Vehicle characteristics associated with LATCH use and correct use in real-world child restraint installations

IntroductionThe objective of this study was to determine if vehicle features associated with LATCH ease-of-use in laboratory studies with volunteers predict LATCH use and misuse in real-world child restraint installations.MethodVehicle characteristics were extracted from prior surveys of more than 100 top-selling 2010–13 vehicles. Use and correct use of LATCH was determined from records of more than 14,000 child restraint installations in these vehicles that were inspected by child passenger safety technicians at Safe Kids car seat checkup events during 2010–12. Logistic regression was used to examine the association between vehicle features and use and correct use of lower anchors and top tethers, controlling for other relevant installation features.ResultsLower anchors were more likely to be used and correctly used when the clearance angle around them was greater than 54°, the force required to attach them to the lower anchors was less than 178 N, and their depth within the seat bight was less than 4 cm. Restraints were more likely to be attached correctly when installed with the lower anchors than with the seat belt. After controlling for lower anchor use and other installation features, the likelihood of tether use and correct use in installations of forward-facing restraints was significantly higher when there was no hardware present that could potentially be confused with the tether anchor or when the tether anchor was located on the rear deck, which is typical in sedans.ConclusionsThere is converging evidence from laboratory studies with volunteers and real-world child restraint installations that vehicle features are associated with correct LATCH use.Practical applicationsVehicle designs that improve the ease of installing child restraints with LATCH could improve LATCH use rates and reduce child restraint misuse.     

Teaching infant car seat installation via interactive visual presence: An experimental trial

Objective: A large portion of child restraint systems (car seats) are installed incorrectly, especially when first-time parents install infant car seats. Expert instruction greatly improves the accuracy of car seat installation but is labor intensive and difficult to obtain for many parents. This study was designed to evaluate the efficacy of 3 ways of communicating instructions for proper car seat installation: phone conversation; HelpLightning, a mobile application (app) that offers virtual interactive presence permitting both verbal and interactive (telestration) visual communication; and the manufacturer's user manual.

Methods: A sample of 39 young adults of child-bearing age who had no previous experience installing car seats were recruited and randomly assigned to install an infant car seat using guidance from one of those 3 communication sources.

Results: Both the phone and interactive app were more effective means to facilitate accurate car seat installation compared to the user manual. There was a trend for the app to offer superior communication compared to the phone, but that difference was not significant in most assessments. The phone and app groups also installed the car seat more efficiently and perceived the communication to be more effective and their installation to be more accurate than those in the user manual group.

Conclusions: Interactive communication may help parents install car seats more accurately than using the manufacturer's manual alone. This was an initial study with a modestly sized sample; if results are replicated in future research, there may be reason to consider centralized “call centers” that provide verbal and/or interactive visual instruction from remote locations to parents installing car seats, paralleling the model of centralized Poison Control centers in the United States.     

Assessing tether anchor labeling and usability in pickup trucks

Objective: The objective of this study was to investigate vehicle factors associated with child restraint tether use and misuse in pickup trucks and evaluate 4 labeling interventions designed to educate consumers on proper tether use.

Methods: Volunteer testing was performed with 24 subjects and 4 different pickup trucks. Each subject performed 8 child restraint installations among the 4 pickups using 2 forward-facing restraints: a Britax Marathon G4.1 and an Evenflo Triumph. Vehicles were selected to represent 4 different implementations of tether anchors among pickups: plastic loop routers (Chevrolet Silverado), webbing routers (Ram), back wall anchors (Nissan Frontier), and webbing routers plus metal anchors (Toyota Tundra). Interventions included a diagram label, Quick Response (QR) Code linked to video instruction, coordinating text label, and contrasting text tag.

Results: Subjects used the child restraint tether in 93% of trials. However, tether use was completely correct in only 9% of trials. An installation was considered functional if the subject attached the tether to a tether anchor and had a tight installation (ignoring routing and head restraint position); 28% of subjects achieved a functional installation. The most common installation error was attaching the tether hook to the anchor/router directly behind the child restraint (near the top of the seatback) rather than placing the tether through the router and attaching it to the anchor in the adjacent seating position. The Nissan Frontier, with the anchor located on the back wall of the cab, had the highest rate of correct installations but also had the highest rate of attaching the tether to components other than the tether anchor (seat adjustor, child restraint storage hook, around head restraint). None of the labeling interventions had a significant effect on correct installation; not a single subject scanned the QR Code to access the video instruction. Subjects with the most successful installations spent extensive time reviewing the vehicle manuals.

