Restraint use in the Eastern Province of the Kingdom of Saudi Arabia

Objectives: This study set out to examine seat belt and child restraint use in the Dammam Municipality of the Kingdom of Saudi Arabia, based on the premise that an increase in seat belt use would significantly reduce personal injury in traffic crashes. It was expected that local data would help identify intervention strategies necessary to improve seat belt use in the region.

Methods: The research involved 2 methodologies. First, 1,389 face-to-face interviews were conducted with male and female adults in regional shopping plazas regarding their own and their children's restraint use in their vehicles and reasons for these attitudes and beliefs. Second, 2 on-road observation studies of adult and child restraint use were conducted by trained observers. Occupants of approximately 5,000 passenger vehicles were observed while stopped at representative signalized traffic intersections.

Results: The findings showed front seat belt use rates of between 43 and 47% for drivers and 26 to 30% for front seat passengers; rear seat belt use rates were lower. While there seemed to be some knowledge about the purpose and reasons for restraining both adults and children in suitable restraints, this failed to be confirmed in the on-road observations.

Conclusions: Reasons for these rates and findings are discussed fully, and recommendations for improving seat belt use in the Dammam Municipality are included.     

Driver and front passenger injury in frontal crashes: Update on the effect of unbelted rear occupants

Purpose: This is a study of the influence of an unbelted rear occupant on the risk of severe injury to the front seat occupant ahead of them in frontal crashes. It provides an update to earlier studies.

Methods: 1997–2015 NASS-CDS data were used to investigate the risk for severe injury (Maximum Abbreviated Injury Score [MAIS] 4+F) to belted drivers and front passengers in frontal crashes by the presence of a belted or unbelted passenger seated directly behind them or without a rear passenger. Frontal crashes were identified with GAD1 = F without rollover (rollover ≤ 0). Front and rear outboard occupants were included without ejection (ejection = 0). Injury severity was defined by MAIS and fatality (F) by TREATMNT = 1 or INJSEV = 4. Weighted data were determined. The risk for MAIS 4+F was determined using the number of occupants with known injury status MAIS 0+F. Standard errors were determined.

Results: The risk for severe injury was 0.803 ± 0.263% for the driver with an unbelted left rear occupant and 0.100 ± 0.039% with a belted left rear occupant. The driver's risk was thus 8.01 times greater with an unbelted rear occupant than with a belted occupant (P <.001). With an unbelted right rear occupant behind the front passenger, the risk for severe injury was 0.277 ± 0.091% for the front passenger. The corresponding risk was 0.165 ± 0.075% when the right rear occupant was belted. The front passenger's risk was 1.68 times greater with an unbelted rear occupant behind them than a belted occupant (P <.001). The driver's risk for MAIS 4+F was highest when their seat was deformed forward. The risk was 9.94 times greater with an unbelted rear occupant than with a belted rear occupant when the driver's seat deformed forward. It was 13.4 ± 12.2% with an unbelted occupant behind them and 1.35 ± 0.95% with a belted occupant behind them.

Conclusions: Consistent with prior literature, seat belt use by a rear occupant significantly lowered the risk for severe injury to belted occupants seated in front of them. The reduction was greater for drivers than for front passengers. It was 87.5% for the driver and 40.6% for the front passenger. These results emphasize the need for belt reminders in all seating positions.     

High-risk behaviors while driving: A population-based study from Iran

Objective: Traffic injuries are becoming one of the most important challenges of public health systems. Because these injuries are mostly preventable, the aim of this study is to evaluate the four main high-risk behaviors while driving.

Methods: This cross-sectional study was conducted on a random sample from the population of Mashhad, Iran, in 2014. A checklist and a previously validated questionnaire for the transtheoretical stages of change model (TTM) were used for data collection. Statistical analyses were performed using SPSS 11.5 software with P <.05 statistically significant.

Results: Totally 431 individuals were included with a mean age of 30 ± 11.3 years. Forty-three percent (183) were male. The TTM model revealed that participants were mostly in pre-actional phases regarding not using a cell phone while driving (80%), fastening the driver's seat belt (66%), front seat belt (68%), and rear seat belt (85%) The penalty was a protective factor only for using cellphone (odd ratio [OR] = 0.82, 95% confidence interval [CI], 0.68–0.98). Lower education (OR = 0.12, 95% CI, 0.01–0.94) and male gender (OR = 0.35, 95% CI, 0.14–0.83) were indicative of lower rates of fastening the front and rear seat belts.

