Roadside observation of child passenger restraint use

Roadside observation of child passenger restraint use
Beth Bruce 1*, Camille Cramm 1, Kim Mundle 2, Devon P. Williams 3, Andrew Conrad 4
1 Faculty of Health Professions, Dalhousie University, Halifax, Canada 2 IWK Health Centre for Women and Children, Halifax, Canada
3 Hospital for Sick Children, Toronto, Canada 4 Halifax Regional Police Headquarters, Halifax, Canada
Abstract
Background: Despite legislation and research evidence supporting the use of childhood vehicle restraints,
motor vehicle crashes remain the leading cause of injury, death and disability among Canadian children.
Methods: Working in collaboration with trained car seat specialists and police officers, roadside checks were
conducted to observe correct use of child restraints.
Results: Of the 1323 child vehicle restraints inspected, 99.6% of the children were restrained, 91% were in
the correct seat, and 48% of restraints were correctly installed. The seat/restraint types most used incorrectly
used were booster seats (31%) and seat belts (53%). The majority of incorrectly installed or fitted seats
(55%) were forward facing. Common errors in installation and fit included the seat not being secured tightly
enough to the vehicle, incorrect tether strap use, the harness not being tight enough, and/or the chest clip
being in the wrong place.
Conclusions: The greatest proportion of incorrect seat use was among those children who transitioned to a
seat belt too soon. The greatest proportion of installation and fit errors were among forward facing seats.
Researchers recommend: 1) targeting parents with older children (ages 3 and above) regarding transitioning
too soon from forward facing seats to booster seats, and from booster seats to seat belts; 2) targeting parents
with younger children regarding correct installation of rear facing and forward facing seats; 3) collaborating
with police officers to review the most common errors and encourage observation at roadside checks; and 4)
creating community awareness by way of roadside checks.
Citation: Bruce B, Cramm C, Mundle K, Williams DP, Conrad A (2015) Roadside observation of child passenger restraint use. Adv
Pediatr Res 2:24. doi:10.12715/apr.2015.2.24
Received: March 23, 2015; Accepted: August 13, 2015; Published: October 20, 2015
Copyright: © 2015 Bruce et al. This is an open access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Competing interests: The authors have declared that no competing interests exist.
Funding sources: The AUTO21 Network Centre of Excellence (Grant A301-ACA) provided funding for this study to BB.
*
Email: [email protected]
[2]. According to Weber [3], the correct use of such
restraint systems could reduce children’s risk of death
in a motor vehicle collision by as much as 74%, with
the chance of serious injury diminishing by 67%.
Unfortunately, the most recent Transport Canada
survey indicates that Canada fell short of this goal,
with the rate of children’s use of restraint systems at
only 91.4% of the population [4]. Although
significant progress has been made in attempts to
reduce the rates of death and serious injury, children
Introduction
While research and legislation continues to support
the use of children’s vehicle restraint systems, motor
vehicle collisions remain the primary cause of death
and serious injury for Canadian children under the
age of 9 years [1]. In an effort to reduce the number
of unrestrained motor vehicle occupant deaths and
injuries by 40%, the Canadian Road Safety Vision
2010 hoped to achieve a rate of seat belt and proper
child vehicle restraint use of 95% by the year 2010
Advances in Pediatric Research
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Bruce et al. 2015 | 2:24
will continue to travel in motor vehicles therefore the
potential for crashes remains imminent [5].
benefits of safety seats during a crash [12, 15]. In the
1980s, a seat belt enforcement program was devised
in the US with an emphasis on the health and safety
benefits of wearing seat belts. The police used a
warning approach prior to issuing tickets, in addition
to many seat belt checkpoints conducted during the
three-week program. Front seat belt use increased
from 69% to 90%. Public opinion surveys indicated
that 79% supported the campaign, suggesting that a
high intensity enforcement program can both increase
rates of seat belt use and gain the support of the
community [16]. More recently, Istre et al. used a
multifaceted community approach that included
roadside observations to improve the use of children’s
restraint systems [17]. Simpson et al. determined that
roadside inspections are one of the best methods for
accurate data collection on restraint system use [18].
Child safety restraints are used for the purpose of
reducing the risk of injury and death from motor
vehicle collisions [6]. There are four stages of child
restraint systems recommended by Transport Canada
that include rear facing, forward facing, booster seats
and seat belts [7]. They are designed to decrease the
risk of ejection from the vehicle, to limit and help
better distribute forces from the crash on the
occupant, and secure the occupant to reduce contact
with structures in the interior of the vehicle [5].