Conclusion: Current implementations of tether anchors among pickup trucks are not intuitive for child restraint installations, and alternate designs should be explored. Several different labeling interventions were ineffective at achieving correct tether use in pickup trucks.     

Usability of non-standard lower anchor configurations for child restraint system (CRS) installation

Abstract

Objectives: The objective of this study was to determine whether the amount of tension required for proper child restraint system (CRS) installation varies with lower anchor spacing and to determine whether nonexperts can produce adequate tension on wider-than-standard lower anchor configurations.

Methods: CRSs were installed by certified child passenger safety technicians (CPSTs; n?=?6 subjects, n?=?72 installations) and nonexperts (n?=?30 subjects, n?=?120 installations) on a mock-up vehicle seat fixture with lower anchors set at 11 (standard), 15, 19, and 23 in. apart from one another. Each CPST installed a rear-facing (RF) infant base, RF convertible, and forward-facing (FF) convertible into each of the 4 spacing configurations in random order. The CPSTs were instructed to tighten the lower connector strap until the tension was exactly at the threshold between passing and failing the 1-in. test. Each nonexpert installed one CRS model into all 4 spacing conditions in random order. Nonexperts were instructed to install the CRS to the best of their ability. The tension produced on the lower connector strap was recorded via load cell in the lower anchor assembly of the vehicle seat. Resultant tension magnitudes were compared across spacing conditions using matched pair t-tests. The CPSTs’ mean 1-in. test threshold values were compared to tensions produced by nonexperts. Installations were visually evaluated for errors and qualitative usability feedback was collected via survey.

Results: CPSTs installed the infant base with higher tensions in the 15-, 19-, and 23-in. configurations compared to the standard 11-in. configuration (P = .034, .032, and .003, respectively). The nonexperts installed the infant base with higher tension in the 15- and 23-in. configurations compared to the 11-in. configuration (P = .004 and .026, respectively). The RF convertible and FF convertible installations showed no significant differences in tension among any of the spacing configurations for either group. Only 19% of the nonexperts’ installations were tight enough to pass CPST thresholds, and the pass rate did not vary with respect to lower anchor spacing. In feedback surveys, the nonexpert group did not show a consistent preference for either standard or wider-than-standard lower anchor configurations.

Conclusions: The amount of tension required to pass the 1-in. rule did not vary with lower anchor spacing configurations for the RF and FF convertible CRS, but the infant base required more tension in wider anchor configurations. Nonexperts tended to produce less than ideal tension in all configurations, although their tension magnitudes increased for the infant base in wider configurations.     

Reasons for Child Passenger Nonrestraint in Motor Vehicles

Objective: Although child passenger restraint use in motor vehicles has increased, there is an important minority of children who remain unrestrained. The goal of this study was to identify the frequency of and under what circumstances parents keep their children unrestrained.

Methods: A cross-sectional, online survey was distributed to parents and caregivers of children 10 years old and younger. Survey participants were asked about child restraint practices, including frequency of and reasons for nonuse of restraints. Parents were specifically asked how acceptable it would be to keep their child unrestrained in certain situations.

Results: One thousand two hundred eighty-five parents and guardians responded to the survey and 1,002 completed it; 23.8% (95% confidence interval [CI], 21.3–26.6%) of respondents said they had driven with their child not fully restrained on at least one occasion. Approximately 1 in 5 parents strongly or somewhat agreed that it would be acceptable to keep their child unrestrained in certain situations, including a short drive, in a rush, an inadequate number of restraints, riding in a taxi, if somebody was holding the child, and as a reward for a child. Parents were more likely to agree that it was acceptable to keep their child unrestrained under nearly all circumstances listed if they were male, ages 18–29, with a graduate school education, in the $100,000+ income bracket, or Latino.

Conclusions: There are certain situations for which parents find it acceptable to leave their children unrestrained. This has implications for targeted child passenger safety efforts designed to maximize consistent restraint use.     

