Evaluation of the California Child Passenger Safety Initiative

1. Evaluation of the California Child Passenger Safety Initiative Jill Cooper, M.S.W.Kara E. MacLeod, M.A.David Ragland, Ph.D., M.P.H.UC Berkeley Traffic Safety Center Transportation Research Board January 12, 2005

2. Outline Background Child Passenger Safety Initiative Goals Intervention Evaluation Results Limitations Implications

3. Background Injuries remain leading cause of death/injury to children. CPS restraint use has increased dramatically in last 15-20 years; injuries/fatalities have decreased. Children of color/poor children have benefited less from CPS advances and face disproportionate risk.

4.  CA Children 0-6 Killed in Motor Vehicle Crashes - Percent UnrestrainedData source: SWITRS 1997-2002

5. Children at Risk Between 1987 and 2000, the smallest declines in the unintentional injury fatality rate were among American Indian/Alaskan Native (20%) and Black (36%) children, whose death rates due to unintentional injury were nearly twice that of white children. Poor children, many of whom are children of color, also face disproportionate risk, and they are twice as likely as higher-income children to die in motor vehicle crashes. Poor children are more likely to die from their injuries than children from higher income families. (Though these data refer to unintentional injury as a whole, motor vehicle crashes were the leading cause of fatal injuries among children in 2000.) (Though these data refer to unintentional injury as a whole, motor vehicle crashes were the leading cause of fatal injuries among children in 2000.)

6. CPSI To address the needs of �the children left behind� from safety advances Launched in 2002 for 18 months Partnership between CA Health Care Safety Net Inst.(a 501(c)3), UC Davis Medical Center The TSC was contracted with to evaluate the project Funded by CA OTS Evaluation at 3 health systems: Contra Costa, Monterey, San Joaquin

7. CPSI Goals To increase CPS use among families using selected public health care sites. To decrease the rate of CPS misuse among these families. 3. To increase awareness of the then-new CA �booster seat� law. Booster seat law � to require child restraints for children up to age 6 OR 60 lbs. Previously, law required use for children up to 4 AND 40 lbs. Certain loopholes exist for bigger children, older cars.Booster seat law � to require child restraints for children up to age 6 OR 60 lbs. Previously, law required use for children up to 4 AND 40 lbs. Certain loopholes exist for bigger children, older cars.

8. CPSI Intervention Focus on health care providers: ~10,000 restraints distributed to low-income families >6,600 low-income parents shown how to fit children into restraints 11,000 parents/caregivers educated about CPS >Almost 200 CPS check-ups held Focus on parents/guardians: >700 public health and children�s workers trained in CPS Focus on health systems: Development of hospital/health system protocols check-ups = trained observers provided technical assistance to parents about correct installation of child safety seats in vehicles. check-ups = trained observers provided technical assistance to parents about correct installation of child safety seats in vehicles.

9. CPSI Evaluation Quasi-Experimental Design with cross-sectional data collection before/after the interventions at sites to measure any changes in use, misuse and parental knowledge of law Interview and observational component Collaborative development of survey tool and study among TSC, sites, UCD and SNI.

10. Interview Parents/guardians asked about: the adult�s relationship to the children the children�s ages how the children usually traveled Knowledge of the �Booster Seat� Law their use of child safety restraints. Demographic information/no. of children present collected Interview conducted in English/Spanish The self-reported data was from drivers (parents, guardians, friends) transporting children to public health systems that day. The goal of the self-reported data was to gain information about use and knowledge among drivers from this population.The self-reported data was from drivers (parents, guardians, friends) transporting children to public health systems that day. The goal of the self-reported data was to gain information about use and knowledge among drivers from this population.