Conclusion: The stages of change model among study participants is a proper reflection of the effectiveness of the current policies. More serious actions regarding these high-risk behaviors should be considered in legislation.     

Seat belt use and fit among drivers aged 75 years and older in their own vehicles

Objective: This article aims to describe seat belt wearing patterns and quality of seat belt fit among drivers aged 75 years and older. A secondary aim is to explore associations between body shape, comfort, and seat belt use patterns.

Methods: This is an observation and survey study of a cohort of 380 drivers aged 75 years and over. During home visits, photographs were taken of the drivers in their vehicles for later analysis of belt fit and a short survey was also administered to collect demographic data and information about seat belt use and comfort. Seat belt fit and use of belt and seat accessories were analyzed from the photographs.

Results: Data from 367 participants with photographs were analyzed. Whereas 97% reported using a seat belt and 90% reported their seat belt to be comfortable, 21% reported repositioning their seat belt to improve comfort. Good sash and lap belt fit were achieved in 53 and 59% of participants, respectively, but only 35% achieved overall good fit. Both poor sash and lap belt fit were observed in 23% of participants. Drivers who were in the obese category had over twice the odds (95% confidence interval [CI], 1.2–4.1) of having a poor lap belt fit than those in the normal body mass index [BMI] range, and drivers who were overweight had 1.8 times the odds (95% CI, 1.1–2.9) of having poor lap belt fit. Older females also had twice the odds (95% CI, 1.3–3.5) of poor lap belt fit compared to older males, regardless of BMI. Sash belt fit did not vary significantly by BMI, stature, or gender. However older drivers who reported that they had not made any adjustments to the D-ring height had 1.7 times the odds of having poor sash belt fit than those who made adjustments (1.2–2.9). Females were 7.3 times more likely to report comfort problems than males (95% CI, 3.2, 16.3) but there was no association between reported comfort and BMI or seat belt fit. Drivers who reported comfort problems had 6 times the odds (3.2–13.6) of also reporting active repositioning of the belt.

Conclusions: The results suggest that older drivers face challenges in achieving comfortable and correct seat belt fit. This may have a negative impact on crash protection. Belt fit problems appear to be associated with body shape, particularly high BMI and gender. There is a need for further investigation of comfort accessories; in the interim, older drivers and occupants should be encouraged to use features such as D-ring adjusters to improve sash belt fit.     

Predicting vehicle belt fit for children ages 6–12

Objective: To predict shoulder belt fit and lap belt fit as a function of child age, vehicle seat characteristics, and belt geometry.

Methods: In a previous study, the lap belt and shoulder belt fit of 44 children aged 5–12 were measured in a simulated vehicle seat while varying cushion length, cushion angle, seatback angle, and belt anchorage geometry. A regression model was developed to predict lap belt fit and shoulder belt fit as a function of vehicle parameters and child stature. These regression models were applied to the stature distribution of 6- to 12-year-olds using a range of vehicle geometry data to predict the proportion of children expected to achieve good belt fit in the second-row, outboard seating positions of 46 vehicles when not using belt-positioning boosters.

Results: Across the ranges observed in vehicles, lap belt angle had the strongest effect on lap belt fit, although vehicle cushion length also contributed. Shoulder belt fit was most strongly affected by D-ring location. Vehicles with the geometric conditions most suitable for children are estimated to provide good lap belt fit for 25% of children aged 6 to 12. In 20% of vehicles, the shoulder belt is too far inboard for the target child population; 20% of vehicles are estimated to have shoulder belt fit too far outboard for children ages 6 to 12.

Conclusions: Based on this geometric analysis, the rear seats of most vehicles are unlikely to provide good lap belt fit for up to 75% of children ages 6–12. Shoulder belt fit is outside the target range for 40% of children. Consequently, children under 12 years of age are likely to experience markedly poorer belt fit when transitioning out of a booster seat.     