Child restraint use and parental perceptions of comfort

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

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

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

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

Evaluating the Effect of a Mechanical Adjunct to Improve the Installation of Child Restraint Systems to Vehicles

Objectives: We explored if an alternative CRS design that utilized a mechanical adjunct to amplify the force applied to the adult seat belt (intervention CRS) results in more accurate and secure attachment between the CRS and the vehicle compared to similar CRS models that use LATCH or the existing adult seat belt. We conducted three separate studies to address this question and additionally explored: (1) the contribution of prior CRS installation experience (Study 1), (2) the value-added of CRS labeling (Study 2), and (3) paper-based vs. video instructions (Study 3).

Methods: In Studies 1 and 2 we assessed a forward facing combination CRS design (intervention CRS) compared to a commercially available LATCH equipped model (control CRS) and in Study 3 we conducted a similar study using a convertible model of both the intervention and control CRS. Participants installed both CRS in a contemporary minivan and could choose which type of attachment to use for the control CRS (LATCH or seat belt); order of installation was counter-balanced. Evaluators systematically examined installations for accuracy and security.

Results: Study 1: A greater proportion of participants in both the experienced and inexperienced groups was able to securely install the intervention CRS compared to the control CRS: (45% vs. 16%, p =.0001 for experienced) and (37% vs. 6%, p =.003 for inexperienced). No differences between the CRS were observed for accuracy of installation in either user group. Study 2: A greater proportion of participants were able to securely install the enhanced intervention CRS compared to the control CRS: (62% vs. 9%, p =.001). The intervention CRS demonstrated reduced installation accuracy: (30% vs. 61%, p =.001). Study 3: A greater proportion of participants was able to securely install the intervention CRS compared to the control CRS: 79% vs. 66% p =.03, but this effect was smaller than in the previous studies. Participants were less likely to achieve an accurate installation with the intervention CRS compared to the control CRS: 54% vs. 79%, p =.004. Common accuracy errors in each study included twisting or misrouting the seatbelt when installing the intervention CRS.

Conclusions: Our results suggest that novel CRS designs that utilize mechanical advantage to facilitate attachment of the CRS to the vehicle result in a tighter installation compared to LATCH equipped models, but an increase in accuracy errors occurred.     

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

Objectives: The objective of the study is to determine whether specific child restraint system (CRS) or vehicle conditions improve top tether attachment rates during volunteer installations.

Methods: A factorial randomized controlled trial was designed to evaluate 4 different experimental categories: (1) Color of tether adjuster casing (black or red), (2) labeling on tether adjuster casing (labeled with “Tether: Use for forward-facing” or unlabeled), (3) storage location of tether (bundled in a rubber band on the back of CRS or Velcroed over the forward-facing belt path), and (4) labeling in vehicle (labeled under head restraint and below anchor or unlabeled). Ninety-six volunteers were randomly assigned to one combination of conditions. One installation per volunteer was completed. The primary outcome measure was acceptable attachment of the top tether to the tether anchor. The secondary outcome measure was overall secureness of the installation. Pearson’s chi-square tests were used to identify significant predictors of acceptable outcomes and logistic regression was used to investigate interaction effects.

Results: A total of 66/96 subjects (68.8%) attached the top tether in an acceptable manner, with either zero errors (n?=?50) or minor errors (n?=?16). A total of 30/96 subjects (31.2%) had unacceptable tether outcomes, with either major errors (n?=?10) or nonuse the tether at all (n?=?20). None of the 4 experimental categories significantly affected tether outcomes. Subjects who opted to install the CRS with the lower anchors (LAs) had higher rates of acceptable tether attachment compared to subjects who installed using the seat belt or those who used both LA and seat belt together (χ² = 6.792, P = .034). Tether outcomes were not correlated with previous CRS experience, use of instruction manual(s), age, or sex. Only 15.6% of subjects produced overall correct and tight installations. Of those who used the seat belt in some manner, 70.2% neglected to switch the retractor into locking mode.

Conclusions: Conditions in this study including tether color, tether labeling, storage location, and vehicle labeling did not significantly affect tether attachment rates. High rates of tether misuse and nonuse warrant further exploration to find effective solutions to this usability problem.     

