Evaluation
of Two
Comprehensive
Infant
Car
Seat
Loaner
Programs
with
1-Year
Follow-up
Edward
R. Christophersen,
PhD,
Deborah
Sosland-Edelman,
MA, and
Susan
LeClaire,
BA
From the Department of Pediatrics, University of Kansas Medical Center, Kansas City
ABSTRACT. Since the American Academy of Pediatrics instituted the “First Ride-Safe Ride” campaign, many
child passenger safety programs have reported that they
have achieved less than optimal results. The present
study compared two comprehensive programs for
encour-aging new parents to use child restraint devices consist-ently and correctly and compared the present results with
the results of a previous program that was conducted at
the same hospital. A total of 129 mother-newborn pairs
were randomly assigned to two groups. All of the partic-ipants had their babies at a hospital that had an
estab-lished car seat loaner program with strong support from
the medical staff, the nursing staff, and the hospital administration; the hospital was in a state that had a law mandating child restraint seat usage. One group was
exposed to the regular hospital program and the other
group had, in addition: a mock-up demonstration for the mothers on the correct method of fastening the baby into
the car seat and the car seat into the automobile seat;
written handouts of how to use a car seat with an infant;
a physician’s order for the mock-up demonstration; and a physician’s order to be discharged in a car seat.
Al-though there was no significant difference between the
two groups, both groups had correct usage rates above 90% at hospital discharge and maintained usage at better than 80% for one full year. A comparison with an earlier study at the same hospital suggested that the duration and comprehensiveness of the programs accounted for the significant increase in the usage rates. The task now is to adapt the program for use with less motivated parents. Pediatrics 1985;76:36-42; child passenger safety,
accident prevention, child restraint seats.
Motor vehicle accidents are the leading cause of death in children, claiming more lives than the six
most fatality-producing pediatric diseases
com-bined.’ During the last decade, more than 10,000
Received for publication June 15, 1984; accepted Sept 6, 1984. Reprint requests to (E.R.C.) Department of Pediatrics, Univer-sity of Kansas Medical Center, 39th and Rainbow Blvd, Kansas City, KS 66103.
PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the American Academy of Pediatrics.
children less than age 5 years were killed while they were in automobiles and thousands more were in-jured.2 Vehicular trauma is the primary cause of
death in children with noncongenital brain damage, permanent spinal cord injury, and seizure disor-ders.3
In a program designed to influence parents to
transport their infants in restraint devices and to
use them correctly, Reisinger and Williams2 offered
three groups of mothers one of the following: (1)
car seat literature and the opportunity to purchase a child restraint device in the hospital; (2)
litera-ture, a personal discussion, and the opportunity to
purchase a restraint device; or (3) literature and a free restraint device. The mothers who received a free restraint seat and car seat literature (group 3) had the best response: 1 1 % of the parents used the
seat correctly on the way home from the hospital,
and 28% of the parents were using the seat correctly
at a 1-month follow-up visit. The educational
treat-ment increased car seat acquisition and subsequent use; however, it had little effect on the key outcome
measure: correct use of seats. Misuse of seats was a substantial problem even though correct use was emphasized in the literature and discussion.
Christophersen and Sullivan4 replicated the
Re-isinger and Williams2 study with two significant
modifications. First, the infant restraint device was
offered to the mother at the time of discharge from
the maternity unit. Second, a staff person brought
the seat into the mother’s room with the baby at
discharge time and offered to demonstrate how to
use the seat. The staff person volunteered to show
the mother how to restrain the seat properly with
the automobile seat belt. Unlike mothers in the
Reisinger and Williams study,2 the mothers were
provided with no literature or discussion. Upon
discharge, 7% of the control group (who were given
no exposure to restraint devices, literature, or
used it correctly. In contrast, 80% of the experi-mental group used the seats and 67% used them correctly.
Christophersen and Sosland-Edelman5 reviewed each of the components that have been identified, to date, that have had a favorable impact on
par-ents’ likelihood of correctly using an infant
re-straint device. The major components are: state legislation,6 hospital loaner programs,2’7 the support of the hospital nurses,4’8 the support of the pedia-trician,#{176}the ease of using the seat,’#{176}and community support.”