Abdominopelvic injuries due to road traffic accidents: Characteristics in a registry of 162,695 victims

Objective: Road traffic accidents (RTAs) are the first cause of abdominopelvic injuries (APIs). The objective of this study was to describe the characteristics and severity of APIs due to traffic accidents in a large French trauma registry and to identify risk factors for API.

Methods: All victims from the French Rhône registry of victims of RTAs were analyzed from 1996 to 2013. This registry contained data that were issued over a 20-year period from 245 medical departments, from prehospital care until re-adaptation, and forensic medicine departments. All APIs, defined as an injury between the diaphragm and the pelvic bone, were extracted and studied.

Results: Among 162,695 victims, 10,165 had an API (6.7%). Accidents frequently involved young men and 2 cars. Mean Injury Severity Score (ISS) was 8.7. Mortality rate was 5.6%. Soft tissue injuries largely predominated (n = 6,388; 54.4% of patients). Overall, 2,322 victims had a pelvic bone injury. Internal abdominal organs were involved in 2,425 patients; the most frequent were the spleen, liver, and kidney. Wearing of the seat belt appeared to be a significant protective factor in API, including serious injuries. A partial analysis over the past 2 years among the most severe patients hospitalized in the intensive care unit indicated that nonoperative management was carried out in two thirds of the wounded. In uni- or multivariate analysis, sex, age, type of user, antagonist, time of occurrence, associated severe lesions, or wearing of the seat belt were statistically associated with the occurrence of API, highlighting a more dangerous user profile.

Conclusions: Abdominopelvic injuries concern a minority of road traffic injuries, but they are responsible for significant mortality. Large solid organs are the most frequently affected. Women drivers wearing a seat belt and driving in town during the day appear to be more protected against API.     

Experimental investigation of the effect of occupant characteristics on contemporary seat belt payout behavior in frontal impacts

Objective: The goal of this study was to investigate the influence of the occupant characteristics on seat belt force vs. payout behavior based on experiment data from different configurations in frontal impacts.

Methods: The data set reviewed consists of 58 frontal sled tests using several anthropomorphic test devices (ATDs) and postmortem human subjects (PMHS), restrained by different belt systems (standard belt, SB; force-limiting belt, FLB) at 2 impact severities (48 and 29 km/h). The seat belt behavior was characterized in terms of the shoulder belt force vs. belt payout behavior. A univariate linear regression was used to assess the factor significance of the occupant body mass or stature on the peak tension force and gross belt payout.

Results: With the SB, the seat belt behavior obtained by the ATDs exhibited similar force slopes regardless of the occupant size and impact severities, whereas those obtained by the PMHS were varied. Under the 48 km/h impact, the peak tension force and gross belt payout obtained by ATDs was highly correlated to the occupant stature (P =.03, P =.02) and body mass (P =.05, P =.04), though no statistical difference with the stature or body mass were noticed for the PMHS (peak force: P =.09, P =.42; gross payout: P =.40, P =.48). With the FLB under the 48 km/h impact, highly linear relationships were noticed between the occupant body mass and the peak tension force (R² = 0.9782) and between the gross payout and stature (R² = 0.9232) regardless of the occupant types.

Conclusions: The analysis indicated that the PMHS characteristics showed a significant influence on the belt response, whereas the belt response obtained with the ATDs was more reproducible. The potential cause included the occupant anthropometry, body mass distribution, and relative motion among body segments specific to the population variance. This study provided a primary data source to understand the biomechanical interaction of the occupant with the restraint system. Further research is necessary to consider these effects in the computational studies and optimized design of the restraint system in a more realistic manner.     

Evaluation of give kids a boost: A school-based program to increase booster seat use among urban children in economically disadvantaged areas

Objective: This study evaluated the effectiveness of a series of 1-year multifaceted school-based programs aimed at increasing booster seat use among urban children 4–7 years of age in economically disadvantaged areas.

Methods: During 4 consecutive school years, 2011–2015, the Give Kids a Boost (GKB) program was implemented in a total of 8 schools with similar demographics in Dallas County. Observational surveys were conducted at project schools before project implementation (P₀), 1–4 weeks after the completion of project implementation (P₁), and 4–5 months later (P₂). Changes in booster seat use for the 3 time periods were compared for the 8 project and 14 comparison schools that received no intervention using a nonrandomized trial process.