Improved protection for children in forward-facing restraints during side impacts

OBJECTIVE: This study aims to determine the potential for improved child occupant protection in side impacts that can be obtained using rigid and semi-rigid anchorage systems and the addition of energy-absorbing padding in the side structures of child restraints. METHODS: This study uses a comprehensive set of simulated side impacts to evaluate the potential for improved side impact protection in forward-facing child restraints. Factors investigated included methods of anchoring the restraint to the vehicle, energy-absorbing materials in the side structure of restraints, and design features of the restraints such as side wing geometry and seat belt routing. RESULTS: The results show clearly that completely rigid lower attachment of restraints offers the potential for great reductions in head injury risk, which anchorage systems employing a combination of a rigid anchorage bar and webbing attached to a child restraint cannot match. The addition of energy absorbing material in the side structure of restraint systems is effective when the head is fully contained within an adequately designed side wing structure. For restraints anchored by seat belts and loop style semi rigid anchorage straps, belt routing has the potential to significantly affect occupant head excursion. CONCLUSIONS: The results suggest that current child restraint standards and consumer testing protocols do not adequately encourage best practice design of child restraints for side impact protection.     

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.     

Occupant restraint use in Canada

Legislation regarding seat belt use in Canada is a provincial/territorial responsibility. Each of the 13 jurisdictions has enacted legislation and set the penalties regarding non-use of seat belts and appropriate child restraint systems. The federal government regulates occupant restraint systems and child restraints. In addition, Transport Canada (TC) gathers annual survey data on the use of seat belts and child restraints on Canadian roads and provides research support. National coordination toward the Canadian Road Safety Vision 2010 goal of a 40% reduction in fatalities and serious injuries related to non-belt/child restraint use and a 95% restraint usage rate is provided by the Canadian Council of Motor Transport Administrators' (CCMTA) National Occupant Restraint Program (NORP). The paper examines the history of legislation, provincial/territorial penalties, NORP, and TC involvement in promoting the use of occupant restraints.     

Investigation of Child Restraint System (CRS) Compatibility in the Vehicle Seat Environment

Objective: Child restraint system (CRS) misuse is common and can have serious consequences to child safety. Physical incompatibilities between CRS and vehicles can complicate the installation process and may worsen CRS misuse rates. This study aims to identify the most common sources of incompatibility between representative groups of CRS and vehicles.

Methods: Detailed dimensional data were collected from 59 currently marketed CRS and 61 late model vehicles. Key dimensions were compared across all 3,599 theoretical CRS/vehicle combinations and the most common predicted incompatibilities were determined. A subset of 34 physical installations was analyzed to validate the results.

Results: Only 58.2% of rear-facing (RF) CRS/vehicle combinations were predicted to have proper agreement between the vehicle's seat pan angle and the CRS manufacturers’ required base angle. The width of the base of the CRS was predicted to fit snugly between the vehicle's seat pan bolsters in 63.3% of RF CRS/vehicle combinations and 62.2% of forward-facing (FF) CRS/vehicle combinations. FF CRS were predicted to be free of interaction with the vehicle's head restraint in 66.4% of combinations. Roughly 90.0% of RF CRS/vehicle combinations were predicted to have enough horizontal clearance space to set the front seat in the middle its fore/aft slider track. Compatibility rates were above 98% regarding the length of the CRS base compared to the length of the vehicle seat pan and the ability of the top tether to reach the tether anchor. Validation studies revealed that the predictions of RF CRS base angle range vs. seat pan angle compatibility were accurate within 6%, and head restraint interference and front row clearance incompatibilities may be more common than the dimensional analysis approach has predicted.

Conclusions: The results of this study indicate that RF CRS base angles and front row clearance space, as well as FF CRS head restraint interference, are frequent compatibility concerns. These results enable manufacturers, researchers, and consumers to focus their attention on the most relevant CRS/vehicle incompatibility issues in today's market.     