The present study was a prospective evaluation of two comprehensive programs that included each of the components enumerated above. Like many of the more recent studies on child passenger safety, the present study included covert observations of the parents’ use or nonuse of the restraint devices, with periodic interobserver reliability checks to substantiate the validity of the observational re-cordings (see Christophersen’2). Because the obser-vation procedures and hospital setting were iden-tical with those in the Christophersen and Sullivan study,4 a comparison between the findings of the two studies is included.
METHOD
Participants
There were originally 129 mothers included in the study. To be included in the study, mothers had to have delivered at the participating hospital and have selected one of the two pediatric groups who practice at the hospital and have their offices in the buildings adjacent to the hospital. Additionally, the mothers had to have a single-birth delivery, without complications, and be discharged from the hospital with their newborn after the customary two- or three-day postpartum stay.
Mothers were entered into the study in three separate groups. The first group began in December
1981, the second in April 1982, and the third in
August 1982. In this way, the major seasons of the year were included in the study for hospital dis-charge and for all follow-up observations. There were no significant differences between the mothers in the three groups on the demographic variables (eg, age, education, marital status).
Experimental
Design
A comparison group design, with prospective ran-dom assignment to groups was utilized. The moth-ers were entered into the study in pairs, with as-signment to one of the two groups determined by the toss of a coin. The mothers were not informed,
at any time, that they were in the study. Although all of the participating pediatricians were ap-proached prior to beginning the study and their permission was obtained to conduct the study through their offices with their patients, the pedia-tricians were informed that they would never be told of any individual mother’s use or nonuse of an infant restraint device, nor would they be told any details about the study except for the information that was made available publicly. This procedure was followed to protect the confidentiality of the patients because their involvement in the study was covert. Prior to its implementation, the study was reviewed and approved by the Institutional Review Board (the Human Subjects Committee) at the
University of Kansas Medical Center.
Setting
The setting for the first part of the study was a large suburban medical center (the same site as the Christophersen and Sullivan4 study), a 400-bed, nonprofit hospital serving the southwestern sub-urban Kansas City area. In 1981, there were 1,765 live births at this hopspital (approximately the same number as in 1982). The follow-up part of the study took place at the offices of the participating
pediatricians located in two medical buildings ad-jacent to the hospital.
EXPERIMENTAL
PROCEDURES
Comparison Group Without Mock-up or Handouts
Comparison Group With Mock-Up and Written Handouts
The nursing staff was given an in-service class by the project director (E.R.C.) on how to demon-strate the correct use of infant restraint devices. In
this class, the nurses had the opportunity to prac-tice placing and fastening an infant into a seat in a mock-up of an automobile front seat. A set of instructions and guidelines was distributed to all personnel who would come into contact with the mothers of newborns. The project director stressed to the nurses the possibility of injury and/or death when infants are allowed to travel unrestrained or in devices that are not crashworthy (ie, infant feed-ing chairs). A special poster was designed to depict the physical differences between the infant re-straint seats and the other devices (such as infant feeding chairs that are not safe for automobile travel). The Insurance Institute for Highway Safety film, “Infants and Children in Car Crashes-TV Version” was shown to the nurses during the in-service.
Written Handouts. The car seat literature, dis-tributed during the in-service class, was specifically designed for this project. The first handout detailed the differences between infant feeding chairs and
approved restraint devices and emphasized that the former offered no crash protection. The second handout was a written set of instructions for par-ents of newborns on how to use an infant restraint seat properly, as well as how to travel by car with an infant. A list of approved restraint devices, their
prices at local stores, and a short description of each was also included. (Copies of these handouts are available from E.R.C.)
Mock-up Demonstration. In the privacy of a small room (used primarily for car seat storage for the ongoing loaner program), the mother with her baby received a one-on-one demonstration of use of a restraint seat and discussion and literature on child passenger safety. The patient was also told that the
car seat with which she had practiced could be
borrowed (through the loaner program) or she could
purchase a seat of her own.
The procedures for each group are summarized in Table 1. Once a mother was assigned to the
comparison group with mock-up and handouts, her
pediatrician was alerted by a yellow sticker placed on the baby’s nursery chart. The participating pe-diatricians, after consultation with the project di-rector, agreed to leave standing orders for an infant
restraint seat demonstration, for participation in
the infant seat loaner program, and, at the time of hospital discharge, an order to “Discharge in Infant
Restraint Seat.” The nurse assigned to the mother
offered the infant restraint seat at a convenient time.
