lower Anchors and Tethers for Children system.
3.3. CR misuse by vehicle year Vehicle year was found to be a significant predictor of two instances of misuse (Table 4). CRs in newer vehicles were significantly less likely to be installed in front of airbags as compared to older vehicles (OR = 0.89; 95% CI = 0.79–1.0). In addition, CRs in newer vehicles were significantly more likely to have the safety belt routed incorrectly as compared to those in older vehicles (OR = 1.1; 95% CI = 1.0–1.1).
3.4. CR misuse by child passenger age and weight 3. Results 3.1. Population characteristics
Child passenger age and weight were also significant predictors of several instances of CR misuse. Child age was inversely associated with CRs being installed in the incorrect direction (OR = 0.82; 95%
One thousand one hundred four CRs were inspected. Child age was collected in 95.2% (n = 1051) of inspections, child weight in 92.4% (n = 1020) of inspections, vehicle year in 78.0% (n = 861) of inspections, and child ethnicity in 46.4% (n = 512) of inspections. CRs were inspected for children aged b17 years and weighing b 135 lb. Child passenger and vehicle characteristics are presented in Table 2.
Table 4 Univariate logisitic regression model for vehicle year, child passenger age, and child passenger weight as predictors of specific instances of CR misuse.
3.2. CR use and misuse In 37.2% (n = 411) of inspections, no data on CR use were collected because the vehicle either arrived without a CR or the CR was present but not installed. Of the 693 inspections in which a CR was present and installed, 3.8% (n = 26) were installed with no observed instances of misuse and were consistent with best practice recommendations outlined in the 2011 update of the AAP Guidelines for Child Passenger Safety (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). The most commonly observed instance of CR misuse was failure to use the top tether correctly. Among inspected CRs for which tether use was recommended, 58.8% of inspected CRs had a tether used inappropriately or were missing the recommended tether altogether. Other frequently observed instances of misuse included failure to secure the seatbelt in locked mode (57.1%), safety belt/LATCH not holding the restraint tightly in vehicle (45.6%), harness retainer clip not at armpit level (42.8%), improper threading of the harness retainer clip (38.0%), and loose harness straps (34.3%). Frequencies of each instance of CR misuse are provided in Table 3. The different N values listed for each aspect of installation reflect the fact that not all scenarios were relevant for each inspected CR. For instance, for CRs initially installed with the LATCH system as opposed to the seatbelt system, seatbelt-related aspects of installation were irrelevant and not inspected.
Vehicle year
Child age
Child weight
OR
OR
OR
(95% CI)
(95% CI)
(95% CI)
1.0 1.0 (0.93–1.1)
1.0 0.82⁎ (0.70–0.96)
1.0 0.98 (0.96–1.0)
CR position relative to airbag Appropriate 1.0 Inappropriate 0.89⁎ (0.79–1.0)
1.0 0.97 (0.76–1.2)
1.0 1.0 (0.98–1.1)
CR position within vehicle Appropriate (rear) Inappropriate (front)
1.0 1.2⁎
1.0 1.0 (1.0–1.0)
Direction of CR Appropriate Inappropriate
LATCH lower anchor usage Appropriate Inappropriate
Seatbelt routing through CR Appropriate Inappropriate
1.0 1.0 (0.99–1.1)
(1.0–1.5)
1.0 1.0 (0.92–1.0)
1.0 1.3⁎⁎ (1.1–1.5)
1.0 1.0⁎⁎ (1.0–1.1)
1.0 1.1⁎⁎ (1.0–1.1)
1.0 1.0 (0.87–1.1)
1.0 1.0 (0.98–1.0)
Note: The table includes only those instances of CR misuse for which child age, child weight, and/or vehicle year were significant predictors. CI = confidence interval; CR = child restraint; LATCH = Lower Anchors and Tethers for Children; OR = odds ratio. ⁎ p b 0.05. ⁎⁎ p b 0.01.