The intervention included (1) train-the-trainer sessions with teachers and parents; (2) presentations about booster seat safety; (3) tailored communication to parents; (4) distribution of fact sheets/resources; (5) walk-around education; and (6) booster seat inspections.

The association between the GKB intervention and proper booster seat use was determined initially using univariate analysis. The association was also estimated using a generalized linear mixed model predicting a binomial outcome (booster seat use) for those aged 4 to 7 years, adjusted for child-level variables (age, sex, race/ethnicity) and car-level variables (vehicle type). The model incorporated the effects of clustering by site and by collection date to account for the possibility of repeated sampling.

Results: In the 8 project schools, booster seat use for children 4–7 years of age increased an average of 20.9 percentage points between P₀ and P₁ (P₀ = 4.8%, P₁ = 25.7%; odds ratio [OR] = 6.9; 95% confidence interval [CI], 5.5, 8.7; P < .001) and remained at that level in the P₂ time period (P₂ = 25.7%; P < .001, for P₀ vs. P₂) in the univariate analysis. The 14 comparison schools had minimal change in booster seat use. The multivariable model showed that children at the project schools were significantly more likely to be properly restrained in a booster seat after the intervention (OR = 2.7; 95% CI, 2.2, 3.3) compared to the P₀ time period and compared to the comparison schools.

Conclusion: Despite study limitations, the GKB program was positively associated with an increase in proper booster seat use for children 4–7 years of age in school settings among diverse populations in economically disadvantaged areas. These increases persisted into the following school year in a majority of the project schools. The GKB model may be a replicable strategy to increase booster seat use among school-age children in similar urban settings.     

Driver's obesity and road crash risks in the United States

Objective: We assessed obesity trends in U.S. drivers involved in fatal crashes since 1999 and distinguished whether crash risk factors were different between obese and nonobese drivers.

Methods: We included only drivers of passenger cars involved in fatal traffic crashes between January 1, 1999, and December 31, 2012. Obesity was classified according to the World Health Organization guidelines and profiled between 1999 and 2012 using the adjusted prevalence ratio (aPR) from log-binomial regression models. Differences in crash risks (e.g., driver's fatality, drunk driving, seat belt nonuse) between obese and nonobese drivers were estimated as adjusted odds ratios (aORs) using logistic regression models.

Results: A total of 753,024 U.S. drivers were involved in fatal crashes, for which obesity information was available for 534,887. About 56% (n = 299,078) were driving passenger cars. The prevalence of class I obesity increased from 10% in 1999 to 14% in 2012 (aPR = 1.50, 95% confidence interval [CI], 1.42–1.58), class II obesity from 3 to 5% (aPR = 2.22, 95% CI, 2.05–3.01), and class III obesity from 1 to 2% (aPR = 2.65; 95% CI, 2.27–3.10). Compared to nonobese controls, obese drivers had significantly higher risks for fatality (1.10 ≤ aOR ≤ 1.47), seat belt nonuse (1.00 ≤ aOR ≤ 1.21), need for extrication (1.01 ≤ aOR ≤ 1.23), and ambulance transport time ≥30 min (1.01 ≤ aOR ≤ 1.28). Compared to nonobese controls, obese drivers were less likely to drink drive (0.41 ≤ aOR ≤ 0.72) or speed >65 mph (0.78 ≤ aOR ≤ 0.93).

Conclusion: The rising national prevalence of obesity extends to U.S. drivers involved in fatal crashes and indicates the need to improve seat belt use, vehicle design, and postcrash care for this vulnerable population.     

Compatibility of booster seats and vehicles in the U.S. market

Objective: The objective of this study was to analyze booster and rear vehicle seat dimensions to identify the most frequent compatibility problems.

Methods: Measurements were collected from 40 high-back and backless boosters and 95 left rear and center rear row seating positions in 50 modern vehicles. Dimensions were compared for 3,800 booster/vehicle seat combinations. For validation and estimation of tolerance and correction factors, 72 booster installations were physically completed and compared with measurement-based compatibility predictions. Dimensions were also compared to the International Organization for Standardization (ISO) volumetric envelopes of forward-facing child restraints and boosters.