Optimal performance of child vehicle restraint
systems depends on a proper fit between the seat and
its occupant at the time of the crash, and the use of
the seat according to the manufacturer’s instructions
[5, 6]. Kahane [6] identified three different levels of
restraint system misuse, labeling them “correct use”,
“partial misuse”, and “gross misuse”. While correct
use implies that safety benefits will not be
compromised with correct installation and fit, even
partially misused seats can provide benefits if the
crash is not too severe, potentially reducing injuries
by 48% and fatalities by 44% [6]. However, grossly
misused seats provide virtually no more protection or
prevention of death or serious injury than having no
restraint at all. Furthermore, the value of partially
misused seats decreases dramatically in front-on
crashes above 48 km/hr in velocity [6]. In an
observational study of over 5000 children traveling in
vehicles in the United States, some form of
installation or fit error was reported for almost three
quarters of the seats [8, 9]. The most common errors
observed were loose harness straps and the seat not
being installed tightly enough to the vehicle when
using the seat belt as an attachment method [8, 9].
Not having the seat firmly secured to the vehicle, as
well as not having the child firmly secured in the
restraint system, can independently result in excessive
movement of the child during a crash, increasing the
risk
of
potentially
fatal
injuries.
[5].
There are many factors that can influence the decision
to both use and take the time to properly use child
restraint systems. Drawing from literature on booster
seat use, both legislation and consistent law
enforcement have been shown to affect parents’
decisions to use safety seats [4, 10–14]. An additional
important factor is knowledge of the risk reduction
Advances in Pediatric Research
The purpose of the present study was to determine the
rates of use and misuse of child vehicle restraint
systems by Nova Scotia drivers. This was done in
collaboration with regional police departments and
the Royal Canadian Mounted Police (RCMP) by
randomly creating roadside checkpoints where child
vehicle restraints could be inspected by certified child
seat technicians.
Methods
Participants
Participants were drivers of motor vehicles traveling
with child passengers throughout the province of
Nova Scotia. Data were collected on a total of 1318
child vehicle restraints, with the children ranging in
age from 1 month to 15 years. The types of vehicle
restraints inspected included rear facing and forward
facing seats, booster seats, and seat belts. All drivers
who entered the checkpoint inspection area were
offered a vehicle restraint check for their children;
however, only those who consented to provide the
child’s age, weight and height for data collection
were included in the study results. Restraint
inspection data were only included in the results if the
child was present at the time of seat inspection, since
this
allowed
technicians
to
address
the
appropriateness and fit of the vehicle restraint for
each individual child. Seat inspections were also
offered to those drivers with child seats but no
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Bruce et al. 2015 | 2:24
children present, although no data were collected on
these restraints for analysis.
correct seat, and the proportion of seats correctly
installed.
Procedure
Results
Data collection took place at 33 roadside checkpoints
scheduled in conjunction with regional police
departments and the RCMP at 27 different random
sites throughout urban and rural Nova Scotia. All
subjects were stopped by police officers at the
roadside checkpoint, where they were then invited to
have their child’s vehicle restraint inspected by
certified car seat technicians at a designated parking
lot or side street nearby. If a child was unrestrained,
police officers required the driver to appropriately
restrain the child, either with their own restraint
system or one provided by the team. Technicians
completed a brief inspection of each child vehicle
restraint, correcting any installation or fit errors
noted, and providing education and recommendations
to drivers as appropriate. Any seats deemed
unsuitable, damaged or unsafe for the child were
replaced with a new one. Drivers also received a
postcard to take home detailing information on the
recommended and legal stages of vehicle restraints
for child passenger safety. For those drivers who
agreed to participate in the study, technicians and
research assistants recorded the details of each
inspection, and documented the children’s age,
weight and height. Technicians looked for whether
the child was seated in the vehicle, if the seat used
was appropriate for the child’s age, weight and
height, and whether the seat was legal for use in
Canada or past its expiry date. The installation of the
seat was inspected, noting things such as whether the
seat was tightly secured to the vehicle, if an
appropriate securing system was used (i.e. seat belt or
Universal Anchorage System [UAS]), and, for
forward facing seats, if the top tether anchor was in
use. Finally, technicians examined whether the child
was properly fitted in the restraint, noting whether the
correct strap height and chest clip placement were
used, if the harness straps were snug, or, for children
in a booster or vehicle seat, if the seat belt fit the child
appropriately. Descriptive data analysis was
conducted using means and frequency counts to
describe the proportion of children restrained in a
Of the 1323 children observed (Table 1), 99.6% were
restrained in the vehicle with some form of restraint
(i.e. were at least using the vehicle seat belt), with
92% of children travelling in the back seat.