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CI = 0.70–0.96). In other words, younger children were more likely to be riding in CRs facing the incorrect direction. Older children were significantly more likely to be prematurely restrained in the front seat of a vehicle (OR = 1.2; 95% CI = 1.0–1.5). CRs of older children were significantly more likely to be installed with improper use of LATCH lower anchors (OR = 1.3; 95% CI = 1.1–1.5). 4. Discussion Consistent with previous assessments of CR use, we found that only a small fraction (3.8%) of inspected CRs were installed with no observed instances of misuse and consistent with best practice recommendations of the AAP (Durbin, & Committee on Injury, Violence, and Poison Prevention, 2011). The most frequently observed instance of misuse was improper use of the top tether, which has been identified in previous studies as a frequently problematic component of CR installation (Klinich et al., 2013; Koppel & Charlton, 2009). It should be noted that for many of the inspected CRs, including rear-facing CRs and booster seats, top tether use was not relevant and therefore not inspected, which is reflected in the low sample size for this aspect of installation. Other instances of misuse we observed have been observed as common errors in past assessments of CR misuse. These include failure to secure seatbelt in locking mode, CR not restrained tightly in vehicle seat, improper threading of harness retainer clip, and loose harness straps (Klinich et al., 2013; Koppel & Charlton, 2009; Rogers et al., 2012). 4.1. CR misuse by vehicle year CRs installed in older vehicles were significantly more likely to be installed in front of airbags compared to those installed in newer vehicles. This finding is consistent with our hypothesis that older vehicles would have more errors in the use of CRs. Due to crash testing and retrospective analyses of crash data, the risk of placing CRs in front of airbags has been emphasized over the past decade (Glass, Segui-Gomez, & Graham, 2000; Kamerling, 2002). As a result, newer vehicles include more airbag warnings designed to make drivers aware of this risk. Additionally, airbag warning signs may be less abundant or more difficult to decipher in older vehicles. CRs in newer vehicles were significantly more likely to have the seatbelt routed incorrectly. We predicted that CRs in older vehicles would more often have the seatbelt routed incorrectly since newer vehicles in the United States have mandated locking systems that facilitate ease of installation of CRs (National Highway Traffic Safety Administration, 1993). Instead, we observed that newer vehicles had more instances of inappropriate seatbelt routing, which may be explained by differences in seatbelt structure in older compared to newer vehicles. While lap-and-shoulder belt systems are typically found in all rear seats of newer vehicles, older vehicles often lack lap-and-shoulder belt systems, especially in the rear middle seating position. This difference in newer vehicles may complicate installation for CRs that require differential routing of the lap-and-shoulder belts. For instance, many infant-only CRs require the lap and shoulder belts to be routed independently, creating additional opportunities for inappropriate installation of CRs in newer vehicles. Overall, our findings are partially consistent with our original hypothesis that CRs in older vehicles would have more errors installation compared to those in newer vehicles. The rationale for this hypothesis was two-fold. First, older cars are more likely to be registered in lowincome areas, where misuse of CRs and lack of CPS knowledge are abundant (Murakami & Young, 1997; Goldberg, 2001; Oliveira et al., 2009; Oliveira et al., 2012; Keay et al., 2013). Secondly, changes in vehicle manufacture policies have been implemented over time in the United States to promote child passenger safety and the installation of CRs. In 1993, NHTSA issued a federal requirement that all vehicles manufactured after September 1995 have lockable seatbelt systems to tightly secure CRs without the use of locking clips or other devices
(National Highway Traffic Safety Administration, 1993). Additionally, in 1999, NHTSA mandated that all vehicles manufactured after September 2002 have a LATCH system (National Highway Traffic Safety Administration, 1999). Designed to improve the ease of installing CRs, the LATCH system offers dedicated attachment points within a vehicle for CR installation as opposed to using the adult seatbelt system (Arbogast & Jermakian, 2007). As a consequence, most newer vehicles are manufactured with features that may simplify installation of CRs, while older vehicles may lack such features. Based on these trends regarding income and legislation, we expected that specific instances of CR misuse would be more likely in older compared to newer vehicles. However, it should also be noted that changes in vehicle design may affect the difficulty of CR use and installation regardless of income level. That being said, care should be taken to understand how to better educate all parents regarding specificities of older and newer vehicle features and their relationship to CR use and installation. 4.2. CR misuse by child passenger age and weight When examining child age and weight as a predictor of errors in the use of CRs, we found that CRs of older, heavier children were more likely to be installed with errors in LATCH lower anchor usage. This finding is consistent with our original hypothesis, which was based on findings that child passenger age is positively associated with restraint misuse and risk of MVC-related injury (Snowdon, Polgar, Patrick, & Stamler, 2006; Yaghoubian et al., 2011; Macy & Freed, 2012; Stewart, Baiden, & Theall-Honey, 2013). This finding may be partially explained by the existence of upper weight limits for usage of the LATCH system, which are specified both by CR and vehicle manufacturers. These weight limits vary among CRs and vehicles but generally encourage children weighing more than 40 lb to ride in CRs installed with a seatbelt rather than LATCH. In our investigation, we observed that many instances of inappropriate LATCH usage involved child passengers exceeding restraint- or vehicle-specified LATCH weight limits. This finding highlights the importance of emphasizing LATCH guidelines and weight limits to parents and caregivers particularly of older, heavier children. Older children were also significantly more likely to