Variations in booster seat use by child characteristics

IntroductionChild weight and height are the basis of manufacturer and best practice guidelines for child restraint system use. However, these guides do not address behavioral differences among children of similar age, weight, and height, which may result in child-induced restraint use errors. The objective of this study was to characterize child behaviors across age in relation to appropriate restraint system use during simulated drives. Methods: Fifty mother–child (4–8 years) dyads completed an installation into a driving simulator, followed by a simulated drive that was video-recorded and coded for child-induced errors. Time inappropriately restrained was measured as the total amount of the simulated drive spent in an improper or unsafe position for the restraint to be effective divided by the total drive time. Kruskal-Wallis tests were used to determine differences across age in the frequency of error events and overall time inappropriately restrained. Results: Children in harnessed seats had no observed errors during trips. Within children sitting in booster seats there were differences in time inappropriately restrained across age (p = 0.01), with 4 year-olds spending on average 67% (Median = 76%) of the drive inappropriately restrained, compared to the rest of the age categories spending less than 28% (Medians ranged from 3% to 23%). Conclusion: Some children may be physically compatible with booster seats, but not behaviorally mature enough to safely use them. More research is needed that examines how child behavior influences child passenger safety. Practical Applications: Not all children physically big enough are behaviorally ready to use belt positioning booster seats. Primary sources of information should provide caregivers with individualized guidance about when it is appropriate to transition children out of harnessed seats. Additionally, best practice guidelines should be updated to reflect what behaviors are needed from children to safely use specific types of child restraint systems.     

Discordance between age- and size-based criteria of child passenger restraint appropriateness

Objectives: In this study, we sought to accomplish the following objectives: to (1) calculate the percentage of children considered appropriately restrained across 8 criteria of increasing restrictiveness; (2) examine agreement between age- and size-based appropriateness criteria; (3) assess for changes in the percentage of children considered appropriately restrained by the 8 criteria between 2011 (shortly after updates to U.S. guidelines) and 2015.

Methods: Data from 2 cross-sectional surveys of 928 parents of children younger than 12 years old (n = 591 in 2011, n = 337 in 2015) were analyzed in 2017. Child age, weight, and height were measured at an emergency department visit and used to determine whether the parent-reported child passenger restraint was considered appropriate according to 8 criteria. Age-based criteria were derived from Michigan law and U.S. guidelines. Weight, height, and size-based criteria were derived from typical restraints available in the United States in 2007 and 2011. The percentage appropriate restraint use was calculated for each criterion. The kappa statistic was used to measure agreement between criteria. Change in appropriateness from 2011 to 2015 was assessed with chi-square statistics.

Results: Percentage appropriate restraint use varied from a low of 19% for higher weight limits in 2011 to a high of 91% for Michigan law in 2015. Agreement between criteria was slight to moderate. The lowest kappa was for Michigan law and higher weight limits in 2011 (κ = 0.06) and highest for U.S. guidelines and lower weight limits in 2011 (κ = 0.60). Percentage appropriate restraint use was higher in 2015 than 2011 for the following criteria: U.S. guidelines (74 vs. 58%, P < .001), lower weight (57 vs. 47%, P = .005), higher weight (25 vs. 19%, P = .03), greater height (39 vs. 26%, P < .001), and greater size (42 vs. 30%, P = .001).

Conclusions: The percentage of children considered to be using an appropriate restraint varied substantially across criteria. Aligning the definition of appropriate restraint use with current U.S. guidelines would increase consistency in reporting results from studies of child passenger safety in the United States. Potential explanations for the increased percentage of children considered appropriately restrained between 2011 and 2015 include adoption of the updated U.S. guidelines and the use of child passenger restraints with higher weight and height limits.     

Legislating child restraint usage -Its effect on self-reported child restraint use rates in a central city

Objective

To assess the effect of the newly enacted child passenger safety law, Wisconsin Act 106, on self-report of proper restraint usage of children in Milwaukee's central city population.

Method

A prospective, non-randomized study design was used. The settings used were (a) a pediatric urban health center, and (b) two Women, Infants and Children offices in Milwaukee, Wisconsin. Participants included 11,566 surveys collected over 18 months that spanned the pre-legislation and post-legislation time periods from February 2006 through August 2008.

Results

The study set out to assess appropriate child passenger restraint. The results showed that the changes in adjusted proper restraint usage rates for infants between the pre-law, grace period, and post-fine periods were 94%, 94%, and 94% respectively. For children 1-3 years old, the adjusted proper usage rates were 65%, 63%, and 59%, respectively. And for children 4-7 years old, the rates were 43%, 44% and 42%, respectively. There was a significant increase in premature booster seat use in children who should have been restrained in a rear- or forward-facing car seat (10% pre-law, 12% grace period, 20% post-fine; p < 0.0005). There was no statistically significant change over time in unrestrained children (2.1%, 1.7%, 1.7%, p = 0.7, respectively).