11. Observations Collected for parents/guardians who had traveled by private vehicle to the hospital or clinic on the day of the interview and who had children with them. Observers accompanied families to their vehicles and documented: vehicle types presence of air bags in the front passenger seats children�s ages and weights restraint types and location in vehicle and position of children in restraints and vehicle. CPS Coordinators, public health nurses, social workers, and outreach workers conducted the observations. CPS Coordinators were all CPS-certified technicians, as were most, but not all, of the other observers. When not certified technicians, they were trained to conduct the observations. The goal of this dat was to obtain info about overall restraint use and misuse of car and booster seats.CPS Coordinators, public health nurses, social workers, and outreach workers conducted the observations. CPS Coordinators were all CPS-certified technicians, as were most, but not all, of the other observers. When not certified technicians, they were trained to conduct the observations. The goal of this dat was to obtain info about overall restraint use and misuse of car and booster seats.

12. Population � Drivers and Children A majority of the drivers were parents (as opposed to guardians), Hispanic and between 25-34. About 1/3 of children were infants, almost � were 1-4 years, and about 20% were 4-6 years.

13. Knowledge of Booster Seat Law 79.4% of adults in �before� sample reported they knew about the new law. In �after� interviews, 75% reported they new about the law. (p<0.05) Law as of January 2002. A reason for this decrease might be that at the time of the pre-tests, there was significant media attention given to the law, and media attention subsequently declined in the period between the pre- and post-tests. Law as of January 2002. A reason for this decrease might be that at the time of the pre-tests, there was significant media attention given to the law, and media attention subsequently declined in the period between the pre- and post-tests.

14. Use: Self-reported vs. Observed Self-reported use did not change much between before and after (not statistically significant) Car seat use stayed at 83%; booster seat use dipped from 57-56%. However, observed use of car seats increased from 89-94% (p<0.05). Re self-reported use: Not much change, impact seen Car seat use matches use in general population in CA (per Betancourt�s 2002 survey) As in general population, use of car seats is greater than use of booster seats. As kids get older, they tend not to be in child restraints. Reasons for this population: they pass their seat down to younger siblings, less of a norm to put older kids in boosters, with multiple children (even 3), it is hard to fit all restraints in one car, structural issues with some older cars (e.g., no rear shoulder belts, which makes it impossible to use booster seat), etc. Observed use could be higher because the observations were conducted only for those families that traveled to the medical appt. by private vehicle that day and also could have been more mindful about healthy behaviors. Parents and guardians who either did not travel by vehicle or who do not own car seats or who do not regularly use car seats would have been included in the self-reported data, but not in the observational data. Difference between knowledge of law and self-reported use of boosters: while 75% of parents and guardians knew about the law, only about 56% reported use of booster seats for their own children age four or older or weighing 40 pounds. It is possible that while parents and guardians knew about the new law, they may not have been aware of the details, misunderstood the law, or had not implemented the provisions concerning restraint use for children over four years and 40 pounds. Further, although efforts were made to ensure that the parents or guardians in the post-intervention sample had already been exposed to the intervention offered, this could not be guaranteed, and adults in the post-intervention sample may have received little or none of the CPS program(s).Re self-reported use: Not much change, impact seen Car seat use matches use in general population in CA (per Betancourt�s 2002 survey) As in general population, use of car seats is greater than use of booster seats. As kids get older, they tend not to be in child restraints. Reasons for this population: they pass their seat down to younger siblings, less of a norm to put older kids in boosters, with multiple children (even 3), it is hard to fit all restraints in one car, structural issues with some older cars (e.g., no rear shoulder belts, which makes it impossible to use booster seat), etc. Observed use could be higher because the observations were conducted only for those families that traveled to the medical appt. by private vehicle that day and also could have been more mindful about healthy behaviors. Parents and guardians who either did not travel by vehicle or who do not own car seats or who do not regularly use car seats would have been included in the self-reported data, but not in the observational data. Difference between knowledge of law and self-reported use of boosters: while 75% of parents and guardians knew about the law, only about 56% reported use of booster seats for their own children age four or older or weighing 40 pounds. It is possible that while parents and guardians knew about the new law, they may not have been aware of the details, misunderstood the law, or had not implemented the provisions concerning restraint use for children over four years and 40 pounds. Further, although efforts were made to ensure that the parents or guardians in the post-intervention sample had already been exposed to the intervention offered, this could not be guaranteed, and adults in the post-intervention sample may have received little or none of the CPS program(s).