be restrained in the front seat of a vehicle. We observed that many of these children were restrained by vehicle seatbelt alone despite requiring CRs by California law. This finding is consistent with several studies demonstrating that child age is positively associated with restraint misuse, likely due to premature graduation to seatbelt (Snowdon et al., 2006; Stewart et al., 2013), which is a prevalent problem and places children at elevated risk for spine and abdominal injury (Snowdon et al., 2006; Yaghoubian et al., 2011; Macy & Freed, 2012; Macy et al., 2014). Our results build upon existing findings, supporting the notion that premature exit from a CR and placement in the front vehicle seat are problematic practices that should be addressed by the public health community. We also found that CRs of younger children were more likely to be facing the incorrect direction compared to those of older children. This result may be explained by the fact that older children more commonly ride in combination or booster seats, for which only one seat direction is possible. In contrast, parents and guardians may be more likely to confuse the intended direction of convertible and rear-facing CRs occupied by younger children. Based on our findings, we offer recommendations to health educators and child passenger safety technicians around the world for optimal assessment and promotion of CR use (Table 5). One can see that some of these practices involve more specified behaviors within the installation process (e.g., proper tether use and seatbelt routing), while others are more reliant on knowledge and reception of public health messaging (e.g., premature restraint in front seat and airbag placement). 4.3. Limitations In interpreting the findings of the present investigation, several limitations must be taken into account. First, selection bias in the study
S.L. Bachman et al. / Journal of Safety Research 56 (2016) 17–22 Table 5 Recommendations based on study findings for clinicians, health educators, and child passenger safety technicians to promote best practices of child passenger safety. Emphasize to all parents and caregivers the importance of: • Using the top tether correctly • Proper routing of seatbelt through the child restraint • Securing the child restraint tightly to the vehicle seat Especially in older vehicles, check that child restraints are: • Not installed in front of an airbag • Installed with the seatbelt routed correctly Ensure that older, heavier child passengers are not: • Prematurely restrained in the front seat • Riding in restraints with errors in use of the Lower Anchors and Tethers for Children system.
sample should be noted, as the participants in this study were those who responded to advertisements in the community about free CR inspection events. It may have been the case that these participants were more concerned about problems in CR installation, but the specific motivation of these participants is unknown. Likewise, those who did not respond to the advertisement may have confidence in their own installation, whether proper or not. Therefore, selection bias exists and should be taken into account upon interpretation of the present findings. Secondly, the majority of the child passengers for whom we collected ethnicity data were Hispanic, preventing us from analyzing ethnicity as a predictor of errors in CR installation. Though ethnicity data were not formally collected until halfway through the data collection period, the majority of families who participated in all the included CR inspection events were Hispanic. Previous studies have demonstrated that African American and Hispanic children are more likely to be unrestrained or restrained inappropriately (Yaghoubian et al., 2011; Macy & Freed, 2012; Rogers et al., 2012; Keay et al., 2013). The present assessment is novel in that it examines specific instances of CR misuse that were particularly common among a largely Hispanic population living in the urban community of Los Angeles County, California. Thus the recommendations made may be particularly applicable for tailoring child passenger safety education and outreach in communities with Hispanic populations. A final limitation is that child passenger age and weight data collected during inspections could not be verified. As Macy and Freed explained, caregivers may overestimate age and weight of a child passenger if he or she had prematurely graduated to a CR designed for older, heavier children (2012). Additionally, in each inspection, CPSTs attempted to verify vehicle age data by inspecting the vehicle itself but in some cases had to rely on potentially inaccurate driver reports of vehicle year. 5. Conclusions In the present study, we have provided an up-to-date assessment of CR misuse in a diverse, urban community. The findings of this study, in conjunction with those of past assessments of CR use, demonstrate a significant need to improve the state of child passenger safety practices. Only 3.8% of inspected CRs were installed with no instances of misuse, which warrants significant future investigation through prospective studies and innovative educational methods. Previous studies have examined fewer specific aspects of misuse, relied upon self-reported versus observed CR use information, and/or quantified CR use dichotomously as either correct or incorrect. These approaches limit the applicability of findings and do not allow for a detailed understanding of the present state of CR misuse. We found that child age, child weight, and vehicle year were significant predictors of specific instances CR
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misuse and should be considered when conducting inspections and addressing deficiencies in CR use. Given the ability of child passenger safety educational interventions to improve proper restraint use, tailored educational interventions are important for reducing the risk of MVC-related injuries and fatalities (Agran & Hoffman, 2008; Keay et al., 2013; Koppel et al., 2013; Snowdon, Hussein, Purc-Stevenson, Follo, & Ahmed, 2009), and other innovative methods should be developed to reduce CR misuse. In the present study, we have taken a further step to understand CR misuse and inform future in child passenger safety investigations and interventions. Future studies should continue to understand why CR misuse persists, and other interventions must be designed to equip parents with the knowledge, skills, and confidence to use CRs consistently and correctly.