Conclusions

The passage of a strengthened child passenger safety law with fines did not significantly improve appropriate restraint use for 0-7 year olds, and appropriate use in 1-7 year olds remained suboptimal with a majority of urban children inappropriately restrained. Although the number of unrestrained children decreased, we identified an unintended consequence of the legislation - a significant increase in the rate of premature belt-positioning booster seat use among poor, urban children.

Impact on Industry

The design of child restraint systems maximizes protection of the child. Increasing reports of misuse is a call to those who manufacture these child passenger restraints to improve advertising and marketing to the correct age group, ease of installation, and mechanisms to prevent incorrect safety strap and harness placement. To ensure accurate and consistent use on every trip, car seat manufacturers must ensure that best practice recommendations for use as well as age, weight, and height be clearly specified on each child restraint. The authors support the United States Department of Transportation's new consumer program that will assist caregivers in identifying the child seat that will fit in their vehicle. In addition, due to the increase in premature graduation of children into belt-positioning booster seats noted as a result of legislation, promoting and marketing booster seat use for children less than 40 pounds should not be accepted. Child passenger safety technicians must continue to promote best practice recommendations for child passenger restraint use and encourage other community leaders to do the same.     

Predictors of restraint use among child occupants

Objectives: The objective of this study was to identify factors that predict restraint use and optimal restraint use among children aged 0 to 13 years.

Methods: The data set is a national sample of police-reported crashes for years 2010–2014 in which type of child restraint is recorded. The data set was supplemented with demographic census data linked by driver ZIP code, as well as a score for the state child restraint law during the year of the crash relative to best practice recommendations for protecting child occupants. Analysis used linear regression techniques.

Results: The main predictor of unrestrained child occupants was the presence of an unrestrained driver. Among restrained children, children had 1.66 (95% confidence interval, 1.27, 2.17) times higher odds of using the recommended type of restraint system if the state law at the time of the crash included requirements based on best practice recommendations.

Conclusions: Children are more likely to ride in the recommended type of child restraint when their state's child restraint law includes wording that follows best practice recommendations for child occupant protection. However, state child restraint law requirements do not influence when caregivers fail to use an occupant restraint for their child passengers.     

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.     

Association between driver and child passenger restraint: Analysis of community-based observational survey data from 2005 to 2019

Introduction: Crash data suggest an association between driver seatbelt use and child passenger restraint. However, community-based restraint use is largely unknown. We examined the association between driver seatbelt use and child restraint using data from a state-wide observational study. Methods: Data from Iowa Child Passenger Restraint Survey, a representative state-wide survey of adult seat belt use and child passenger safety, were analyzed. A total of 44,996 child passengers age 0–17 years were observed from 2005 to 2019. Information about driver seatbelt use and child restraint was directly observed by surveyors and driver age was reported. Logistic regression was used to examine the association between driver seatbelt use and child restraint adjusting for vehicle type, community size, child seating position, child passenger age, and year. Results: Over the 15-year study period, 4,114 (9.1%) drivers were unbelted, 3,692 (8.2%) children were completely unrestrained, and another 1,601 (3.6%) children were improperly restrained (analyzed as unrestrained). About half of unbelted drivers had their child passengers unrestrained (51.8%), while nearly all belted drivers had their child passengers properly restrained (92.3%). Compared with belted drivers, unbelted drivers had an 11-fold increased odds of driving an unrestrained child passenger (OR = 11.19, 95%CI = 10.36, 12.09). The association between driver seatbelt use and child restraint was much stronger among teenage drivers. Unbelted teenage drivers were 33-fold more likely (OR = 33.34, 95%CI = 21.11, 52.64) to have an unrestrained child passenger. Conclusion: These data suggest that efforts to increase driver seatbelt use may also have the added benefit of increasing child restraint use. Practical applications: Enforcement of child passenger laws and existing education programs for new drivers could be leveraged to increase awareness of the benefits of seatbelt use for both drivers themselves and their occupants. Interventions aimed at rural parents could emphasize the importance of child safety restraints.     

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

ProblemChild 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.MethodsThis 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.ResultsOf 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.ConclusionsThe 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 ApplicationsThe 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.