15. Observed Misuse � Car Seats Car seats include all types of restraints for infants and children <4 and <40 lbs: infant (rear-facing) seats, convertibles, forward facing, etc. Included types of misuse identified in the literature as �critical� forms of misuse. Besides gross misuse (e.g., seat not attached to car at all, or child not restrained in seat), the most common and critical forms of misuse that can increase the risk of injury include loose harness straps on the child or a loose seat belt securing the child restraint to the vehicle. Other common mistakes are incorrect use of chest clips, use of shoulder straps at an inappropriate ht, restraints inappropriate for age or wt. of the child (e.g., being advanced too quickly into the �next� type of restraint). To come up with the categories for misuse to study, we used the literature and worked with the hospital or health system sites. The CPS Coordinators there particularly interested in the above categories. We also studied placement of seat (in front or back) and presence of airbags (if seat were in the front) and shoulder belts. With regard to misuse, this paper reports on forms of misuse that are seen as particularly dangerous for children. The CPSI had an impact on these forms of misuse, an outcome that also leads to the assertion that the project should continue and be expanded. Car seats include all types of restraints for infants and children <4 and <40 lbs: infant (rear-facing) seats, convertibles, forward facing, etc. Included types of misuse identified in the literature as �critical� forms of misuse. Besides gross misuse (e.g., seat not attached to car at all, or child not restrained in seat), the most common and critical forms of misuse that can increase the risk of injury include loose harness straps on the child or a loose seat belt securing the child restraint to the vehicle. Other common mistakes are incorrect use of chest clips, use of shoulder straps at an inappropriate ht, restraints inappropriate for age or wt. of the child (e.g., being advanced too quickly into the �next� type of restraint). To come up with the categories for misuse to study, we used the literature and worked with the hospital or health system sites. The CPS Coordinators there particularly interested in the above categories. We also studied placement of seat (in front or back) and presence of airbags (if seat were in the front) and shoulder belts. With regard to misuse, this paper reports on forms of misuse that are seen as particularly dangerous for children. The CPSI had an impact on these forms of misuse, an outcome that also leads to the assertion that the project should continue and be expanded.

16. Misuse � Booster Seats

17. Limitations Population-based sample: Different samples before and after Different sites had different interventions Subjectivity: Many different people conducted interviews, observations

18. Implications Target underserved populations Integrate CPS into health care systems and continuing education efforts Use research to plan safety programs and injury patterns Pay attention to policy and advocacy Collaborate through multidisciplinary coalitions The results of this study suggest important areas for future work on child passenger safety. Research and experience from the field highlight barriers to use that, specifically, low-income people and people of color face in promoting child safety. To work so that all children see the positive impacts of child passenger safety efforts, it is crucial to target underserved populations, integrate CPS into health care systems and continuing education efforts, use research to plan safety programs and injury patterns, to pay attention to policy and advocacy, and collaborate through multidisciplinary coalitions. The results of this study suggest important areas for future work on child passenger safety. Research and experience from the field highlight barriers to use that, specifically, low-income people and people of color face in promoting child safety. To work so that all children see the positive impacts of child passenger safety efforts, it is crucial to target underserved populations, integrate CPS into health care systems and continuing education efforts, use research to plan safety programs and injury patterns, to pay attention to policy and advocacy, and collaborate through multidisciplinary coalitions.