Results: Seat belt buckles in outboard positions accommodated the width of boosters better than center positions (success rates of 85.4 and 34.7%, respectively). Adequate head restraint clearance occurred in 71.9 to 77.2% of combinations, depending on the booster's head support setting. Booster recline angles aligned properly with vehicle seat cushion angles in 71.5% of combinations. In cases of poor angle alignment, booster angles were more obtuse than the vehicle seat angles 97.7% of the time. Head restraint interference exacerbated angle alignment issues. Data indicate success rates above 90% for boosters being fully supported by the length of the seat cushion and for adequate height clearance with the vehicle roofline. Comparison to ISO envelopes indicates that most boosters on the U.S. market are taller and angled more obtusely than ISO target envelopes.

Conclusions: This study quantifies some of the common interferences between boosters and vehicles that may complicate booster usage. Data are useful for design and to prioritize specific problem areas.     

An energy-absorbing sliding seat for reducing neck injury risks in rear impact—analysis for prototype built

Objective: This study investigated overall performance of an energy-absorbing sliding seat concept for whiplash neck injury prevention. The sliding seat allows its seat pan to slide backward for some distance under certain restraint force to absorb crash energy in rear impacts.

Methods: A numerical model that consisted of vehicle interior, seat, seat belt, and BioRID II dummy was built in MADYMO to evaluate whiplash neck injury in rear impact. A parametric study of the effects of sliding seat parameters, including position and cushion stiffness of head restraint, seatback cushion stiffness, recliner characteristics, and especially sliding energy-absorbing (EA) restraint force, on neck injury criteria was conducted in order to compare the effectiveness of the sliding seat concept with that of other existing anti-whiplash mechanisms. Optimal sliding seat design configurations in rear crashes of different severities were obtained. A sliding seat prototype with bending of a steel strip as an EA mechanism was fabricated and tested in a sled test environment to validate the concept. The performance of the sliding seat under frontal and rollover impacts was checked to make sure the sliding mechanism did not result in any negative effects.

Results: The protective effect of the sliding seat with EA restraint force is comparable to that of head restraint–based and recliner stiffness–based anti-whiplash mechanisms. EA restraint force levels of 3 kN in rear impacts of low and medium severities and 6 kN in impacts of high severity were obtained from optimization. In frontal collision and rollover, compared to the nonsliding seat, the sliding seat does not result in any negative effects on occupant protection. The sled test results of the sliding seat prototype have shown the effectiveness of the concept for reducing neck injury risks.

Conclusion: As a countermeasure, the sliding seat with appropriate restraint forces can significantly reduce whiplash neck injury risk in rear impacts of low, medium, and high severities with no negative effects on other crash load cases.     

Drink driving and risky behavior among university students in southwestern Nigeria—Implications for policy development

Background: Drink driving contributes significantly to road traffic injuries. Little is known about the relationship between drink driving and other high-risk behaviors in non-Western countries. The study aimed to assess the relationship between drink driving and other risky behaviors including making phone calls, sending text messages, nonuse of protective gear, and driving against traffic.

Methods: A cross-sectional survey of risky behavior among undergraduates was conducted. A stratified random sampling method was used to identify young undergraduates who had driven a motorized vehicle in the past year. The Alcohol Use Disorder Identification Test (AUDIT) and other tools developed by researchers were used to identify the risky behaviors.

Results: Of 431 respondents, 10.7% had engaged in drink driving in the past 12 months. The most common risky behavior was making phone calls (63.7%), followed by nonuse of helmets (54.7%), driving against traffic (49.2%), nonuse of seat belts (46.8%), and sending text messages (26.1%). Alcohol use was significantly associated with making phone calls (U = 1.148; P < .0001), sending text messages (U = 1.598; P = .021), nonuse of helmets (U = 1.147; P < .0001), driving against traffic (U = 1.234; P < .0001), and nonuse of seat belts (U = 3.233; P = .001). Drink driving was associated with all risky behaviors except nonuse of seat belts (U = 1.842; P = .065).

Conclusion: Alcohol use and drink driving were associated with multiple risky driving behaviors. This provides useful insight for policy development and presents additional challenges for traffic injury prevention.     

Seat strength in rear body block tests

Purpose: This study collected and analyzed available testing of motor vehicle seat strength in rearward loading by a body block simulating the torso of an occupant. The data were grouped by single recliner, dual recliner, and all belts to seat (ABTS) seats.