Advances in Pediatric Research
Table 1. Proportion of restraint inspections by seat category
Type of restraint
n
Percent (%)
Rear facing
190
14
Forward facing
494
38
Booster seat
459
35
Seat belt
175
13
Total
1318
100
A small proportion of seats inspected (4.5%) were
damaged or past their expiration dates. Replacements
were provided where the expiry date had passed, or if
the seat was incorrect for the child using it. The use
of incorrect seats was evenly distributed throughout
both rural and urban areas. An overall incorrect
installation and usage rate of 53% was observed
throughout the roadside checks, with the largest
proportion of installation errors occurring in the
forward facing car seat stage (Table 2). Of the
installation errors observed, 61% were seen in urban
areas, while 49% were observed in rural
communities.
The most common installation errors were the seat
not being tightly secured to the vehicle (32% of rear
facing seats, 36% of forward facing seats), and the
tether strap not being used properly with forward
facing seats (28%). The most common usage error
was the harness straps not being secured tightly
enough when the child was sitting in the restraint; this
was observed in 40% of rear facing seats and 46% of
forward facing seats. The chest clip was also
problematic with rear facing and forward facing seats:
28% of rear facing and 31% of forward facing
children observed did not have the chest clip at the
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Bruce et al. 2015 | 2:24
Discussion
proper armpit level. Of the booster seat and seat belt
users observed, fit concerns were primarily seen in
the seat belt category. Improper fitting lap belts
(24%) and shoulder belts (17%) were the key errors at
this stage.
Although close to 100% of children observed were
restrained in vehicles by at least a seat belt, it appears
that both correct installation and use of correct child
vehicle restraints continues to be an issue.
Children restrained in the incorrect seat stage for their
age, weight and height was seen throughout all four
stages [7]. Transport Canada recommends restraining
a child in rear facing, forward facing or booster seats
for as long as possible, until the child exceeds the
weight and height ranges for each restraint system
[19]. The majority of children observed in an unsafe
restraint category were those children using a seat
belt. In Nova Scotia, legislation rules that a child
should be at or above 145 cm, or at least 9 years of
age to use a seat belt. However, since adult seat belts
are designed for passengers over 145cm and best
practice recommends that children under 145 cm,
regardless of age, should be restrained in a booster
seat until they properly fit the adult seat belt restraint
in the vehicle [20]. While there are children currently
using seat belts who do not meet the legislative
requirements, there are many more who do not meet
the recommended best safety practice guidelines,
leaving many children at risk while travelling in a
vehicle. According to best practice recommendations,
almost 50% of children restrained in a seat belt would
be more safely restrained in a booster seat. This
finding suggests that most drivers comply with the
law, but may have little or no awareness of best
practice guidelines, or may choose to ignore best
practice.
Similarly,
children
inappropriately
restrained in a booster seat were found to have
transitioned too soon from a forward facing seat. The
current findings, although higher than previously
reported, are consistent with earlier reports that
school-age children between 4 and 8 years old have
the lowest rates of correct safety seat use, with reports
of booster seat use ranging from 20 to 40% among
Canadians [4]. These children were too small to be
safely protected in a crash, according to Nova Scotia
legal limits and best practices.
Table 2. Proportion of installation and usage errors per seat stage
Type of
restraint
n
Percent
overall
incorrect (%)
Percent
incorrect by
stage (%)
Rear facing
119
17
65
Forward
facing
379
55
79
Booster seat
134
20
30
Seat belt
53
8
31
Total
685
52
Nine percent of children were restrained in the
incorrect seat for their age, weight and height. The
majority of children who were in the wrong restraint
were observed in the seat belt category, followed by
those in booster seats (Table 3).
Table 3. Proportion of children restrained in the incorrect seat per
seat stage
Type of restraint
Percent (%)
Rear facing
1
Forward facing
16
Booster seat
31
Seat belt
52
Of the 60 children incorrectly restrained in a seat belt,
52% of these were both under 145 cm and under 9
years of age. This indicates that half of the children in
seat belts were non-compliant with provincial
legislation for child vehicle restraints. For those
children using a booster seat who should not have
been, 94% of these children weighed less than 18 kg,
which is the minimum legal limit to be safely
restrained in a booster seat.
