Evaluation of an Education, Restraint Distribution, and Fitting Program to Promote Correct Use of Age-Appropriate Child Restraints for Children Aged 3 to 5 Years: A Cluster Randomized Trial

摘要

Objectives. We evaluated an education, distribution, and fitting program for increasing age-appropriate and correct child restraint use. Methods. We performed a cluster randomized trial involving 28 early childhood education centers in low socioeconomic status areas in Sydney, Australia. The main outcome was optimal restraint use defined as age-appropriate restraints, installed into the vehicle correctly and used correctly. Results. One service withdrew after randomization, so data are presented for 689 child passengers, aged 3 to 5 years, from 27 centers. More children attending intervention centers were optimally restrained (43% vs 31%; P =?.01; allowing for clustering). More 3-year-olds were using forward-facing seats rather than booster seats, more 4- to 5-year-olds were using booster seats instead of seat belts alone, and there were fewer errors in use at intervention centers. Among non–English-speaking families, more children attending intervention centers were optimally restrained (43% vs 17%; P =?.002; allowing for clustering). Conclusions. The program increased use of age-appropriate restraints and correct use of restraints, which translates to improved crash injury protection. Multifaceted education, seat distribution, and fitting enhanced legislation effects, and the effect size was larger in non–English-speaking families. Injury in road traffic crashes is a major cause of death and disability in children. In the United States each year more than 800 children younger than 10 years are killed, 1 and many more are seriously injured as passengers in road crashes. Although restraint systems appropriate for a child’s size are proven to reduce crash injury, 2–5 best-practice child restraint use continues to be low. 6–8 Reductions in fatalities and serious injuries are possible through increasing both age-appropriate restraint use and correct use of these systems. 5 Legislation has an important role 9,10 and in 2009 the Australian Road Rules were changed, specifying different restraint systems by age for children aged up to 7 years. 11 However, achieving widespread best-practice child restraint use requires education and restraint distribution programs. 12 Furthermore, legislation has been shown to be less effective in low-income and minority groups. 13 Among the few well-designed studies that have evaluated community-based programs to increase child restraint use, success has been mixed. 9,10,14 To our knowledge, no study has investigated the impact of such programs on correct installation and securing of the child within the restraint, which is critical for performance of a child restraint system. 15 We developed a multifaceted program aimed at enhancing legislative effects to increase best-practice child restraint use and used a cluster randomized trial to evaluate the program. Cluster randomized trials are well suited to evaluation of injury prevention initiatives that are typically delivered to groups or communities. This design recognizes that there are societal norms for child restraint use and that peers can influence behavior.