References Agran, P. F., & Hoffman, B. (2008). Child passenger safety: Direction, selection, location, installation. Pediatric Annals, 37(9), 614–621. http://dx.doi.org/10.3928/0090448120080901-01. Arbogast, K. B., & Jermakian, J. S. (2007). Field use patterns and performance of child restraints secured by lower anchors and tethers for children (LATCH). Accident; Analysis and Prevention, 39(3), 530–535. http://dx.doi.org/10.1016/j.aap.2006.12.009. Arbogast, K. B., Durbin, D. R., Morris, S. D., & Winston, F. K. (2000). Assessing child restraint misuse by parental survey. Injury Prevention, 6(2), 145–147. http://dx.doi. org/10.1136/ip.6.2.145. Centers for Disease Control and Prevention (2007). Ten leading causes of death and injury charts: Causes of death by age group, causes of injury death: Highlighting unintentional injury. Retrieved from http://www.cdc.gov/injury/wisqars/leadingcauses.html Centers for Disease Control and Prevention (2013). Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/ index.html Durbin, D. R., & Committee on Injury, Violence, and Poison Prevention (2011o). Child passenger safety. Pediatrics, 127(4), 788–793. http://dx.doi.org/10.1542/peds.2011-0213. Glass, R. J., Segui-Gomez, M., & Graham, J. D. (2000). Child passenger safety: Decisions about seating location, airbag exposure, and restraint use. Risk Analysis, 20(4), 521–527. http://dx.doi.org/10.1111/0272-4332.204049. Glassbrenner, D. (2009). The 2006 national survey of the use of booster seats—Methodology report. Washington DC: National Highway Traffic and Safety Administration. Goldberg, H. (2001). State and county supported car ownership programs can help lower-income families secure and keep jobs. Retrieved from http://www.cbpp.org/ archiveSite/11-8-01wel.pdf Kamerling, S. N. (2002). Airbags & children: Making correct choices in child passenger restraints. MCN: American Journal of Maternal Child Nursing, 27(5), 264–273. http://dx. doi.org/10.1097/00005721-200209000-00004. Kapoor, T., Altenhof, W., Snowdon, A., Howard, A., Rasico, J., Zhu, F., & Baggio, D. (2011). A numerical investigation into the effect of CRS misuse on the injury potential of children in frontal and side impact crashes. Accident; Analysis and Prevention, 43(4), 1438–1450. http://dx.doi.org/10.1016/j.aap.2011.02.022. Keay, L., Hunter, K., Brown, J., Bilston, L. E., Simpson, J. M., Stevenson, M., & Ivers, R. Q. (2013). Child restraint use in low socio-economic areas of urban Sydney during transition to new legislation. Accident; Analysis and Prevention, 50, 984–991. http://dx.doi. org/10.1016/j.aap.2012.08.002. Klinich, K. D., Flannagan, C. A., Jermakian, J. S., McCartt, A. T., Manary, M. A., Moore, J. L., & Wells, J. K. (2013). Vehicle LATCH system features associated with correct child restraint installations. Traffic Injury Prevention, 14(5), 520–531. http://dx.doi.org/10. 1080/15389588.2012.701030. Koppel, S., & Charlton, J. L. (2009). Child restraint system misuse and/or inappropriate use in Australia. Traffic Injury Prevention, 10(3), 302–307. http://dx.doi.org/10.1080/ 15389580902856392. Koppel, S., Charlton, J. L., & Rudin-Brown, C. M. (2013). The impact of new legislation on child restraint system (CRS) misuse and inappropriate use in Australia. Traffic Injury Prevention, 14(4), 387–396. http://dx.doi.org/10.1080/15389588.2012.700746. Ma, X., Layde, P., & Zhu, S. (2012). Association between child restraint systems use and injury in motor vehicle crashes. Academic Emergency Medicine, 19(8), 916–923. http://dx.doi.org/10.1111/j.1553-2712.2012.01403.x. Macy, M. L., & Freed, G. L. (2012). Child passenger safety practices in the U.S.: Disparities in light of updated recommendations. American Journal of Preventive Medicine, 43(3), 272–281. http://dx.doi.org/10.1016/j.amepre.2012.05.023. Macy, M. L., Clark, S. J., Freed, G. L., Butchart, A. T., Singer, D. C., Sasson, C., ... Davis, M. M. (2012). Carpooling