Advances in Pediatric Research
Results are mirrored when taking a closer look at the
most common fit errors of those children observed
wearing only a seat belt. The most commonly seen
errors were: the lap belt not sitting properly on the
child’s thighs, or the shoulder belt not fitting properly
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Bruce et al. 2015 | 2:24
across the chest. These observations suggest that the
child is too small to be using only a seat belt, and
would be safer in a crash if using the appropriate seat
for their height and weight in order that the restraint
system could be properly positioned [21].
Researchers report that seat belts alone may result in
ejection, and even for the largest of children (over
145 cm) the fit of a seat belt may still be inadequate
[22]. Macy et al. discovered that 78% of drivers report
improper positioning of the seat and lap belts for 4–9year-old passengers, indicating that many children
using only seat belts would benefit from riding in
booster seats instead [23].
Opportunities exist to better inform parents, and
influence future legislation and enforcement that
could address these unsafe practices. Drawing from
the study findings, researchers recommend that
parents and caregivers of older children (aged 3 years
and above) be targeted with information to transition
their children safely and appropriately through the car
seat stages (i.e., from forward facing to booster seats
and booster seats to seat belts). Secondly, parents of
younger children should be targeted with specific
information on the proper installation and fit of their
child’s rear facing or forward facing restraints.
Furthermore, the benefits of restraining children in a
forward facing seat until they are greater than 18 kg,
and in a booster seat until they are taller than 145 cm
and properly fit an adult seat belt restraint, should be
reinforced with parents. Opportunities also exist to
approach policy makers to adopt legislation
supporting the recommended best practice of seat belt
use for children over 145 cm, regardless of the child’s
age. Providing education and awareness support to
police enforcement departments about the key
assessments of child restraint regulations can promote
police confidence in assisting families with proper
child vehicle restraint. Finally, the use of roadside car
seat checks in collaboration with police officers can
promote community awareness for child vehicle
safety, educate the public, and engage police officers
in promoting safe travel for children.
Rates of installation and fit error were most
prominent with forward facing restraints. The current
study observed an overall error rate of 53%, which is
lower than the 73% observed in a large US
observational study of 5000 seats [8, 9]. However, as
Kahane describes, even partially misused safety seats
can lose their effectiveness in head-on crashes at
speeds above 48 km/hr, putting the child occupant at
increased risk of injury [6]. Some of the most
common installation and fit errors observed were
consistent with those seen in the US, including an
insecure fit of the seat to the vehicle, and loose
harness straps, both of which increase the risk of the
child being ejected from the seat or the vehicle during
a crash [5, 8, 9]. These errors were observed with
both rear and forward facing seats, although rates of
error were higher for forward facing seats – perhaps
because parents and caregivers of infants and younger
children receive more guidance from health care
professionals early in their child’s life [24]. Bliston et
al. discovered a similar pattern to that found in the
present study, stating that older children and seat belt
users are more likely to correctly use restraints,
suggesting that younger children and their caregivers
need to be the target of education [25].
Acknowledgements
The researchers would like to thank the Halifax
Regional Police Department, Bridgewater Municipal
Police Department, and RCMP for their cooperation
and collaboration, as well as all of the child restraint
systems technicians who volunteered their time and
expertise.
Anecdotally, researchers discovered that both police
and the general community in rural and urban areas
were very receptive to the roadside car seat checks.
Police officers were seen to be proactively promoting
child passenger safety, rather than having a punitive
role, such as issuing tickets and fines. As with the
seat belt program in the US, it appears this
enforcement initiative was beneficial and well
supported by the community [16].
Advances in Pediatric Research
References
1.
2.
5
Parachute Canada. Car Seats. [updated ; accessed 2015
August
27].
Available
from:
http://www.parachutecanada.org/child-injuryprevention/item/child-passenger-restraints.
Canadian Council of Motor Transport Administrators
(CCMTA) [Internet]. National occupant restraint
program 2010: annual monitoring report 2010. Ottawa,
Bruce et al. 2015 | 2:24
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15. Will KE, Geller ES. Increasing the safety of children’s
vehicle travel: from effective risk communication to
behavior change. J Safety Res. 2004;35:263–274.
16. Williams AF, Wells JK, McCartt AT, Preusser DF.
“Buckle Up NOW!” An enforcement program to
achieve high seat belt use. J Safety Res. 2000;31:195–
201.
17. Istre GR, Stowe M, McCoy MA, Moore BJ, Culica D,
Womack KN, et al. A controlled evaluation of the WHO
Safe Communities model approach to injury prevention:
increasing child restraint use in motor vehicles. Inj Prev.
2011;17:3–8.
18. Simpson JC, Wren J, Chalmers DJ, Stephenson SC.
Examining child restraint use and barriers to their use:
lessons from a pilot study. Inj Prev. 2003;9:326–331.