19. Implications � cont�d Target underserved populations Eliminate cost and access barriers Focus on the most serious and common types of misuse Distribute safety seats free or through vouchers to families in need Hold hands-on workshops in multiple languages and through culturally-appropriate venues Focus on most serious injuries � because research has also shown that, even when misused, forward-facing child restraints still are effective in preventing serious injury. (Aside from gross misuse, �Any car seat better than no car seat?� Aiming for perfect fit among population with older cars and other numerous barriers is a �safety-defeating� proposition. There are numerous ways to misuse a car seat, and structural or technical (car or seat) barriers are only two of them. When dealing with a population which faces the structural, cultural, language barriers, it is critical to safety to focus on the MOST IMPORTANT elements for safe travel.Focus on most serious injuries � because research has also shown that, even when misused, forward-facing child restraints still are effective in preventing serious injury. (Aside from gross misuse, �Any car seat better than no car seat?� Aiming for perfect fit among population with older cars and other numerous barriers is a �safety-defeating� proposition. There are numerous ways to misuse a car seat, and structural or technical (car or seat) barriers are only two of them. When dealing with a population which faces the structural, cultural, language barriers, it is critical to safety to focus on the MOST IMPORTANT elements for safe travel.

20. Implications � cont�d Integrate CPS into health care systems and continuing education efforts Incorporate CPS programs into regular health care and health education services Incorporate CPS into education/training for health professionals who then can educate parents and guardians and promote outreach and car seat distributions to low-income families. Traffic injuries cost California $20 billion in 2000. Increasing children�s safety in vehicles can reduce emergency room and rehabilitation costs; hence, public health care systems can potentially benefit financially from good prevention programs. Unfortunately, prevention programs often fall prey to budget cuts, and child passenger safety programs are no exception. Public hospitals and health systems can support CPS efforts by incorporating CPS programs into regular health care and health education services and into education for health professionals who then can educate parents and guardians and promote outreach and car seat distributions to low-income families. Traffic injuries cost California $20 billion in 2000. Increasing children�s safety in vehicles can reduce emergency room and rehabilitation costs; hence, public health care systems can potentially benefit financially from good prevention programs. Unfortunately, prevention programs often fall prey to budget cuts, and child passenger safety programs are no exception. Public hospitals and health systems can support CPS efforts by incorporating CPS programs into regular health care and health education services and into education for health professionals who then can educate parents and guardians and promote outreach and car seat distributions to low-income families.

21. Implications � cont�d Use research to plan safety programs and injury patterns Comprehensive programs that include legislation, training, enforcement, and community-oriented strategies show promise. Evaluation of these programs, though, is essential. Recent research has focused on promising interventions to increase use of child restraints in vehicles among vulnerable populations. These, too, must be evaluated. Research injury patterns among children in MVC. The current study suggests that a program that a) developed protocols around CPS service delivery, b) reached out directly to vulnerable populations by coupling health care with health education, and c) established mechanisms for getting child safety seats into the hands of those who need them has been successful, overall, in increasing CPS use and decreasing misuse. This program may be a model intervention for helping to prevent motor vehicle injuries among children. Research is still needed to demonstrate efficacy, improve design of such programs, and facilitate implementation. The current study suggests that a program that a) developed protocols around CPS service delivery, b) reached out directly to vulnerable populations by coupling health care with health education, and c) established mechanisms for getting child safety seats into the hands of those who need them has been successful, overall, in increasing CPS use and decreasing misuse. This program may be a model intervention for helping to prevent motor vehicle injuries among children. Research is still needed to demonstrate efficacy, improve design of such programs, and facilitate implementation.

22. Implications � cont�d Pay attention to policy and advocacy Laws often provide the muscle behind educational and enforcement efforts to promote public health. According to NHTSA, good child-restraint laws: include guidelines for age/wt. of children; cover all seating positions in a vehicle; require all vehicles to have safety belts; contain provisions for enforcement; and eliminate exemptions. One area for potential advocacy for low-income populations: addressing the lack of booster seats manufactured for older cars that do not have shoulder belts.

23. Implications � cont�d Collaborate through multidisciplinary coalitions Health care leaders, law enforcement and traffic safety professionals, social workers, educators, business leaders, automobile and car seat manufacturers and retailers, and community members are all natural partners for child safety efforts. Child safety is and should be everyone�s business.

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