and booster seats: A national survey of parents. Pediatrics, 129(2), 290–298. http://dx.doi.org/10.1542/peds.2011-0575. Macy, M. L., Cunningham, R. M., Resnicow, K., & Freed, G. L. (2014). Disparities in ageappropriate child passenger restraint use among children aged 1 to 12 years. Pediatrics, 133(2), 262–271. http://dx.doi.org/10.1542/peds.2013-1908. Mathieu, R., Peter, S., Yvan, C., & Philippe, L. (2014). National roadside survey of child restraint system use in Belgium. Accident; Analysis and Prevention, 62, 369–376. http://dx.doi.org/10.1016/j.aap.2013.08.021. Murakami, E., & Young, J. (1997). Daily travel by persons with low income. Retrieved from http://www-cta.ornl.gov/npts/1995/Doc/LowInc.pdf National Highway Traffic Safety Administration (1993). Federal Motor Vehicle Safety Standards No. 208; Occupant Crash Protection, Lockability Provision. 49 CFR 571.
22
S.L. Bachman et al. / Journal of Safety Research 56 (2016) 17–22
208. Retrieved from http://www.fmcsa.dot.gov/rules-regulations/administration/ fmcsr/fmcsrruletext.aspx?reg=r49CFR571.208 National Highway Traffic Safety Administration (1999). Federal Motor Vehicle Safety Standards Final Rule; Child Restraint Systems, Child Restraint Anchorage Systems. 49 CFR 571 & 596. Retrieved from http://www.nhtsa.gov/cars/rules/rulings/UCRAOMB-J08/FinalRule.html Nie, C., Colunga, I., McCoy, M., Stephens-Stidham, S., & Istre, G. R. (2013). Impact of errors in age estimates on the classification of proper child occupant restraint use: An observational survey. Injury Prevention, 19(2), 130–133. http://dx.doi.org/10.1136/ injuryprev-2012-040581. Oliveira, S. R., Carvalho, M. D., Santana, R. G., Camargo, G. C., Luders, L., & Franzin, S. (2009). Child safety restraint use among children attending day care centers. Revista de Saúde Pública, 43(5), 761–767. http://dx.doi.org/10.1590/S003489102009005000052. Oliveira, S. R., Leone, C., Carvalho, M. D., Santana, R. G., Luders, L. E., & Oliveira, F. C. (2012). Child safety seat usage errors in under-4 s. Jornal de Pediatria, 88(4), 297–302. http:// dx.doi.org/10.2223/JPED.2189. Quistberg, D. A., Lozano, P., Mack, C. D., Schwartz, R., & Ebel, B. E. (2010). A comparison of self-report and direct observation of booster seat use in Latino families. Injury Prevention, 16(4), 225–229. http://dx.doi.org/10.1136/ip.2009.025338. Raman, S. R., Landry, M. D., Ottensmeyer, C. A., Jacob, S., Hamdan, E., & Bouhaimed, M. (2013). Keeping our children safe in motor vehicles: Knowledge, attitudes and practice among parents in Kuwait regarding child car safety. International Journal of Injury Control and Safety Promotion, 20(4), 358–367. http://dx.doi.org/10.1080/17457300. 2012.745578. Rice, T. M., & Anderson, C. L. (2009). The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005. American Journal of Public Health, 99(2), 252–257. http://dx.doi.org/10.2105/AJPH.2007. 131128. Rogers, S. C., Gallo, K., Saleheen, H., & Lapidus, G. (2012). Wishful thinking: Safe transportation of newborns at hospital discharge. Journal of Trauma and Acute Care Surgery, 73(4 Suppl 3), S262–S266. http://dx.doi.org/10.1097/TA.0b013e31826b0146. Snowdon, A. W., Hussein, A., Purc-Stevenson, R., Follo, G., & Ahmed, E. (2009). A longitudinal study of the effectiveness of a multi-media intervention on parents' knowledge and use of vehicle safety systems for children. Accident; Analysis and Prevention, 41(3), 498–505. http://dx.doi.org/10.1016/j.aap.2009.01.013. Snowdon, A. W., Polgar, J., Patrick, L., & Stamler, L. (2006). Parents' knowledge about and use of child safety systems. The Canadian Journal of Nursing Research, 38(2), 98–114 Retrieved from http://docserver.ingentaconnect.com/deliver/connect/mcgill/08445621/ v38n2/s10.pdf?expires=1418255749&id=80167937&titleid=6601&accname= University+of+Southern+California&checksum= F9BA34E01232D70E67CAE231F83A5FD5. Snowdon, A., Rothman, L., Slater, M., Kolga, C., Hussein, A., Boase, P., & Howard, A. (2010). Methodology of estimating restraint use in children: Roadside observation or parking lot interview survey. Accident; Analysis and Prevention, 42(6), 1545–1548. http://dx. doi.org/10.1016/j.aap.2010.02.020. Stewart, S. L., Baiden, P., & Theall-Honey, L. (2013). Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities. International Journal of Mental Health Nursing, 22(1), 56–68. http://dx.doi.org/10.1111/j.1447-0349.2012.00831.x. Yaghoubian, A., De Virgilio, C., Kaji, A. H., Putnam, B., Neville, A. L., Bricker, S., & Lee, S. L. (2011). Are there racial disparities in the use of restraints and outcomes after motor
vehicle collisions in Los Angeles County? The American Surgeon, 77(10), 1346–1348 Retrieved from http://docserver.ingentaconnect.com/deliver/connect/sesc/00031348/ v77n10/s16.pdf?expires=1418255465&id=80167919&titleid=11737&accname= University+of+Southern+California&checksum=47F71E15BF21C46D4E17459A92 706062. Yanchar, N. L., Kirkland, S. A., LeBlanc, J. C., & Langille, D. B. (2012). Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia—A population-based study. Accident; Analysis and Prevention, 45, 326–333. http://dx.doi.org/10.1016/j.aap.2011.07.020. Shelby L. Bachman, BS Ms. Bachman is a Program Assistant in the Trauma Program at Children's Hospital Los Angeles where she participates in research related to pediatric trauma and disaster preparedness, injury prevention outreach, and trauma registry. Ms. Bachman is a certified Child Passenger Safety Technician and has additional qualifications in transportation for children with special healthcare needs. Garrett A. Salzman, BA Mr. Salzman is a Program Assistant in the Trauma Program at Children's Hospital Los Angeles where he participates in research related to pediatric trauma and disaster preparedness, injury prevention outreach, and disaster preparedness planning. Mr. Salzman is a certified Child Passenger Safety Technician and a future medical student. Rita V. Burke, PhD, MPH Dr. Burke is an Assistant Professor of Research in the Division of Pediatric Surgery at Children's Hospital Los Angeles. She received her MPH and PhD in Epidemiology from UCLA. She supervises outcomes research related to acute surgical care and injury prevention interventions. Dr. Burke is a also certified Child Passenger Safety Technician. Helen Arbogast, MPH Ms. Arbogast is the Injury Prevention Manager at Children's Hospital Los Angeles. She has 17 years of public health experience in coordination of intervention programs, collection and analysis of data, development of educational materials, curriculum and presentation development through collaboration with federal, state and local agencies and community-based organizations in both the public and private sector. Ms. Arbogast leads the local Injury Free Coalition for Kids chapter and the local Buckle Up For Life Initiative. She is a certified Special Needs Child Passenger Safety Technician Instructor and serves on the National Child Passenger Safety Board. Pearl Ruiz, BA Ms. Ruiz is a Health Education Associate in the Injury Prevention Program at Children's Hospital Los Angeles. She coordinates the local Buckle Up for Life Initiative, organizes community car seat check events, and teaches car seat classes at Children's Hospital Los Angeles and throughout her community. Ms. Ruiz is a certified Child Passenger Safety Technician Instructor with additional qualifications in transportation for children with special healthcare needs. Jeffrey S. Upperman Dr. Upperman is the Trauma Medical Director at Children's Hospital Los Angeles and an Associate Professor at Keck School of Medicine of the University of Southern California. He is a board-certified pediatric surgeon and a fellow of both the American College of Surgeons and the American Academy of Pediatrics.