At the time of hospital discharge, the attending nurse and the parent(s) placed the infant in the car
seat and carried the newborn to the car. The nurse
instructed the mother and father how to place and
fasten the infant seat in the car. If the parents
elected to hook the seat belt over the restraint device, the nurse would simply observe. Placement of the car seat in the front or the back varied depending on the make of the car and the prefer-ence of the parents. If the participant did not have a seat of her own and declined the offer to rent one,
she was discharged in the same manner as the
control group.
At the 1-month well-child visit, the participating pediatricians gave each mother in the comparison group with mock-up and handouts a “pep talk” on child pasenger safety. The pediatrician was alerted to the placement in this group by a yellow sticker on the patient’s chart. When mothers returned to their pediatrician for the 6-month well-child visit,
the pediatrician gave them two written handouts. The handouts provided a description of how to travel with a toddler, including suggestions on
en-tertaining toddlers during automobile travel and
helping the toddlers to get used to the toddler restraint seat, and suggestions on possible toys
TABLE 1. Procedures for Comparison Groups
Without Mock-up and Handouts
With Mock-up and Handouts
Hospital Restraint Seat Loaner Program Auto safety discussion in
pre-natal classes
Restraint Seat Loaner Program
Auto safety discussion in prenatal classes
Nurses Administer loaner program Administer loaner program
Demonstrate use of infant seat using car mock-up Handout: Caution notice on infant feeding seats Handout: “Guidelines for Parents”
Pediatricians No specific procedures Write nursery orders for infant seat demonstration Write prescription for infant seat acquisition
(soft, stuffed toys) to give the child during auto-mobile travel. Also at 6 months, the mothers were given a copy of a magazine article (Consumer Re-ports 1982;46:171) that rated different child re-straint seats.
Observation Procedures
The research staff checked with the nursing staff regularly to ascertain when participating mothers and babies were ready to be discharged. Observa-tions were made to determine whether the
demon-stration procedures took place and whether the
newborn was correctly placed in the infant restraint device for the first ride home. The observation procedures (which were identical with procedures used by Christophersen and Sullivan4) involved the observer’s walking past the mother’s automobile at the time that she started her car, so the observer could actually observe how the infant was
trans-ported in the car.
Subsequent observations were made at the offices
of the pediatricians when the infants were brought
in for their 1-month, 6-month, and 12-month
well-child visits.
At discharge and during all follow-up
observa-tions, the observer recorded on a data sheet “Yes”
or “No” to the following questions: (1) Was the infant carried to the car in a restraint device? (2)
Was the infant placed in a restraint device in the car? (3) Was the infant seat fastened correctly (i.e,
secured with the lap belt)? (4) How was the infant
transported if not in a car seat? (a) mother’s arms, (b) other’s arms, (c) other device unsafe for auto-mobile travel, or (d) unrestrained.
The observers also recorded what type or brand of restraint device the parents used. Each observer
was provided with a looseleaf folder that contained
pictures of all of the car seats currently approved for use with infants to aid in the identification of the restraint seats. During the follow-up portion of the study, the observers checked each pediatrician’s office weekly to determine whether one ofthe moth-ers in the study was scheduled for that week. If one
was scheduled, then the observer planned to arrive at the office about the time of the appointment. The office staff identified the mother for the ob-server. As the mother left the pediatrician’s office
at the termination of her office visit, the observer (or observers) acted as though he or she was also leaving. The observer timed the trip to the parking lot in such a way that he or she could walk past the
study mother after she was in her car but before
she left the parking lot. When there were two observers, each one would usually walk past either side of the car and separately record their obser-vations.
Reliability
Interobserver reliability was conducted for 20% of the total observations in each phase of the study. Reliability was recorded by having two observers independently observe and record their observa-tions. Later, comparisons were made to ascertain whether they agreed on what they had recorded. An interobserver reliability coefficient was calculated for each observation category using the formula: (sum of agreements)/(sum of agreements plus dis-agreements) x 100. Reliability ranged from 75% to
100% with an average of 99%.