Methods: The strength of seats to rearward loading has been evaluated with body block testing from 1964 to 2008. The database of available tests includes 217 single recliner, 65 dual recliner, and 18 ABTS seats. The trends in seat strength were determined by linear regression and differences between seat types were evaluated by Student's t-test. The average peak moment and force supported by the seat was determined by decade of vehicle model year (MY).

Results: Single recliner seats were used in motor vehicles in the 1960s to 1970s. The average strength was 918 ± 224 Nm (n = 26) in the 1960s and 1,069 ± 293 Nm (n = 65) in the 1980s. There has been a gradual increase in strength over time. Dual recliner seats started to phase into vehicles in the late 1980s. By the 2000s, the average strength of single recliner seats increased to 1,501 ± 335 Nm (n = 14) and dual recliner seats to 2,302 ± 699 Nm (n = 26). Dual recliner seats are significantly stronger than single recliner seats for each decade of comparison (P < .001). The average strength of ABTS seats was 4,395 ± 1,185 in-lb for 1989–2004 MY seats (n = 18). ABTS seats are significantly stronger than single or dual recliner seats (P < .001). The trend in ABTS strength is decreasing with time and converging toward that of dual recliner seats.

Conclusions: Body block testing is an quantitative means of evaluating the strength of seats for occupant loading in rear impacts. There has been an increase in conventional seat strength over the past 50 years. By the 2000s, most seats are 1,700–3,400 Nm moment strength. However, the safety of a seat is more complex than its strength and depends on many other factors.     

Differences in the kinematics of booster-seated pediatric occupants using two different car seats

Objective: The objective of this article is to compare the performance of forward-facing child restraint systems (CRS) mounted on 2 different seats.

Methods: Two different anthropomorphic test device (ATD) sizes (P3 and P6), using the same child restraint system (a non-ISOFIX high-back booster seat), were exposed to the ECE R44 regulatory deceleration pulse in a deceleration sled. Two different seats (seat A, seat B) were used. Three repetitions per ATD and mounting seat were done, resulting in a total of 12 sled crashes. Dummy sensors measured the head tri-axial acceleration and angular rate and the thorax tri-axial acceleration, all acquired at 10,000 Hz. A high-speed video camera recorded the impact at 1,000 frames per second. The 3D kinematics of the head and torso of the ATDs were captured using a high-speed motion capture system (1,000 Hz). A pair-matched statistical analysis compared the outcomes of the tests using the 2 different seats.

Results: Statistically significant differences in the kinematic response of the ATDs associated with the type of seat were observed. The maximum 3 ms peak of the resultant head acceleration was higher on seat A for the P3 dummy (54.5 ± 1.9 g vs. 44.2 ± 0.5 g; P =.012) and for the P6 dummy (56.0 ± 0.8 g vs. 51.7 ± 1.2 g; P =.015). The peak belt force was higher on seat A than on seat B for the P3 dummy (5,488.0 ± 198.0 N vs. 4,160.6 ± 63.6 N; P =.008) and for the P6 dummy (7,014.0 ± 271.0 N vs. 5,719.3 ± 37.4 N; P =.015). The trajectory of the ATD head was different between the 2 seats in the sagittal, transverse, and frontal planes.

Conclusion: The results suggest that the overall response of the booster-seated occupant exposed to the same impact conditions was different depending on the seat used regardless of the size of the ATD. The differences observed in the response of the occupants between the 2 seats can be attributed to the differences in cushion stiffness, seat pan geometry, and belt geometry. However, these results were obtained for 2 particular seat models and a specific CRS and therefore cannot be directly extrapolated to the generality of vehicle seats and CRS.     

Pelvic restraint cushion sled test evaluation of pelvic forward motion

Objective: This study was designed to evaluate the performance of a pelvic restraint cushion (PRC), a submarining countermeasure that deploys under the thighs when a crash is detected in order to block the forward motion of the pelvis.

Methods: Sled tests approximating low- and high-speed frontal impacts were conducted with 4 female postmortem human subjects (PMHS) restrained by a lap and shoulder belt in the right front passenger seat. The subjects were tested with and without a PRC.

Results: The PRC is effective in reducing forward motion of the PMHS pelvis and reduces the risk of injury due to lap belt loading in a high-speed frontal crash.