19. Transport Canada [Internet]. Stage 2: forward-facing
seats [updated 2015 August 21; accessed 2015 Feb 9].
Available
from:
https://www.tc.gc.ca/eng/motorvehiclesafety/safedrivers
-childsafety-stage2-forward-facing-1085.htm.
20. Canadian Pediatric Society [Internet]. Position
Statement. Transportation of infants and children in
motor vehicles. [April 1 2008; accessed 2015 August
30].
Available
from:
http://www.cps.ca/documents/position/car-seat-safety
21. Fluit J. Design and implementation of a unique child
restraint enforcement and education project in Halton
Region. Proceedings of the 19th Canadian
Multidisciplinary Road Safety Conference; 2010 Jun 6–
9; Niagara Falls, Ontario, Canada.
22. Reed MP, Ebert-Hamilton SM, Klinich KD, Manary
MA, Rupp JD. Effects of vehicle seat and belt geometry
on belt fit for children with and without belt positioning
booster seats. Accid Anal Prev. 2013;50:512–22.
23. Macy ML, Reed MP, Freed GL. Driver report of
improper seat belt position among 4- to 9-year-old
children. Acad Pediatr. 2011;6:487–492.
24. Bull MJ, Durbin DR. Rear-facing car safety seats:
getting the message right. Pediatrics. 2008;121:619–620.
25. Bilston LE, Du W, Brown J. Factors predicting incorrect
use of restraints by children travelling in cars: a cluster
randomized observational study. Inj Prev. 2011;17:91–
96.
Ontario:
CCMTA;
2011.
Available
from:
http://ccmta.ca/images/publications/pdf/norp_report10.p
df.
Weber K. Crash protection for child passengers: a
review of best practice. UMTRI Res Rev [Internet].
2000;31:1–27.
Available
from:
http://www.umtri.umich.edu/content/rr31_3.pdf.
Snowdon AW, Hussein A, Ahmed E. Canadian national
survey on child restraint use 2010. Transport Canada
[Internet]. 2011 May [updated 2013 Dec 10; accessed
2014
Apr
24].
Available
from:
http://www.tc.gc.ca/eng/roadsafety/resourcesresearchstats-child-restraint-survey-2010-1207.htm.
Durbin DR, Committee on injury, violence, and poison
prevention. Child passenger safety. Pediatrics.
2011;127:788–93.
Kahane CJ. An evaluation of child passenger safety: the
effectiveness and benefits of safety seats. NHTSA report
number DOT HS 806 890. National Health
Transportation Safety Administration [Internet]. 1986
Feb [accessed 2014 Mar 8]. Available from:
http://www.nhtsa.dot.gov/cars/rules/regrev/evaluate/806
890.html.
Transport Canada [Internet]. Car Seats, Seat Belts and
your Child. [updated 2013 December 11; accessed 2015
August
27].
Available
from:
https://www.tc.gc.ca/eng/motorvehiclesafety/safedrivers
-childsafety-car-index-873.htm
Decina LE, Lococo KH. Child restraint system use and
misuse in six states. Accid Anal Prev. 2005;37:583–590.
Bulger EM, Kaufman R, Mock C. Childhood crash
injury patterns associated with restraint misuse:
implications for field triage. Prehosp Disaster Med.
2008;23:9–15.
Bruce BS, Snowdon AW, Cunningham C, Cramm CL,
Whittle K, Correale H, et al. Predicting parents’ use of
booster seats. Inj Prev. 2011;17(5):313–8.
Bingham CR, Ebay DW, Hockanson HM. Factors
influencing the use of booster seats: a state-wide survey
of parents. Accid Anal Prev. 2006;38:1028-1037.
Cunningham CE, Bruce BS, Snowdon AW, Chen Y,
Kolga C, Piotrowski C, et al. Modeling improvements in
booster seat use: a discrete choice conjoint experiment.
Accid Anal Prev. 2011;43(6):1999–2009.
Correale H, Clark E, Piotrowski CC, Warda L, Bruce B,
Cunningham CE. Injury prevention/child passenger
safety: factors influencing parents’ correct and
consistent use of booster seats. Inj Prev. 2010;16:A177.
Brown J, Burton D, Nikolin S, Crooks PJ, Hatfield J,
Bilston LE. A qualitative approach using an integrative
model of behaviour change to identify intervention
strategies to increase optimal child restraint practices
among culturally and linguistically diverse families in
New South Wales. Inj Prev. 2013;19(1):6–12.
Advances in Pediatric Research
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