RESULTS
Effectiveness of Safety Program
The results showed that the comprehensive child
passenger safety program was effective, from
hos-pital discharge to 12-month follow-up; mothers did correctly restrain their infants/toddlers for auto-mobile travel. Although there was not a significant difference between the two groups (if anything, the group without the mock-up and the written hand-outs did better than the group with these added features), results in both groups were significantly better than any previously published results. The
results for the three different waves (December,
April, and August) were nearly identical (and were not significantly different); therefore, they have been combined to simplify their presentation. The
percent of the mothers in the two groups who
correctly utilized an infant/toddler restraint device at each of the observation intervals is shown in Table 2. Whereas the mothers could and did use the same infant seats at discharge and at 1-month and 6-month visits to their pediatrician, by the
12-month visits, the mothers had to have switched to
either a toddler seat or to the toddler (forward
facing) position on convertible seats in order to be
scored as using the seats correctly. A summary of
the entire statistical analysis is available from
E.R.C.
Patient Attrition
Because 53 (41%) mothers in the study were lost
to follow-up (some because they moved, others
be-cause they changed pediatricians, and some because
TABLE 2. Mothers Correctly Using Restraint Device
Mock-up and Handouts
No Mock-up or Handouts
Discharge 92% 94%
1 mo 84% 78%
6 mo 79% 83%
they either did not keep their appointment with the pediatrician or were missed by the observers when they did keep their appointments at other than the originally scheduled time), a separate analysis (at a later point in time) was made of the patients who were lost to follow-up. The attrition rate is similar to the 50% rate reported by Berger et al.8 After
identifying those mothers in the present study who
were not included in the follow-up data, an attempt was made to locate as many of these mothers as possible and to observe them one time to ascertain the correct usage rates among the mothers who were lost to follow-up. A total of 12 mothers were located and observed for follow-up data. Because there was no way to control for when these obser-vations were conducted, the data from all of the patients who were lost to follow-up were combined. Eleven of the 12 mothers were correctly restraining their children, an average of 91.6%. Of the mothers who had been lost to follow-up and who could be located, a high percentage were still using a re-straint device correctly.
DISCUSSION
In the present study, mothers in both of the comparison groups were observed to have a high rate of infant restraint seat usage at the time of discharge from the hospital’s maternity unit, at the 1-month well-child yisit, as well as the 6-month and the 12-month visit. A statistical analysis of the
TABLE 3. Procedures of Two Studies
Christophersen Present Study
and (Group Without
Sullivan4 Mock-up or
(Control Group) Demonstration)
No loaner program in Loaner program in
effect effect for >2 yr
No child restraint seat Child restraint seat
law law
No prior staff or hos- Two years of staff
pital support and hospital
sup-port
No car seat education Car seat education in
in prenatal classes prenatal classes
No car seat literature Car seat literature in in obstetrics unit obstetrics unit
TABLE 4. Findings of Two Studies
differences between the two groups
(x2)
revealed no significance. These findings suggest that the extra procedures incorporated with the group with the mock-up and handouts are not necessary in order to offer adequate protection to the vast majority of infants.Although the results from the present study do not support the use of extra hospital procedures, which require extra staff time, they do demonstrate an acceptable level of restraint seat usage with this population. In an effort to try to determine what variables may account for the high usage, a com-parison was made between the present results and the results of a previous study.4 The earlier study was conducted at the same hospital with the same pediatricians, the same staff nurses, and with fam-ilies from the same socioeconomic class (middle to upper-middle class). The same observation proce-dures (including the same data sheets, operational definitions, etc) were used for both studies. The major differences between the procedures in effect
when the data from the two studies were gathered are summarized in Table 3.
The control group from the Christophersen and Sullivan study4 can be used as a control group for the present study in the sense that it provides data on car restraint seat usage prior to the introduction ofthe hospital’s restraint seat loaner program, prior to the passage of the state law, and prior to the active support of the nursing and medical staff (see Table 4).
Christophersen and Sullivan4 suggested that
when the infant restraint seat is demonstrated at the time of discharge, instead of allowing hospital staff to routinely discharge patients with the infant in the mother’s arms, a higher percentage of the parents used their restraint devices correctly. The parents in the present study, who received demon-strations at discharge, were included in Table 4 to show they did as well as or better than the mothers in the experimental group in the previous study. A
x2 test revealed that the difference between the
present study and the control group in the previous study is statistically significant at the .0001 level. The fact that the present study produced remark-able results, compared with the efforts of prior
Infant with correctly fastened restraint seat at discharge Infant with correctly fastened restraint seat at 1 mo Infant in mother’s arms at discharge
Infant in mother’s arms at 1 mo
Christophersen and Sullivan4
0% 23% 87% 23%
Present Study
Group With Group Without
Mock-up and Mock-up and
Handouts Handouts
92% 94%
84% 78%
10% 15%
investigators (see Christophersen and Sullivan4; Reisinger and Williams2; Reisinger et al9) compels the present authors to speculate as to what accounts for the high usage rates in the present study. There are several possibilities. First, the infant restraint seat loaner program had been operational, with the active nursing and administratiye support, for more than 1#{189}years prior to the onset of the present study. The loaner program now has more than 400 seats that are almost continuously in use, and, a further reflection on the staff support for the pro-gram is the fact that the loaner program actually shows a small profit for the hospital.