Conclusions: Although small sample size limits the utility of the study's findings, the results suggest that the PRC can limit pelvic forward motion and that pelvic injury due to PRC deployment is not likely.     

Rating child passenger safety laws relative to best practice recommendations for occupant protection

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.     

Emergency department visits by pediatric patients sustained as a passenger on a motorcycle

Objective: Currently only 5 out of the 50 states in the United States have laws restricting the age of passengers permitted to ride on a motorcycle. This study sought to characterize the visits by patients under the age of 16 to U.S. emergency departments (EDs) for injuries sustained as a passenger on a motorcycle.

Methods: In this retrospective cohort study, data were obtained from the Nationwide Emergency Department Sample (NEDS) for the years 2006 to 2011. Pediatric patients who were passengers on a motorcycle that was involved in a crash were identified using International Classification of Diseases, Ninth Revision (ICD-9) External Cause of Injury codes. We also examined gender, age, disposition, regional differences, common injuries, and charges.

Results: Between 2006 and 2011 there were an estimated 9,689 visits to U.S. EDs by patients under the age of 16 who were passengers on a motorcycle involved in a crash. The overall average patient age was 9.4 years, and they were predominately male (54.5%). The majority (85%) of these patients were treated and released. The average charges for discharged patients were $2,116.50 and amounted to roughly $17,500,000 during the 6 years. The average cost for admission was $51,446 per patient and totaled over $54 million. The most common primary injuries included superficial contusions; sprains and strains; upper limb fractures; open wounds of head, neck, and trunk; and intracranial injuries.

Conclusion: Although there were only about 9,700 visits to U.S. EDs for motorcycle crashes involving passengers less than 16 years old for 2006 to 2011, the total cost of visits that resulted in either ED discharge or hospital admission amounted to over $71 million.     

Cross-sectional study of road accidents and related law enforcement efficiency for 10 countries: A gap coherence analysis

Objective: Road crashes are considered as the eighth leading causes of death. There is a wide disparity in crash severity and law enforcement efficiency among low-, medium-, and high-income countries. It would be helpful to review the crash severity trends in these countries, identify the vulnerable road users, and understand the law enforcement effectiveness in devising efficient road safety improvement strategies.

Method: The crash severity, fatality rate among various age groups, and law enforcement strategies of 10 countries representing low-income (i.e., India and Morocco), medium-income (i.e. Argentina, South Korea, and Greece), and high-income (i.e., Australia, Canada, France, the UK, and the United States) are studied and compared for a period of 5 years (i.e., 2008 to 2012). The critical parameters affecting road safety are identified and correlated with education, culture, and basic compliance with traffic safety laws. In the process, possible road safety improvement strategies are identified for low-income countries.

Results: The number of registered vehicles shows an increasing trend for low-income countries as do the crash rate and crash severity. Compliance related to seat belt and helmet laws is high in high-income countries. In addition, recent seat belt– and helmet-related safety programs in middle-income countries helped to curb fatalities. Noncompliance with safety laws in low-income countries is attributed to education, culture, and inefficient law enforcement.

Conclusion: Efficient law enforcement and effective safety education taking into account cultural diversity are the key aspects to reduce traffic-related injuries and fatalities in low-income countries like India.     

An observational study of child safety seat use in an international safe community: Tehran,Iran

Objective: Despite strong evidence of the effectiveness of child safety seats in reducing injuries, the use of these devices in some communities is still rare. The purpose of this study was to determine the prevalence of child safety seat use and the factors influencing its use in the safe community of Tehran.

Methods: This roadside observational study was conducted in 2015 and 2,178 personal cars with a child under 12 years aboard were observed on Tehran's streets in regard to use of child safety seats. Other variables such as the gender of the driver, driver's age group, type of street, region of municipality, time of day, and day of the week were also collected.

Results: Prevalence of child safety seat use was 4.3% and was significantly higher among women drivers, on freeways, and in municipal regions 1, 4, and 7.

Conclusions: The prevalence of child safety seat use in Tehran as a most populous member of the international safe community was very low and most children commuted in insecure situations in the vehicle. Therefore, it is proposed that plans should be made to increase the use of child safety seats in international safe communities.