Second, the majority of mothers who deliver at the hospital (approximately 85%) have had some kind of parent education (childbirth classes, effec-tive parenting seminars) which always includes a unit on car safety and the importance of infant and child restraint devices. If the parents had scheduled a prenatal visit with one of the participating pedia-tricians, it is likely they were told about the impor-tance of restraint seats. Similarly, the nurse prac-titioners who work in the pediatricians’ offices spend time counseling new mothers and routinely advocate restraint seat usage. The majority of the mothers in both the present study and in the Chris-tophersen and Sullivan4 study were of middle or upper-middle socioeconomic status.
Thus, the child passenger safety program at the hospital might best be characterized as ideal: the patients were comparatively well educated, the ma-jority were married, and in all families at least one of the parents was employed. The characteristics are similar to the demographics identified by Hletko et al’3 as good predictors of correct restraint device usage. The nursing staff and the medical staff are strong supporters of local child passenger
safety efforts. The hospital administration has
ac-tively supported the program. Each time the loaner program has needed additional infant restraint seats (because the demand for loaner seats exceeded
the supply), they purchased them. In less than 2 years, the loaner program grew from the 200 seats originally purchased to the more than 400 seats currently in the program. The improvement in re-straint device usage, after several years with the program in operation confirms the similar finding reported by Colletti.7
Although the present program produced positive results, there is no reason to believe that the same results could be obtained in a markedly different setting. In the first attempt to replicate these
re-sults in another setting, a brand new loaner
pro-gram was evaluated (L. A. James, unpublished data, 1983). The setting was a large, urban, tertiary care teaching hospital. Many of the maternity patients
were from poor families, some were single parents, and many (65%) did not attend prenatal classes or do much reading about labor and delivery prior to their maternity hospitalization. When the program was initiated, there were problems with the loaner program including storage of the seats, recycling, distribution, educating and acclimating hospital staff and business office staff to the program, and gaining the cooperation of the staff from both ob-stetrics/gynecology and pediatrics. With a total of 30 patients in this evaluation, only 25% properly
restrained their newborn infants on the first ride home from the hospital and only 28% were observed to restrain their infant properly when they came in for their 1-month well-child visits.
That the present authors obtained dramatically different results between the two settings was prob-ably to be expected. Future researchers have basi-cally two major challenges: (1) to replicate the present results in other settings, settings that serve similar populations and have similar high levels of support from the nursing and medical staffs as well as the hospital administration, and (2) to continue research in tertiary care hospitals that cater to a different population in an attempt to determine whatever changes may be necessary in order to raise the percentage of new parents from these hospitals who choose to properly restrain their infants. The recent report of Berger et a18 is a good example of such an effort.
It is clear that when some means of passively restraining infants and young children is readily available and routinely installed in automobiles, child restraint seats may no longer be necessary. However, until such a passive restraint is developed and available, restraint seats are the only alterna-tive to reduce the carnage to children on our na-tion’s highways, sidestreets, and parking lots.
ACKNOWLEDGMENTS
This study was supported by Innovative Project Grant 7-A02 from the National Highway Traffic Safety Admin-istration. Collection of the follow-up data was supported
by Grant OR-84-02-02 from the Kansas Department of
Transportation. Preparation of this manuscript was
sup-ported in part by Grants HD 03144 and HD 02528 from
the National Institute of Child Health and Human De-velopment.
The authors acknowledge the assistance of Janice Thompson for data collection, Janet Levy, PhD, for statistical analysis, and Barbara Cochrane for editorial assistance.
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1983; 137:1061
TENTH
EUROPEAN
CONGRESS
OF PERINATAL
MEDICINE
Tenth European Congress of Perinatal Medicine, Leipzig, German Demo-cratic Republic, August 12-16, 1986. Contact:
Klaus J#{227}hrig,Greifswald Frauenklinik
im Univ.-Klinikum Kr#{246}llwitz POB 63
